CKD is a significant medical problem affecting anything between 6 to 11% of the UK adult population. It is a disorder in which the kidneys are damaged causing a reduction in their ability to clean the blood. If the CKD is progressive (which means it slowly deteriorates over time) the person suffering this disorder is at risk of kidney failure and the need to start a treatment to replace their kidney function in the form of either dialysis or kidney transplant. Importantly, as well as the issue of suffering kidney failure, people with CKD have a much higher chance of suffering cardiovascular diseases in the form of heart attacks, heart failure, strokes and damage to the blood supply to the legs and feet.
The treatment of CKD has been centred around control of blood pressure, the reduction in other cardiovascular risk factors (for example, stopping smoking and managing cholesterol) and the use of a group of medications known as angiotensin-converting enzyme inhibitors (or ACE inhibitors – the names of which usually end with “-pril”) or angiotensin-II receptor blockers (ARBs – the names of which usually end with “-sartan”). However, even with the use of these interventions, people with CKD still suffer considerable harm related to their underlying kidney disorder.
The SGLT 2 inhibitors is the name given to a group of medications that were initially developed to treat people with diabetes by providing them with better control of their blood glucose (sugar) and can be recognised by the drug name ending in “-gliflozin”. As part of the developmental program for this group of medications, each of the individual SGLT 2 inhibitors underwent a large study to ensure that, not only are they effective in helping people with diabetes reduce blood glucose, but that they also did not cause any increased risk of cardiovascular disease. The findings from these large studies, which have been undertaken and reported over the last six years, has had a significant impact on the care of people with heart disease and CKD. This is because all of these medications have been shown to have unexpected beneficial effects in relation to reducing the rate of progression of CKD and reducing the risk of heart failure complications. In relation to CKD, this benefit was seen even though the study participants were already being treated with current best practice and even in this circumstance the SGLT 2 inhibitor provided very significant additional benefit.
As a result of these studies and the further specific studies directly examining the effects of SGLT 2 inhibitors in people with kidney disease and heart failure, it is recognised that these medications need to be offered to people who are likely to experience benefit. It is the purpose of this guideline to review the evidence related to the benefits and the potential adverse risks of SGLT 2 inhibitors, in order to provide clear recommendations as to which people with CKD are most likely to benefit from this medication, and in order to encourage the healthcare system to ensure that those individuals receive this beneficial treatment as speedily as possible.
All medical interventions can have side effects and for SGLT 2 inhibitors, we are clear as to the nature of the side effects and their frequency. These medications have a low risk of side effects but it is also possible to reduce that risk further by making careful choices about which individuals receive the medications and by informing people prescribed SGLT 2 inhibitors how to take specific actions to reduce the risk of coming to any harm should they suffer from any side effects. People with CKD should only be offered an SGLT 2 inhibitor if the benefits significantly outweigh the risks. Therefore, this guideline also provides information around the side effects of SGLT 2 inhibitors and how those side-effect risks can be reduced.