This protocol applies to patients with type 2 diabetes mellitus and chronic kidney disease (CKD) who are already on kidney-protective therapy with an SGLT2 inhibitor but have not reached their individualised glycaemic target — and require an evidence-based next pharmacological step.

Previous treatment line — failure condition

The prior step used a sodium-glucose cotransporter-2 (SGLT2) inhibitor with proven kidney benefit — specifically canagliflozin, dapagliflozin, or empagliflozin. The trigger for escalation is failure to achieve HbA1c < 7% on an individualised basis despite this therapy.

Next-step approach

When glycaemic targets are not met on the established kidney-protective regimen, the next pharmacological step involves adding a GLP-1 receptor agonist with demonstrated kidney benefit. The full eligibility criteria, specific agent selection, and all prescribing details are contained in the complete protocol below.

References

DOI: 10.1016/j.nefro.2024.11.002

Patients with T2D and CKD with an eGFR ≥20 ml/min/1.73 m² should be treated with a sodium-glucose cotransporter-2 inhibitor and continue until end-stage kidney disease (dialysis or kidney transplant).
Glucagon-like peptide-1 receptor agonists are recommended as additional pharmacological treatment, as they have proven cardiovascular benefit and, recently, kidney benefit in terms of CKD progression in people with T2D.
Patients with T2D, an eGFR ≥ 25 ml/min/1.73 m², and increased albuminuria (uACR > 100 mg/g) on a stable maximal tolerated dose of RAS inhibitors should be treated with a GLP1RA with proven kidney benefit.

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Diabetic Nephropathy in Type 2 Diabetes and Chronic Kidney Disease: What to Do When SGLT2 Inhibitor Therapy Has Not Achieved Glycaemic Control

References