May 28, 2023

Innovations in the treatment of heart failure and chronic kidney disease continue to emerge.
These are diseases in which our blood vessels especially our arteries are damaged and are the leading cause of hospitalization and deaths worldwide.
Diabetes mellitus is a common cause of arterial damage (called microvascular for small blood vessels and macrovascular for bigger vessels) leading to cardiovascular diseases. Heart failure and severe kidney disease lead to decreased individual productivity and loss of income. They drain not only individual finances but also the country’s economy because of health care expenditures.
A new class of drugs was initially introduced in the market for the treatment of diabetes mellitus. Sodium glucose co-transporter inhibitors or SGLT2 inhibitors were first launched to control blood sugar but as new studies showed improvement in heart failure and chronic kidney disease outcomes, the drugs are now recommended for the treatment not only of diabetes mellitus but also of heart failure and kidney disease.
In the normal process of recovering substances from the urine as it passes through, the kidneys recover or reabsorb glucose (simplest form of sugar or carbohydrates) and sodium (salt).
To help in this reabsorption there are so-called transporters or carriers inside small pipelike passageways called tubules in the kidneys. SGLT2 inhibitors block these transporters so that more glucose is removed from the body and blood sugar levels can be controlled.
Because the transporters in the kidneys also carry sodium, blockade of these transporters lead to the excretion or removal of more sodium in the kidneys. We know that glucose and sodium are substances that attract and hold water in our body, so that removal of more glucose and sodium leads to removal of some water (mild diuresis) from the body. It was later shown in studies that SGLT2 inhibitors had beneficial effects among patients with heart failure. Death and hospitalization rates were reduced.
In August, 2021 the United States Food and Drug Administration approved the use of the SGLT2 inhibitor empaglifozin (marketed in the Philippines as Jardiance) for the treatment of heart failure.
It was also noted in studies that the drugs slowed down the progression of kidney disease not only among patients with diabetes mellitus but also kidney disease caused by other diseases like chronic inflammation or glomerulonephritis.
The results of a landmark trial called the Empa-Kidney were released during the yearly conference of the American Society of Nephrology in November, 2022. The study showed that empaglifozin slowed down progression of kidney disease to end-stage kidney failure by as high as 28 percent. The implication of this study is that the drug can delay the need for dialysis or transplantation. A one-month delay in dialysis translates to savings of at least P40,000.
The study also showed that the drug reduced hospitalizations from all causes by 14 percent.
The outcomes are favorable and could affect the approach to the management of patients with kidney disease, either due to diabetes mellitus, obesity, hypertension, or inflammation.

In the 1980’s, drugs called angiotensin converting enzyme (ACE) inhibitors were at first introduced for blood pressure control. Later studies showed benefits beyond just blood pressure control. Another innovation for hypertension were the angiotensin II receptor blockers (AIIRBs). These medicines are now used to treat hypertension, heart failure, and are standard of care in delaying the deterioration of kidney function.
Like ACEIs and AIIRBs, SGLT2 inhibitors will become cornerstones in the management not only of diabetes mellitus but also of heart failure and chronic kidney disease.
The drugs should be taken when prescribed and under supervision by your physician or health care provider because like other medications, they have side effects. Your kidney function and response to treatment has to be monitored and you will be observed for drug interactions. These drugs will work if used in conjunction with basic health measures that include diet, smoking cessation, and use of statins or cholesterol lowering drugs when indicated. In the Philippines, We await FDA approval for the use of SGLT2 inhibitors in the treatment of patients with chronic kidney disease in the Philippines.

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