Optimising Management with SGLT-2i-based Strategies in Primary Care

Hello, I'm Dr. Sarah Davis. I'm a primary care physician from Cardiff in the United Kingdom. I'm a general primary care physician, so I see the breadth of primary care. But I have a particular special interest in cardiorenal metabolic syndrome and that early optimization and the role that primary care can play in exactly that.

Here are my disclosures. So let's meet David, a fictional case study. Dave is a 68-year-old man. He's been living with type 2 diabetes for around 14 years. HbA1c, perhaps not fully optimized, 7.7% on a perhaps slightly historical regimen of metformin and a sulfenol urea.

Not my normal approach these days, but we definitely still see people on these combinations of therapies for their type 2 diabetes, either historically or perhaps because in that particular area the local primary care doctors are unable to use the newer approaches. He also has hypertension, not particularly well controlled on ramapril 5 milligrams.

David also has chronic kidney disease. His current EGFR is 42. We look back over the last few years, of course, it's important to look at what's happened in time gone by, and it's just been falling gradually, 3 to 5 mil per year. And crucially, we have David's urinary albumin creatinine ratio, and it's raised at. 202.

We look back again. He's had a couple done over the last few years. They've all been slightly elevated, but it's increasing. He's also an ex-smoker. His BMI is raised at 31, and he has dyslipidemia on atorvastatin 20 milligrams. That's the history, but actually David's presenting to us in the primary care clinic with new shortness of breath on exertion.

He's noticed when he's walking the dog with his wife that he's getting really quite short of breath and finding it difficult to catch up with her. This is very much a typical patient that I would see as a primary care physician. David absolutely has cardio kidney metabolic disease, doesn't he?

Across that spectrum, he's got type 2 diabetes, hypertension, dyslipidemia, chronic kidney disease, and maybe also now developing cardiovascular disease. He's very high cardiovascular risk, and frankly, there's an awful lot that I need to do.

In this 10-minute appointment, lots I need to address to try and reduce his risks going forwards. And it can be difficult sometimes to know when to start. Actually, what matters to David today is the fact that he feels really short of breath and can't keep up with his wife on the dog walks.

But what we have in primary care is opportunity, already rather delayed in David, I would argue, for that cardiorenal protection, that optimization of David's outcomes going forward, because I am worried for David's future. As things currently stand, his CKD is particularly a concern.

We know that we worry about progression, of course, of his kidney disease over time, but also we know the impact this has on his cardiovascular risk. We go back to the Codigo heat map and actually put David onto it. I will sometimes do this in the clinic when I'm talking to patients about kidney disease and what it means for their risk.

David's in a red box. He has very high risk of progression. Of this kidney disease, stage G3B A2, but also very high risk of having a cardiovascular event, which I think is probably we'd all agree the biggest threat to the premature ending of David's life.

So, what happens to David over the next year? Well, he has a bit of a bumpy and busy ride over the next 12 months. Like I said, plenty for me to get on with in my primary care clinic once I've decided where to start. I'm going to do a workup for his new shortness of breath, and we do that.

We check his NT pro BNP, which I'm able to do in my primary care clinic, and it's raised. So I refer him on to my cardiology colleagues for echocardiogram. I definitely want to optimize his blood pressure medications. Hypertension is such an important risk factor to consider.

I put the ramipril up because I know that I need to try and maximize that RAASi inhibition, but his potassium rises and. I don't know about you, but if you're working in primary care, managing hyperkalemia out there in the wilds of the community can be very challenging indeed.

Still, sometimes that belief that those ACE inhibitors, those angiotensin receptor blockers, can be nephrotoxic. We need to empower primary care and remind them that actually these are protective over time. But holding your nerve with hyperkalemia can be quite challenging sometimes. I want to look at optimizing his lipid lowering therapy.

And I'm going to refer him actually. He's got quite a lot going on here. I want to refer him to my endocrinology colleagues and indeed my nephrology colleagues as well for some further advice. Now, actually, because I have a special interest in this whole area of medicine, I have the confidence to do my own optimization in my clinic.

I'd be happy to start David on these medications, on an SGLT2 inhibitor and others going forwards. But I'm well aware that some of my colleagues don't lack that passion, that enthusiasm and experience in this area. So often we do need to involve, of course, our specialist colleagues.

In other areas of the world, I know we're sometimes unable to start these medications in a primary care setting. So he gets seen by the nephrology team about four months later. We refer him because of his declining kidney status, and they do initiate at that clinic appointment an SGLT2 inhibitor.

A few months later, off he goes to the hospital again. He's seen by the endocrinology team. They look at his glycemic control. They noted that he's recently been started on an SGLT2 inhibitor, but it hasn't had much effect on his A1C, probably because of his lowish EGFR, of course.

So they advise a GLP1 receptor agonist to be considered as the next step. He's suddenly on rather a few more medications than he started. He then gets seen by my cardiology colleagues. Yes, folks, I'm afraid the waiting list for cardiology in the UK is probably the longest of these specialty areas.

He has an echocardiogram and that confirms he has heart failure with. Preserved ejection fraction. They absolutely advise continuing the SGLT2 inhibitor, noting that actually now it's serving three indications at once. So Dave has been seen by multiple specialists now for his cardio kidney metabolic disease.

He hasn't enjoyed the year very much. He's been up and down to different clinics. He's found it really quite confusing. And have we missed an opportunity? Could we have done all of this that bit earlier on? How can we empower PCPs to optimize earlier? I truly believe that primary care is a key opportunity for early and effective cardiovascular risk identification, for identifying those patients that are continuing to develop disease across the cardio kidney metabolic spectrum, so that we can start to put in that early optimization, because we all know that that vascular risk starts to increase well before even that diagnosis of type 2 diabetes.

Certainly, as soon as that urinary ACR is up. That's when we need to be taking action, not at this stage, when his EGFR is already declining. I think a really good reminder to primary care is sometimes to go back to that data. Why do I want to do this early? Well, I want to do it because we have that great evidence of those hard clinical outcomes from starting SGLT2 inhibitors and other cardiorenal protective medications.

We go all the way back to Empareg some 11 years ago now, of course, demonstrating those. Cardiovascular benefits with that early separation of the lines, just after two months, showing significant reductions in cardiovascular death. And of course, since then, we've had Declare Timmy and many other trials showing similar benefits.

So, for every month that we delay someone like David starting on these cardiorenal protective medications, we lose out on potentially really important benefits for someone just like David. I think one potential barrier is the confusion around, well, when do we start in heart failure?

When is it in CKD that we add these medications again? When should we be

doing it in people with type 2 diabetes? Well, actually, for me, the message is that now the evidence is clear. CKM foundational therapy should be SGLT2 inhibitors for all, plus or minus GLP1 receptor agonists in cretin-based medications for some as well.

If we look across the guidelines for diabetes, for heart failure, for chronic kidney disease across the world, they are in agreement. We just have to identify perhaps that dominant risk domain if it's clear. Is it type 2 diabetes? Is it established atherosclerotic disease, heart failure, or CKD?

In the UK now, our type 2 diabetes guidance from NICE actually advises using metformin and an SGLT2 inhibitor. For all patients, perhaps excluding those with severe frailty, from a diagnosis of type 2 diabetes, 80% of my patients with type 2 diabetes are now on an SGLT2 inhibitor.

So it absolutely can be done, and at that early stage, so we reap the rewards for that patient many, many years down the line. So why doesn't it just get done? Why are we not doing this early? Well, I tell you what, being a PCP is very challenging. All areas of medicine are challenging, of course they are.

But we are the ultimate generalist. We know a little about an awful lot. The breadth of the patients we see is vast, and of course the role varies between different countries. For everybody across the world, though, the role of a PCP is definitely increasing in complexity as we see more patients living longer with multiple long-term conditions, just like David.

Having decision support from our specialist colleagues is really important, and a little patience as it takes time. To become familiar with the breadth of evidence guidelines and medications available. I have a number of perhaps tips and ideas about how we can enable and empower PCPs and work together with them to maximize early identification and intervention.

Certainly, simplifying the message and understanding that this is foundational therapy across CKM is important, and important benefits come early. Leading by example is so important. So when we see our cardiology, our Renal colleagues starting medications and communicating well in terms of the indications for those medications, that's really important.

And easy access to support and advice. I can email my local cardiologist, my local nephrologist. I get advice about individual patients, which is brilliant. They don't necessarily need to go to the clinic. I just perhaps need a bit of advice on the next steps. And some more practical support as well, having the confidence to use.

SGLT2 inhibitors, for example, beyond HbA1c, that change in message over time has taken a bit of time to land. It takes time to get our heads around that. So, understanding about those different indications is important, and making sure our patients are aware of the reason they're taking their medications as well.

Expecting things like the dip in EGFR after starting medications is important. Understanding the nephroprotective benefits rather than nephrotoxicity, and perhaps holding our nerve a little bit as a result. It's important that we remember to continue prescribing that patients need to continue these medications to reap the rewards in the longer term.

Even for example, as EGFR falls over time, or if someone's temporarily stopped a medication, perhaps after a hospital admission, we need to make sure that we're keeping prescribing cardioreenal protected medications for our patients. And for me, the take-home message: we shouldn't need to wait to see what the specialist says.

For our patients to improve their outcomes, to reduce their chance of important long-term complications, early optimization is key, and primary care with specialist support provides a vital role here.