Cost Top Barrier to CKD Drug Access

Nephrology providers cite cost as one of the most frequent obstacles they face when striving to provide optimal care via newer cardio-kidney protective medications to individuals living with chronic kidney disease (CKD), according to new data published in Kidney Medicine.¹ Polypharmacy, prior authorization, and confusion toward prescribing responsibility are other prominent concerns.

Authors distributed an anonymous online survey to US-based nephrology providers between April and June of 2025 through professional networks, word of mouth, and electronic mailing lists. Overall, there were 61 responses, comprising 44 nephrologists and 17 advanced practice providers (APPs). Close to half (46%) had more than 15 years of experience, and the most common practice site was a nonacademic group setting (58%).

Who Responded and What They Prescribe

Between 2019 and 2024 among patients with stage 3 CKD and type 2 diabetes, 40% used sodium-glucose cotransporter 2 (SGLT2) inhibitors, 33% used glucagon-like peptide 1 receptor agonists (GLP1 RAs), and less than 2% used nonsteroidal mineralocorticoid antagonists (nsMRAs). These findings echo earlier research showing that approximately two-thirds of patients with diabetic kidney disease were not prescribed SGLT2 inhibitors.²

Forty-seven percent of care providers prescribed SGLT2 inhibitors more than 5 times/month compared with 10% who prescribed GLP1 RAs and 5% who prescribed nsMRAs.¹ Also, however, 52% reported never having prescribed a GLP1 RA and 39% an nsMRA.

The care providers’ comfort level with prescribing was also evaluated. Overall, 93% were comfortable prescribing SGLT2 inhibitors, 77% were comfortable prescribing nsMRAs, and half were comfortable prescribing GLP1 RAs; APPs reported feeling both less comfortable with prescribing and having less knowledge of these medications.

What Are the Most Common Barriers to Prescribing?

As previously cited, costs topped this list, with 57%, 74%, and 84% of nephrologists and APPs making this their top barrier for nsMRAs, SGLT2 inhibitors, and GLP1 RAs, respectively. Breaking down further for each medication class, the second and third most common obstacles when prescribing SGLT2 inhibitors were polypharmacy and patient preferences/hesitation, at 66% each, and for GLP1 RAs, prior authorization and uncertainty about prescribing responsibility, at 70% each. For nsMRAs, polypharmacy was the other most common barrier, at 57%.

The study authors explained that manufacturer-sponsored programs may help, but also that these initiatives can be limited by restrictive qualifying criteria, lack of provider awareness, and inadequate patient-focused time or resources. Knowing that each class of medications helps to reduce needs of hospitalizations, cardiovascular interventions, and dialysis, the authors note an “urgent need for innovative value-based and alternative payment models of care.”

How to Improve Managed Care Access

Multidisciplinary team-based care was proposed. Pharmacists, the authors explained, can address polypharmacy by conducting comprehensive medication management, identifying assistance programs, helping with dose titration, and addressing patient hesitancy. Integrating pharmacists into kidney care is supported by Kidney Disease: Improving Global Outcomes and the National Kidney Foundation.³ In addition, social workers, medical assistants, nurses, and other clinic staff can help with health care cost resources, prior authorization, patient education, and care coordination.¹

Still, this study had its limits. There was potential for self-selection bias, it was not possible to accurately calculate the response rate, the total responses were small in number overall and restricted primarily to academic/group practices, and sampling of foundation members and volunteers may also have biased these results. The authors are planning future in-depth qualitative interviews with patients, providers, and payers.

References

1. Weltman MR, Lavenburg LU, Zupa MF, Jhamb M. Barriers to use of cardio-kidney protective medications in chronic kidney disease: results of a nephrology provider survey. Kidney Med. 2026;8(10):101474. doi:10.1016/j.xkme.2026.101474
2. Hanover L. Most eligible patients with diabetic kidney disease not receiving SGLT2 inhibitor prescriptions. AJMC^®. May 17, 2021. Accessed October 8, 2026. https://ajmc.com/view/most-eligible-patients-with-diabetic-kidney-disease-not-receiving-sglt2-inhibitor-prescriptions
3. Hudson JQ, Chang AR, Condon Martinez AJ, Maxson R, Meaney CJ, St Peter WL. Optimizing comprehensive medication management in CKD: an opportunity to integrate pharmacists in the kidney care team. Am J Kidney Dis. 2026;87(3):433-442. doi:10.1053/j.ajkd.2025.09.024