Sponsored CPD: Improving uptake of SGLT2 inhibitors in eligible patients: the Dapagliflozin Patient Identification Resource

This promotional module has been initiated, funded, and organised by AstraZeneca, and produced in collaboration with Cogora. For UK healthcare professionals only.

Clinical pharmacist Niraj Lakhani discusses the current NICE recommendations for use of SGLT2 inhibitors and how use of the Dapagliflozin Patient Identification Resource (DAPA-id) can support GPs and other healthcare professionals in primary care to identify patients in their practice who may benefit from this agent.

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FORXIGA® (dapagliflozin) 10 mg film-coated tables. Consult Summary of Product Characteristics (SmPC) before prescribing.

For Prescribing Information, please click here.

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Learning objectives
This module will enhance your knowledge of appropriate use of SGLT2 inhibitors and dapagliflozin specifically, in particular regarding:
• Current recommendations for use of SGLT2 inhibitors in different conditions and how to interpret this in daily practice.
• The potential for greater uptake of SGLT2 inhibitors both in newly diagnosed and existing eligible patients on your register.
• Use of the AstraZeneca Dapagliflozin Patient Identification Resource (DAPA-id) to identify patients in your practice who may benefit from taking dapagliflozin.
• Opportunities to improve your practice and PCN population health through systems approaches to improving uptake of dapagliflozin.

1. What are the current indications for prescribing SGLT2 inhibitors in diabetes, heart failure and CKD?
Sodium-glucose co-transporter-2 inhibitors (SGLT2 inhibitors) have been commonplace for glycaemic control in type 2 diabetes mellitus (T2DM) for some time. However, more recently, large trials have proven that SGLT2 inhibitors have wider benefits in terms of cardiovascular disease (CVD), symptomatic chronic heart failure (HF) and chronic kidney disease (CKD) outcomes.^1-15

Current NICE guidelines on the use of SGLT2 inhibitors in management of T2DM and CKD, and NICE technology appraisal guidance for use of certain SGLT2 inhibitors in CKD and HF,^16-23 are outlined in Box 1 below.

Box 1. Summary of NICE recommendations on SGLT2 inhibitor use

Patients with T2DM

In patients started on metformin therapy, once tolerability has been confirmed, and following cardiovascular disease (CVD) risk assessment:¹⁶

• Offer an SGLT2 inhibitor with proven CV benefit in patients with co-existing chronic heart failure or established atherosclerotic CVD (eg, coronary heart disease, acute coronary syndrome, previous myocardial infarction, stable angina, previous coronary or other revascularisation, cerebrovascular disease [ischaemic stroke and transient ischaemic attack] or peripheral arterial disease).
• Consider an SGLT2 inhibitor with proven CV benefit in patients considered at high risk of developing cardiovascular disease, ie:

– QRISK >10% in adults aged ≥40 or
– One or more CV risk factors in adults <40 years.¹⁶

If metformin is contraindicated or not tolerated:¹⁶

• Offer an SGLT2 inhibitor with proven CV benefit for first-line drug treatment in patients with co-existing chronic heart failure or established atherosclerotic CVD (defined as above).
• Consider an SGLT2 inhibitor with proven CV benefit for first-line drug treatment in patients considered at high risk of developing cardiovascular disease (defined as above).¹⁶

If metformin is contraindicated or not tolerated, for patients not in any of the groups above, consider a DPP-4 inhibitor, or pioglitazone, or a sulfonylurea, or an SGLT2 inhibitor^.16

CKD with T2DM

For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate):¹⁶

• Offer an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:

– ACR is over 30mg/mmol and

– they meet the criteria in the marketing authorisation (including relevant estimated glomerular filtration rate [eGFR] thresholds).

• Consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:

– ACR is between 3 and 30mg/mmol and

– they meet the criteria in the marketing authorisation (including relevant eGFR thresholds).¹⁶

CKD without T2DM

Dapagliflozin is recommended as an option for treating CKD in adults, only if it is an add-on to optimised standard care, including the highest tolerated licensed dose of an ACE inhibitor or ARB unless contraindicated, in people with:^17,18

• eGFR of 25ml/min/1.73m² to 75ml/min/1.73m² at the start of treatment and a urine albumin-to-creatinine ratio (uACR) of 22.6mg/mmol or more.^17,18

Empagliflozin is recommended as an option for treating CKD in adults, only as an add-on to optimised standard care, including the highest tolerated licensed dose of an ACE inhibitor or ARB unless contraindicated, in people with:^17,19

• eGFR of 20 ml/min/1.73m² to less than 45ml/min/1.73m² or

• eGFR 45 ml/min/1.73 m² to 90ml/min/1.73m² and uACR of 22.6mg/mmol or more.^17,19

HF without T2DM

In patients with symptomatic chronic HF with reduced ejection fraction (HFrEF, LVEF ≤40%):

• Dapagliflozin or empagliflozin are recommended as an option for treating symptomatic chronic HFrEF in adults, only if used as an add-on to optimised standard care with:

– ACE inhibitors or ARBs, with beta blockers and, if tolerated, mineralocorticoid antagonists (MRAs), or with

– sacubitril valsartan, with beta blockers, and, if tolerated, MRAs.^20,21

In patients with preserved ejection fraction (HFpEF, LVEF ≥50%) or mildly reduced ejection fraction (HFmrEF, LVEF 41-49%):

• Dapagliflozin or empagliflozin can be considered as an option for treating symptomatic chronic HFpEF or HFmrEF.^22,23

There are currently four licensed SGLT2 inhibitors available in the UK. They are all once daily tablets taken orally.^1-4 The current SGLT2 inhibitors available and their licensed indications are outlined below.^1-4 (Please refer to each product’s SmPC for more information on the licensed indication, posology and safety profile.)

Forxiga (dapagliflozin)¹

T2DM: In adults and children aged 10 years and above, for the treatment of insufficiently controlled T2DM as an adjunct to diet and exercise:

as monotherapy when metformin is considered inappropriate due to intolerance;
in addition to other medicinal products for the treatment of T2DM.

HF: Treatment of symptomatic chronic HF in adults.
CKD: Treatment of CKD in adults.

Invokana (canagliflozin)²

T2DM: Treatment of adults with insufficiently controlled T2DM as an adjunct to diet and exercise:

as monotherapy when metformin is considered inappropriate due to intolerance or contraindications;
in addition to other medicinal products for the treatment of diabetes.

Jardiance (empagliflozin)³

T2DM: In adults and children aged 10 years and above for the treatment of insufficiently controlled T2DM as an adjunct to diet and exercise:

as monotherapy when metformin is considered inappropriate due to intolerance;
in addition to other medicinal products for the treatment of type 2 diabetes.

HF: Treatment of symptomatic chronic HF in adults.
CKD: Treatment of CKD in adults.

Steglatro (ertugliflozin)⁴

T2DM: Treatment of adults with insufficiently controlled T2DM as an adjunct to diet and exercise:

as monotherapy when metformin is considered inappropriate due to intolerance or contraindications.
in addition to other medicinal products for the treatment of diabetes.

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Niraj Lakhani is Lead Clinical Pharmacist, Willows Health, and Pharmacist Adviser to the RCGP for Primary Care Development

References

Electronic Medicines Compendium (EMC). Forxiga 10 mg film-coated tablets – Summary of Product Characteristics (SmPC)
EMC. Jardiance 25 mg film-coated tablets – Summary of Product Characteristics (SmPC)
EMC. Invokana 100 mg film-coated tablets – Summary of Product Characteristics (SmPC)
EMC. Steglatro 15 mg Film-Coated Tablets – Summary of Product Characteristics (SmPC)
Wiviott S, Raz I, Bonaca M et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2019;380:347-357
McMurray J, Solomon S, Inzucchi S et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019;381:1995-2008
Solomon S, McMurray J, Claggett B et al. Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med 2022;387:1089-98
Heerspink H, Stefánsson B, Correa-Rotter R et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med 2020;383:1436-46
Zinman B, Wanner C, Lachin J et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-128
Packer M, Anker S, Butler J et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med 2020;383:1413-24
Anker S, Butler J, Filippatos G et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med 2021;385:1451-61
The EMPA-Kidney Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med 2023;388:117-27
Neal B, Perkovic V, Mahaffey K. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017;377:644-57
Perkovic V, Jardine M, Neal B et al. Canagliflozin and renal Outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019;380:2295-306
Cannon C, Pratley R, Dagogo-Jack S et al. Cardiovascular outcomes with ertugliflozin in type 2 diabetes. N Engl J Med 2020;383:1425-35
NICE. Type 2 diabetes in adults: management. [NG28] Last updated June 2022
NICE. Chronic kidney disease: assessment and management. [NG203] Last updated 24 November 2021
NICE. Dapagliflozin for treating chronic kidney disease. [TA775] 09 March 2022
NICE. Empagliflozin for treating chronic kidney disease. [TA942] 20 December 2023
NICE. Dapagliflozin for treating chronic heart failure with reduced ejection fraction. [TA679] 24 February 2021
NICE. Empagliflozin for treating chronic heart failure with reduced ejection fraction. [TA773] 09 March 2022
NICE. Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. [TA902] 21 June 2023
NICE. Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. [TA929] 01 November 2023