Choosing the Right Diabetic kidney disease Treatment for Type 2 Diabetes with SGLT2 Inhibitors or GLP-1s
New insights on how to individualize care for diabetic kidney disease using updated ADA guidance and trial evidence
Topline
SGLT2 inhibitors and GLP-1 receptor agonists are now both proven to reduce the progression of chronic kidney disease (CKD) in type 2 diabetes, with the FLOW trial confirming kidney benefits for semaglutide. Choosing between the two depends on individual risk factors, comorbidities, and patient goals.
Study Details
Chronic kidney disease affects up to 40% of patients with type 2 diabetes and often progresses silently until late stages. The updated ADA guidelines and recent trials like CREDENCE, DAPA-CKD, EMPA-KIDNEY, and FLOW offer robust evidence for disease-modifying therapy in this population.
Methodology
The FLOW trial (2024) enrolled patients with type 2 diabetes, eGFR 20–75, and UACR 100–5000. Over 3.4 years, semaglutide was tested against placebo in patients already receiving optimized ACE/ARB therapy. The trial was stopped early due to demonstrated benefit.
Earlier landmark trials like CREDENCE (canagliflozin), DAPA-CKD (dapagliflozin), and EMPA-KIDNEY (empagliflozin) used similar placebo-controlled designs to evaluate SGLT2 inhibitors, with inclusion criteria based on eGFR and albuminuria thresholds.
Key Findings
Semaglutide (FLOW trial): 24% risk reduction in CKD progression or death from kidney/cardiovascular causes.
SGLT2 inhibitors (CREDENCE, DAPA-CKD, EMPA-KIDNEY): 30%-40% reduction in risk of kidney failure and cardiovascular events.
FDA Indications: Semaglutide (CKD in type 2 diabetes); dapagliflozin and empagliflozin (with or without diabetes).
CKD detection gap: UACR testing remains underutilized, leading to underdiagnosis despite normal eGFR.
Implications for Practice
For Patients:
Early identification of kidney disease, even with a normal eGFR but elevated albumin is crucial. Lifestyle changes, blood pressure control, and kidney-protective medications can delay or prevent disease progression.
For Providers:
Assess both eGFR and UACR yearly.
Use KDIGO heat maps for risk stratification.
Optimize ACE/ARB before initiating SGLT2i or GLP-1 therapy.
Select agent based on comorbidities: GLP-1s for weight loss or high A1c; SGLT2i for early kidney and heart protection.
Consider combination therapy for additive benefits.