The SGLT2 Revolution

Sodium-glucose cotransporter-2 (SGLT2) inhibitors were originally approved as glucose-lowering agents for type 2 diabetes. Then came a series of landmark trials that revealed something extraordinary: these drugs protect the kidneys and heart independently of their glucose-lowering effects.

Key Trials

DAPA-CKD (Dapagliflozin, 2020)

• •Population: CKD patients (eGFR 25–75) with albuminuria, with or without diabetes
• •Result: 39% reduction in composite of sustained ≥50% eGFR decline, ESRD, or renal/CV death
• •First drug to show kidney protection in non-diabetic CKD

EMPA-KIDNEY (Empagliflozin, 2022)

• •Population: CKD patients (eGFR 20–45 or eGFR 45–90 with ACR ≥ 200)
• •Result: 28% reduction in kidney disease progression or CV death
• •Extended benefit down to eGFR 20

EMPEROR-Reduced (Empagliflozin, HFrEF)

• •25% reduction in CV death or HF hospitalisation
• •Benefit regardless of diabetes status

DELIVER (Dapagliflozin, HFpEF/HFmrEF)

• •18% reduction in worsening HF or CV death
• •First pharmacological therapy with positive trial in HFpEF

Current Indications

Practical Prescribing

Starting dose: Dapagliflozin 10 mg OD or Empagliflozin 10 mg OD eGFR monitoring: Check at baseline, 4 weeks (expect 3–5 mL/min/1.73m² dip — this is haemodynamic, not nephrotoxic), then 3–6 monthly Sick day rules: Hold SGLT2i during acute illness, surgery, or prolonged fasting (euglycaemic DKA risk) Genital mycotic infections: Most common side effect — counsel patients, especially women

Key Takeaway

SGLT2 inhibitors are now first-line therapy for CKD with albuminuria (regardless of diabetes) and for both HFrEF and HFpEF. If your patient has CKD + HF, they should almost certainly be on an SGLT2 inhibitor unless contraindicated.