GLP-1 vs SGLT2 Inhibitors: Balancing Evidence and Care Continuity

In "GLP-1 vs SGLT2 Inhibitors: Balancing Evidence and Care Continuity," our experts turn to how emerging GLP-1 kidney data should - and shouldn't - reshape SGLT2 utilization.

Dr. Haumschild compares SGLT2 inhibitors and GLP-1 receptor agonists as evidence in both classes keeps evolving. He acknowledges GLP-1s carry real budget impact that payers cannot ignore. Semaglutide now has dedicated kidney outcomes data showing a 24% reduction in a composite endpoint. That data covered patients with type 2 diabetes and chronic kidney disease specifically. Dr. Haumschild says he no longer considers GLP-1 renal evidence purely secondary given this data. Still, he would not treat GLP-1 receptor agonists and SGLT2 inhibitors as interchangeable kidney therapies. DAPA-CKD and EMPA-KIDNEY already demonstrated kidney protection with SGLT2 inhibition, with and without diabetes present. DAPA-CKD showed a 39% relative reduction while EMPA-KIDNEY showed 28% in their respective trials. GLP-1 therapy brings compelling kidney, cardiovascular, and weight benefits, particularly in type 2 diabetes. He views the two classes as complementary rather than substitutable, given how the evidence diverges. Cost-effectiveness differs between them too, reflecting that different totality of evidence. He would be cautious about forcing a stable SGLT2 patient onto a GLP-1 purely for formulary economics. The clinical question should instead be which therapy, or combination, best addresses each patient's overlapping conditions. Dr. Haumschild then turns to continuity of care for patients already succeeding on SGLT2 therapy. If a patient is achieving benefit, he says plans need to lean into that success. Formulary transitions between inpatient and outpatient settings require real care and planning. He advocates for policies that consider grandfathering therapy through formulary changes when appropriate. Reasonable utilization management criteria should let inpatient-started therapy continue smoothly into the outpatient setting. Too much fragmentation between care settings risks patients falling off therapy entirely. That loss, he warns, means losing the protective renal and cardiovascular benefit they had gained.

The next episode in this series, "Weighing Pharmacy Savings Against Downstream Medical Costs in CKD," features Dr. Haumschild modeling how pharmacy savings can hide costly medical trade-offs.