SGLT2 Inhibitors: Guidance and Implementation Challenges in the EHR

By Sandeep Das, M.D., M.P.H.

Professor of Internal Medicine

In patients with a broad array of cardiometabolic disease, including heart failure (HF), diabetes, and kidney disease, sodium glucose cotransporter-2 (SGLT2) inhibitors improve clinical outcomes. Proven benefits include improved quality of life and reductions in mortality, hospitalizations, heart attacks, strokes, and kidney disease progression. However, despite these benefits, SGLT2 inhibitors are underused in clinical practice.

Barriers to SGLT2 inhibitor use

As noted in my presentation at #AHA24, patients are often reluctant to take additional medications due to concerns over side effects and cost. Some clinicians may be unfamiliar with these agents and less likely to prescribe them. Patients might not be started on SGLT2 inhibitors because they are “clinically stable,” with residual risk underestimated by their clinicians. Time constraints may make it easier for clinicians to not prescribe a new medication. Access to primary care or specialists is also a barrier. As multiple providers become involved, fragmentation of care can lead to diffusion of responsibility, with each provider believing that someone else will act.

Leveraging the EHR

The landmark EPIC-HF trial leveraged principles of direct-to-consumer advertising and shared decision-making to engage patients. While patients reported a better understanding of their disease and increased satisfaction, there was only a modest increase in new prescriptions, which was not statistically significant. The REVEAL-HF trial tested educating providers but showed no increase in medication use. The PROMPT-HF trial randomized providers to receive individualized medication recommendations and demonstrated a modest, nonsignificant increase in SGLT2 inhibitor prescriptions. The related PROMPT-AHF trial of hospitalized patients again failed to demonstrate an increase in SGLT2 inhibitor prescriptions. In the IMPLEMENT-HF trial, a virtual care physician-pharmacist team resulted in a modest increase in SGLT2 inhibitor use that was not statistically significant. A second trial also found a modest increase in the prescription of HF medications with virtual care consultations.

Current state and future directions

Thus, we have no evidence that direct patient or clinician education increases the use of SGLT2 inhibitors. There might be a modest benefit from electronic alerts, and multidisciplinary interventions appear the most promising. These could be augmented by leveraging non-physician providers and virtual care to control costs and using predictive analytics to target interventions to high-risk patients. Although the results to date have been less than hoped for, the combination of alerts and multidisciplinary teams appears to be the most promising path forward.