Closing the Gap: Why SGLT2 Inhibitors Remain Underused

This episode, "Closing the Gap: Why SGLT2 Inhibitors Remain Underused," features Dr. Haumschild examining the fragmentation that keeps eligible patients off guideline-directed therapy.

Dr. Haumschild identifies several contributors to SGLT2 inhibitor underuse, starting with fragmentation in care. He says the biggest issue is often the gap between identifying an appropriate patient and starting therapy. Chronic kidney disease illustrates the problem well because it can be relatively silent in practice. A clinician may have an EGFR value but never order the urine-albumin-creatinine ratio. That ratio, he explains, is a hallmark measure of how a patient is performing renally. Specialty silos compound the issue further across cardiology, nephrology, and endocrinology. Cardiology may recognize the heart failure indication while nephrology sees only the renal piece. Endocrinology may focus on the diabetes indication and assume someone else manages the SGLT2 inhibitor. Dr. Haumschild also points to a persistent knowledge gap among some clinicians. Many still think of these agents purely through the lens of glucose lowering. At a lower EGFR, glucose-lowering effects do diminish, but he stresses that isn't the full picture. Kidney and cardiovascular effects remain clinically important even as glycemic benefit fades. Current ADA guidance specifically supports initiation at an EGFR above 20 for cardiorenal benefit. Practical barriers add another layer, including prior authorization, copay burden, and adverse event concerns. Reconciliation after a hospital stay matters too, since many patients start therapy during admission given expanded indications. From a payer perspective, Dr. Haumschild says the question needs to change entirely. Rather than asking how to manage utilization, payers should ask how to find eligible patients missing therapy. He frames this as part of a broader population health strategy for health plans. Integrated systems, he notes, can match claims data, lab results, and EHR data together. That combination helps identify appropriate patients and close the care gap that currently exists.

The next episode in this series, "Generic SGLT2 Inhibitors and Interpreting Divergent CKD Trial Data," features Dr. Haumschild on generic tiering and how to read two very different CKD trials.