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Evolving Standard of CKD Care for Patients with Significant Comorbidities


The current treatment landscape for CKD patients with preexisting comorbidities is explored.

Ryan Haumschild, PharmD, MS, MBA: Dr Nicholas, I’d like to put it back to you again. Can you provide an overview…of the current treatment landscape, or if you want to call it the standard of care, for patients with CKD [chronic kidney disease] and coexisting conditions? And what are some of the roles of these therapeutics within CKD?

Susanne B. Nicholas, MD, PhD, MPH : A great question. And therapy is so important, right? It’s not just about screening and identifying patients but knowing which therapies to place and to initiate for these patients. So we mentioned a little bit earlier about standard of care in terms of comorbidities of diabetes and high blood pressure and optimizing those therapies. And there are many medications out there that target controlling diabetes as well as controlling high blood pressure as primary risk factors for chronic kidney disease. Now we have the newer cardiovascular and renal protective agents, now we’re able to layer these medications onto that standard of care that’s becoming the new standard of care. It could really improve patients’ outcomes overall. There are also newer therapies—for example, the nonsteroidal mineralocorticoid receptor antagonists for those individuals who are already on care. They’re on an ACE [angiotensin-converting enzyme] inhibitor or an angiotensin receptor blocker. They are on an SGLT2 [sodium-glucose cotransporter-2] inhibitor, but they still are experiencing residual risk of chronic kidney disease progression, maybe because their albuminuria levels are quite high. These individuals would be ideal for adding the newer nonsteroidal mineralocorticoid receptor antagonist, the one that right now is approved by the FDA within the United States. It is called finerenone and has been shown to provide additional cardiac and renal protection in individuals such as these who are even at significant risk. We’ve done everything that we can, and now we have newer therapies that we can add to protect these patients. So this is a new landscape, and I think it’s so wonderful for our patients that we have these choices; not only having the choices, but we have guidelines [for] how we can initiate these therapies and algorithms that we can follow in terms of whether there are complications from some of these medications, such as high potassium, for example. We’ve heard about the costs of high potassium management, but there are guidelines to help us manage these conditions in patients to really optimize their care, when it comes to the medications that…patients will benefit most from.

Ryan Haumschild, PharmD, MS, MBA: Excellent. Dr Cohen, from a payer’s perspective, anything you want to add?

Ken Cohen, MD:I think there are 2 quick points to keep in mind. One is…to identify these patients early [because] as CKD progresses, our tool chest narrows, so we lose the ability to use metformin; [when a patient has] a GFR [glomerular filtration rate] of 30 [or even] a GFR under 20, SGLT2s lose their beneficial effect. So it’s important to identify these patients early so that we can give them therapies that can then prevent them from progressing. The other important concept is when you think about a value-based care landscape. Think about the cost-effectiveness of any therapy that we administer. What [is] the number needed to treat or prevent an event? What is the cost to prevent an event? Because part of this is really a question about what can our health care system afford? And ICER, the Institute for Clinical and Economic Review, does these analyses. They use a QALY [quality-adjusted life year] methodology, and sometimes they find these drugs to be cost-effective and sometimes not. That places us in a conundrum about how to use these drugs when they’re very expensive and may not provide value. And I can’t provide answers today, but keep in mind that we need to continue to ask these questions.

Ryan Haumschild, PharmD, MS, MBA: I agree with you, we have to pivot toward, “Is this going to be cost-effective?” Because a disease like CKD or type 2 diabetes could be a rather large population. And so as a payer, they’re thinking, what’s the incremental cost that would be associated with covering these lives and providing optimal care and really relying on the clinical efficacy? But the cost effectiveness is an important perspective. So I really appreciate you bringing that forward.

Transcript is AI-generated and edited for clarity and readability.

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