A Case for SGLT2 Inhibitors in Non-Diabetic CKD: Sandra Chaparro, MD

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are no longer a diabetes-only therapy, according to Sandra Chaparro, MD, director of advanced heart failure at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida. In an interview with The American Journal of Managed Care^® (AJMC^®), Chaparro discussed how the clinical evidence supporting SGLT2 inhibitors in chronic kidney disease (CKD) extends well beyond patients with type 2 diabetes, who should be prescribing these agents, and what she expects as generic versions enter the market.

This interview has been lightly edited for clarity.

AJMC: How do you make the clinical case for an SGLT2 inhibitor in a patient with CKD who has never had diabetes?

Chaparro: As a cardiologist, I will say that the SGLT2 inhibitors are one of the best tools that we have to prevent the progression of heart disease, but also kidney disease. When I have a patient who has an abnormal creatinine, that’s already an indication to start patients on SGLT2 inhibitors, regardless of any other comorbidity.

AJMC: Which CKD subtype or etiology did you find most compelling for SGLT2 inhibitor use, and where do you remain cautious?

Chaparro: All the SGLT2 inhibitors have been studied in all types of CKD, so it’s not related to a specific type—I will use it regardless of the etiology. Which one would I use? I will usually use the ones that have been studied in this patient group: dapagliflozin, empagliflozin, and sotagliflozin.

AJMC: Who do you think should own the SGLT2 prescription in patients with non-diabetic CKD—the cardiologist, nephrologist, or primary care provider? How does that play out in the renal multidisciplinary setting?

Chaparro: Any physician should embrace the SGLT2 inhibitor. It should not be defined by specialty. We all know the benefits of these medicines, so it should be up to primary care physicians, cardiologists, endocrinologists, and nephrologists—all of us should be able to start prescribing these medicines.

AJMC: With generics entering the market, how do you expect formulary coverage to evolve for non-diabetic CKD indications specifically?

Chaparro: Having generics will hopefully expand the availability of these medicines. However, what we have seen is that there’s a lot of variability in the coverage of these medicines, and sometimes patients end up with high co-payments, even with generics. I think over time that’s going to get better, but we’ll have to see if we get better pricing.

AJMC: Payers have historically used a diabetes diagnosis as a gating criterion for SGLT2 coverage. How do you make the case to a utilization reviewer that this is now the standard of care?

Chaparro: We need to go with where the data are, and now the data suggest that all patients should benefit, because we’re going to decrease the likelihood that a patient is going to end up on dialysis. Dialysis is a high-cost intervention, so anything we can do to prevent that progression—and that’s with the SGLT2 inhibitor—will hopefully encourage payers and providers to be more proactive.

AJMC: What’s the risk that cheaper generics push payers toward a one-size-fits-all formulary stance that ignores clinically meaningful differences between agents?

Chaparro: Fortunately, the 3 most important agents in the cardiometabolic and renal space have the same outcomes, so we can choose from empagliflozin, dapagliflozin, and sotagliflozin, and all of them will give us cardiovascular and renal benefits. It’s not limited to a single drug.