Defining the Role of SGLT2 Inhibitors in Primary Care: Time to Think Differently

Abstract

Disease burden in people with diabetes is mainly driven by long-term complications such as cardiovascular disease, heart failure and chronic kidney disease. This is a consequence of the interconnection between the cardiovascular, renal and metabolic systems, through a continuous chain of events referred to as 'the cardiorenal metabolic continuum'. Increasing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial effects across all stages of the cardiorenal metabolic continuum, reducing morbidity and mortality in a wide range of individuals, from those with diabetes and multiple risk factors to those with established heart failure and chronic kidney disease, regardless of the presence of diabetes. Despite this robust evidence base, the complexity of label indications and misconceptions concerning potential side effects have resulted in a lack of clear understanding in primary care regarding the implementation of SGLT2is in clinical practice. With this in mind, we provide an overview of the clinical and economic benefits of SGLT2is across the cardiorenal metabolic continuum together with practical considerations in order to help address some of these concerns and clearly define the role of SGLT2is in primary care as a holistic outcomes-driven treatment with the potential to reduce disease burden across the cardiorenal metabolic spectrum.

Keywords: Cardiorenal metabolic continuum; Chronic kidney disease; Diabetes; Heart failure; Primary care; SGLT2 inhibitors.

Fig. 1

SGLT2 inhibitor cardiorenal metabolic effects. The figure summarizes main mechanisms of action and beneficial effects of SGLT2 inhibitors across the cardiorenal metabolic spectrum, including reduction of CV events, renal protection, and improvement of metabolic control in diabetes. CKD chronic kidney disease, CV cardiovascular, CVD cardiovascular disease, eGFR estimated glomerular filtration rate, ESKD end-stage kidney disease, HbA1c glycated haemoglobin, HHF hospitalisation for heart failure, MACE major adverse cardiovascular event, T2DM type 2 diabetes mellitus