Optimizing Outcomes for Patients With CKD and T2DM

Steps that need to be taken to address unmet needs and optimize outcomes for patients who have chronic kidney disease and type 2 diabetes.

Neil B. Minkoff, MD: This question is open to everybody. Maybe I could ask Dr Agarwal to start. We’ve talked a lot over the last hour and a half about the disease state, the different risk factors, progression, and some of the new therapies. What are we missing? What should we be doing? What should your colleagues like me who are more in primary care be doing to be more aggressive, to have more awareness here? Part of that is, what are the needs that still haven’t been met or might not be met with these new therapies?

Rajiv Agarwal, MD: I’ll summarize it in 3 words. It’s awareness, access, and implementation. That’s it. There’s nothing more.

Neil B. Minkoff, MD: Those are pretty big “that’s its.”

Rajiv Agarwal, MD: Those are basically the 3 large buckets. What do I mean by awareness? Awareness is basically [overcoming] lack of awareness of kidney disease. If you look at what George pointed out, the FIDELITY analysis, if you rely on eGFR [estimated glomerular filtration rate], you’re going to miss 40% of the patients who are otherwise eligible for these effective therapies. Awareness of kidney disease is truly lacking in our society.

Access is the next big thing. The biggest selling drug in America for diabetes is actually insulin, but followed by the gliptins, the sitagliptin-metformin combination for instance. Then it’s followed by the other drugs that have no cardiovascular protection. In fact, most of us have to get prior authorization for SGLT2 inhibitor use. I have no idea why, because they cost less than the price of insulin for a month, and they’re cardioprotective and protect the cardiovascular system. Yet everybody in their wisdom is saying, “You need to get prior authorization for these.”

It reminds me of the stories of the debates we had on what dose of statins we should use. When statins were $2 a pill, we always debated this. But now that they’re free, nobody talks about it anymore. Access is going to be a big deal. If patients can’t use these drugs, then it’s going to be a problem.

The third is implementation, which is especially the case when people get genital mycotic infections and stop the drug. That’s a problem. I say, “I can fix it for you, I can treat it for you, and if you practice good hygiene, you might not get it again. Would you rather have another genital mycotic infection, or go on dialysis, or be in the hospital with heart failure?” It’s a call that only a patient can make, but many of my patients refuse to take the medication once they’ve had 1 episode of genital mycotic infection.

The same problem will be faced by finerenone. Once people get hyperkalemia, they’re going to label the patient as allergic to the medication and never use it again. Hyperkalemia is manageable; end-stage renal disease isn’t. The prognosis of a patient with type 2 diabetes on dialysis is worse than stage IV colon cancer. People need to make decisions on how we implement this in our practice so people can use these drugs for a long time and stave off cardiovascular disease and kidney disease.

Neil B. Minkoff, MD: We’re hitting the hour and a half point. I’d like to make sure that we collect all of these other thoughts. I’m going to ask Dr Wright if he could give us some closing thoughts about where we are with this.

Eugene Wright Jr., MD: I would add that both the patient and the practitioner need to be aware. I’m looking back at the Know Your Numbers campaign. That was very successful in engaging patients in knowing what their lipids were and their blood pressure.

The other thing I would add to that is perspective. What I mean by that is, why do we even treat diabetes? Because we want to optimize the quality of life for the patient, and we want to prevent or significantly delay the onset of complications. If we take that type of an approach, I look at it from a

triple aim. We want to improve the patient experience of care over time, both in quality and in their satisfaction. We want to improve the health of a population. We have a large group of patients who are headed toward death or dialysis. And then we look at reducing the per capita cost of health care. That’s the trick for me, because if we look at it over time, what’s the cost of 1 year of dialysis? And what’s the benefit that you get in delaying that cost for 2 years?

Neil B. Minkoff, MD: Dr Bakris?

George L. Bakris, MD: This is like what we’ve been talking about. I’ll give you a very homey analogy. It’s like building a house. You’ve built the house, everything is fine, and where the money goes in to really maintain it is maintenance. What we’re talking about here is, if we look at our bodies as a house and all of a sudden we’ve got diabetes, hypertension, or the combination, you’ve got a little crack in the wall. Are you going to let it go? We’ll let it go, and then the ceiling is falling in. If you wait until the ceiling falls in, it’s too late and you’ve got irreversible problems. You can fix the ceiling, but it’s never really going to be the same.

Here, it’s the same thing. The moment you’ve noticed problems, you need to jump on them. And while there are no data on primary prevention of any of these things, it makes good sense that if you control blood pressure, glucose, and lipids, guess what? You don’t need primary prevention data. Common sense will tell you that you’re going to do well.

If you can simplify everything we’ve said, that’s really the key: have a relationship with the patient, make sure the patient understands what you’re trying to tell them, and I don’t think the patient is going to argue with you about primary prevention. That’s really the way to do this. Also, get the business and government people out of here.

Neil B. Minkoff, MD: I want to thank all of the panelists today for what has been an incredibly engaging and robust discussion that covered a lot of ground for only 90 minutes. I want you to know that I appreciate all of your engagement and the discussion we had. I’d like to thank all of you. I’d also like to thank everybody in our viewing audience who’s come in and been a part of this discussion. We certainly hope you found this AJMC® Peer Exchange to be informative and useful in your own practices. Thank you again.

Transcript edited for clarity.

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