New Therapeutic Horizons in Chronic Kidney Disease: The Role of SGLT2 Inhibitors in Clinical Practice

Cost-effectiveness of sodium-glucose cotransporter 2 inhibitors in the treatment of chronic kidney disease: a systematic review

INTRODUCTION

Chronic kidney disease (CKD) is a severe, progressive condition with a significant economic burden. We performed a systematic review to assess the cost-effectiveness of sodium-glucose cotransporter 2 (SGLT2) inhibitors in treating CKD.

METHODS

A comprehensive search was conducted across PubMed, Embase, Web of Science, Scopus, INAHTA, NHS EED, and relevant websites. Two reviewers independently screened titles and abstracts, extracted data, and assessed study quality using CHEERS 2022 and Phillips's checklist.

RESULTS

Thirteen model-based cost-utility studies met the inclusion criteria, evaluating Empagliflozin (n = 3), Canagliflozin (n = 3), and Dapagliflozin (n = 8). Empagliflozin or Dapagliflozin plus standard care (SoC) was cost-effective compared to SoC alone in CKD patients, regardless of type 2 diabetes (T2D) status. In CKD patients with T2D, SGLT2 inhibitors combined with SoC were cost-saving in high-income countries under health system perspective whereas Dapagliflozin was not cost-effective compared to Canagliflozin. No study met all criteria of the CHEERS 2022 checklist, and most did not fully satisfy Phillips's checklist for economic models.

CONCLUSION

Adding SGLT2 inhibitors to SoC is cost-saving for treating CKD with T2D and cost-effective for CKD patients with or without T2D.

REGISTRATION

The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023469005.

Short-term costs in patients with chronic kidney disease treated with dapagliflozin: a retrospective cohort study

OBJECTIVES

This real-world study evaluated the impact of dapagliflozin on short-term medical costs in patients with stage 3 chronic kidney disease (CKD).

METHODS

This retrospective, observational cohort study used medical and pharmacy claims data from IQVIA PharMetrics Plus. Patients aged ≥18 years with a filled dapagliflozin prescription after stage 3 CKD diagnosis between September 2020 and December 2021 were 1:1 propensity score matched with patients with stage 3 CKD who did not receive dapagliflozin. The primary endpoint was cardiorenal medical costs to payers over 6 months; all-cause medical and pharmacy costs were also analyzed. Within the overall population, there was a new-user subgroup of patients with no sodium-glucose co-transporter-2 use during baseline.

RESULTS

The new-user subgroup included 503 matched patients per cohort. Mean per-patient cardiorenal medical costs were reduced by 49.0% in the dapagliflozin versus non-dapagliflozin cohort ($3172.15 vs $6219.50; P < 0.001). Mean all-cause medical costs were reduced ($8043.58 vs $12,194.87; P < 0.001) and mean all-cause pharmacy costs were increased ($9056.98 vs $7453.23; P = 0.22). Results were similar for the overall population.

CONCLUSION

This study showed dapagliflozin was associated with reduced cardiorenal medical costs over 6 months compared with no dapagliflozin treatment in patients with stage 3 CKD, demonstrating real-world medical cost savings.

Trends in add-on medications following metformin monotherapy for type 2 diabetes

BACKGROUND: Although metformin is generally universally recommended as a first-line pharmacologic therapy for most people living with type 2 diabetes, second-line and third-line choices can require a tailored approach to achieve optimal blood glucose and glycated hemoglobin levels. OBJECTIVE: To examine national trends in second- and third-line antihyperglycemic medications following metformin monotherapy, comparing 2015 and 2019. METHODS: This retrospective cohort analysis of deidentified pharmacy claims from a large national pharmacy benefits manager from January 1, 2015, to December 31, 2015, and again in January 1, 2019, to December 31, 2019, included adults (aged ≥ 18 years) continuously enrolled in commercial or Medicare insurance plans who filled an index metformin prescription in either year. Proportions of patients by second-line and third-line antihyperglycemic class were calculated. RESULTS: Second-line use of sulfonylureas (-10.1%; P < 0.001), combination drugs (-3.0%; P < 0.001), and dipeptidyl peptidase-4 inhibitors (-2.0%; P = 0.031) significantly declined, whereas second-line use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) (+4.9%; P < 0.001) and glucagon-like peptide-1 receptor agonists (GLP-1Ras) (+10.0%; P < 0.001) significantly increased. Similarly, third-line use of sulfonylureas declined (-5.5%; P = 0.005), whereas third-line use of SGLT2is (+3.4%; P = 0.005) and GLP-1RAs (+8.3%; P < 0.001) increased. Similar trends between 2015 and 2019 were found in commercial and Medicare subgroups. Among all groups in 2015 compared with 2019, sulfonylureas were the most prescribed second-line class and insulins the most common third-line class. Although SGLT2i and GLP-1RA together represented more than one-third of second-line and third-line prescriptions for commercially insured patients in 2019 (34.3% and 35.0%, respectively), these classes were less frequently prescribed in the Medicare subgroup (18% and 25.6%, respectively). CONCLUSIONS: This report provides updated second-line and third-line antihyperglycemic medication prescribing trends in the United States, which suggests that evidence-based guidelines are being used in practice to prevent complications and individualize diabetes care. DISCLOSURES: Ms Swart and Drs Peasah and Good are employed by UPMC Health Plan. Dr Neilson was employed by UPMC Health Plan at the time of the study. Drs Munshi and Henderson were employed by Evernorth at the time of the study.

Defining the Role of SGLT2 Inhibitors in Primary Care: Time to Think Differently

Disease burden in people with diabetes is mainly driven by long-term complications such as cardiovascular disease, heart failure and chronic kidney disease. This is a consequence of the interconnection between the cardiovascular, renal and metabolic systems, through a continuous chain of events referred to as 'the cardiorenal metabolic continuum'. Increasing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial effects across all stages of the cardiorenal metabolic continuum, reducing morbidity and mortality in a wide range of individuals, from those with diabetes and multiple risk factors to those with established heart failure and chronic kidney disease, regardless of the presence of diabetes. Despite this robust evidence base, the complexity of label indications and misconceptions concerning potential side effects have resulted in a lack of clear understanding in primary care regarding the implementation of SGLT2is in clinical practice. With this in mind, we provide an overview of the clinical and economic benefits of SGLT2is across the cardiorenal metabolic continuum together with practical considerations in order to help address some of these concerns and clearly define the role of SGLT2is in primary care as a holistic outcomes-driven treatment with the potential to reduce disease burden across the cardiorenal metabolic spectrum.