A Pilot Study Embedding Clinical Pharmacists Within an Interprofessional Nephrology Clinic for the Initiation and Monitoring of Empagliflozin in Diabetic Kidney Disease

Abstract

Background: The American Diabetes Association (ADA) recommends sodium-glucose cotransporter-2 (SGLT2) inhibitors as the second medication to be started, after metformin, for patients with chronic kidney disease (CKD). Sodium-glucose cotransporter-2 inhibitors may cause volume, blood pressure, and electrolyte disturbances; consequently, frequent monitoring and adjustments to other diabetes, blood pressure, and/or diuretic medications may be necessary. Objective: To evaluate the safety and efficacy of an interprofessional clinic model partnering nephrologists and pharmacists for the initiation and monitoring of SGLT2 inhibitors. Methods: A clinical pharmacist was embedded within the nephrology clinic to provide patient education, telephone follow-up, and to work collaboratively with the nephrologists. Diabetes, hypertension, and diuretic regimens were adjusted as needed after empagliflozin initiation. Diabetes regimens were adjusted to adhere to the 2019 ADA guidelines that promote agents with CKD and atherosclerotic cardiovascular disease benefit. Results: Fourteen patients were initiated on empagliflozin during the study period. Urine albumin-to-creatinine ratio (UACR) improved (mean % change −12% ± 61%); the mean percentage change was greater in patients with a higher baseline UACR. The mean change in hemoglobin A1c was 0.3% ± 0.6%. Common adverse reactions were observed and improved over time; no serious adverse drug reactions occurred. Finally, empagliflozin initiation necessitated adjustments to diabetes, hypertension, and diuretic regimens in almost all patients (n = 13, 93%). Conclusion: The implementation of an innovative, interprofessional care model within a nephrology clinic for the initiation and monitoring of empagliflozin in patients with DKD demonstrated clinical benefit with minimal safety concerns.

Prescribing Patterns of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD: A Cross-Sectional Registry Analysis

“…37 A pilot study of clinical pharmacists using an SGLT-2i prescribing algorithm 38 in a CKD clinic was safe and efficient for SGLT-2i initiation and encompassed many of the opportunities outlined above. 39 A remote care management program that is CKD registry-guided, algorithm-driven, led by either a pharmacist or care navigator, and supported by a specialist can overcome numerous barriers. Finally, advocacy efforts are needed to encourage policymakers, payors, and pharmaceutical companies to lower the cost of this class of medication to ensure equitable access.…”

Medication Optimization for New Initiators of Empagliflozin for Diabetic Kidney Disease

“…In 2018, we established an interprofessional model of care in which nephrologists and clinical pharmacists partnered to initiate and monitor SGLT2 inhibitor therapy in patients with DKD (18). This model occurred in a Veterans Affairs (VA) outpatient nephrology clinic in the Northeastern United States.…”

“…In brief, the nephrologist prescribed an SGLT2 inhibitor, and the pharmacist and nephrologist adjusted the patient's diabetes medications, antihypertensives, and diuretics at SGLT2 inhibitor initiation. Then, the pharmacist contacted patients regularly for 6 months, adjusting medications as needed based on patients' self-monitoring of blood glucose (SMBG) results, blood pressure, weight, and adverse effects (18). We previously noted that SGLT2 inhibitor prescription led to several medication changes for each patient, including modifications to diabetes, blood pressure, and diuretic medications.…”

Potential Safety Issues with Use of Sodium-Glucose Cotransporter 2 Inhibitors, Particularly in People with Type 2 Diabetes and Chronic Kidney Disease

“…SGLT2 inhibitors should not be initiated in patients who are hypovolaemic and/or hypotensive, because this could contribute to AKI. Further, patients prescribed loop and/or thiazide diuretics may need dose reduction of these medications to prevent volume depletion (Table 2) [63,64]. Patients should be instructed when acutely unwell (for example, vomiting, diarrhoea, and reduced oral intake) to withhold their SGLT2 inhibitor (part of a sick day management plan) [43].…”