Why Increasing Uptake of Kidney-Protective Drugs Requires a Team

Tim Pflederer, MD, chief medical officer for Evergreen Nephrology, discussed how sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have reshaped chronic kidney disease (CKD) care and what it takes to get eligible patients on therapy. CKD rarely travels alone, he explained; its growing overlap with diabetes and heart failure makes it better understood as cardiovascular-kidney-metabolic syndrome, which both drug classes treat across. Most patients with CKD benefit, and the prescribing question is the risk of progression rather than diabetes status.

Pflederer stressed class-specific starting care: Control diabetes before an SGLT2 inhibitor, titrate GLP-1s slowly, and counsel patients so they stay on therapy. He identified pharmacists as critical to education, affordable drug selection, and ongoing adjustment, and argued that uptake depends on team-based infrastructure rather than the prescriber alone. Value-based care, he concluded, is what brings that team together.

You can watch part 1 and part 2 of Tim Pflederer’s video interview on Pharmacy Times.

Pharmacy Times: How have SGLT2 inhibitors and GLP-1 receptor agonists changed the way clinicians approach CKD treatment?

Tim Pflederer, MD: That's a great question. There was a study published in the New England Journal of Medicine this month that showed that the prevalence of chronic kidney disease has not changed over the past 2 decades, but that diabetes and heart failure are increasingly associated with CKD. We know, as nephrologists and providers, that CKD doesn't travel alone. It's a syndrome with heart failure and diabetes and obesity, and SGLT2 inhibitors and GLP-1 receptor agonists treat all of those conditions. They're beneficial for all of those conditions. They've really revolutionized our thinking in terms of not just CKD but rather a cardiovascular-kidney-metabolic syndrome.

Pharmacy Times: Which patients with CKD are most likely to benefit from these therapies, and what factors should providers consider before prescribing them?

Pflederer: Most patients with CKD are going to benefit from these therapies. Patients with CKD who have proteinuria absolutely benefit. Patients with CKD and diabetes or heart failure also benefit. It's no longer just the patient with CKD and diabetes, but it's really the patient who's at risk of progression of kidney disease, who's at risk of cardiovascular events, or who has diabetes, because these agents both really have benefits in all of those areas. Most importantly for providers, we want to think about, with an SGLT2 inhibitor, as you're starting that therapy, that you want the diabetes under control, because those work by causing sugar to go out into the urine. If a patient's diabetes is out of control, then they will have a lot more urination and could get dehydrated. And with the GLP-1 receptor agonists, starting low and starting slow is important so that patients don't have gastrointestinal intolerance. Because both of those things will cause patients to start a therapy and stop it, and then they don't get the benefit.

Pharmacy Times: What are some of the most important counseling points or monitoring considerations for patients starting an SGLT2 inhibitor or a GLP-1 receptor agonist?

Pflederer: It's always important that the patient understands the purpose of their medication and the adverse event profile. With SGLT2 inhibitors, they are going to urinate more. They need to be alert for urinary tract infections, particularly in women, and report any symptoms of those relatively quickly. And then they also need to just understand that if they get sick, because the SGLT2 inhibitor causes them to urinate more, they should contact their doctors so that if they're not able to keep up with fluid intake, they probably will have that medication held until they're better and they're drinking more normally. With a GLP-1, it's really important to counsel patients that they will experience some gastrointestinal [adverse] effects and that those diminish over time, and just to stay in contact with the physician or the provider so that they can ease into those medications and adjust, and then stay on them and get the benefit.

Pharmacy Times: What role can pharmacists play in helping optimize the use of SGLT2 inhibitors and GLP-1 receptor agonists for patients with CKD?

Pflederer: Pharmacists are really critical for these medications. No. 1, pharmacists can do a great job of educating patients on the benefits of the drug, the purpose of the drug, and the adverse events to watch for. Pharmacists are also very helpful in helping patients identify the best medication to be on. These medications are very expensive, and there are a number of options in both SGLT2 inhibitors and GLP-1 receptor agonists, and so often a pharmacist can identify an option that a patient's going to be able to afford, that's going to be covered by their insurance or otherwise tolerated, and a pharmacist can work with them. And then pharmacists also can interact with the patient and help to recommend adjustments and work with their provider to make adjustments in the medication based on the patient's response and symptoms, should they [experience] symptoms. Again, the goal is to ensure that the patient is getting the medication, actually taking it, and benefiting in the long term from reduction in progression of kidney disease, reduction in cardiovascular events—particularly heart attacks and heart failure—and reduction in mortality.

Pharmacy Times: What are the biggest opportunities to improve uptake of these therapies and ensure more eligible patients with CKD receive guideline-directed care?

Pflederer: I think we're making a lot of progress in that regard, but I think the biggest opportunity is to ensure that providers have a team that can work with the patient. These medications don't just require a provider in a 15-minute office visit to write a prescription and tell the patient to get the medication. They really do take patient education. It often takes prior authorization to ensure that the medication is covered. It takes ongoing communication with the patient to ensure they're taking the medication and that they're not experiencing [adverse] effects. Those kinds of supportive care, if you will, or care management, require a team, and that team is the provider, the pharmacist, a nurse navigator, or a care manager. And we're having more and more success helping patients access the medications as we develop the systems that have a team-based approach.

Pharmacy Times: Is there anything else you want to add, or anything you think I missed before we finish things out?

Pflederer: I would just add that value-based care is, at its core, team-based care. At Evergreen Nephrology, we have pharmacists, we have care managers, and we have dietitians, all working with the nephrologist and the primary care physician in many cases to ensure patients are cared for not only during their office visit but also throughout their journey managing chronic kidney disease. CKD—cardiovascular-kidney-metabolic syndrome—is complex, and it's a challenge for patients living with those disorders. It's great to have a team, and value-based care brings that team together in a way that's unique in our health care system.