Lucia Novak, MSN, NP: Canagliflozin for Renal, Cardiovascular Outcomes

September 30, 2019
This morning, the US Food and Drug Administration (FDA) expanded the approval of SGLT-2 inhibitor canagliflozin (INVOKANA) to include end-stage kidney disease and cardiovascular event risk reduction in patients with type 2 diabetes.

Canagliflozin, which is now the first drug approved for diabetic kidney disease in almost 20 years, may actually be the first of a multitude of competitors in its drug class to reach this patient population, as clinical findings from large-scale trials including the pivotal CREDENCE study show its cardiovascular and renal benefits.

In an interview with MD Magazine®, Lucia Novak, MSN, NP, a specialist in the fields of Advanced Diabetes Management and Adult Health, detailed what the new canagliflozin indication means for patients and physicians, how it may influence renal screening, and what to expect with SGLT2 inhibitors.



MD Mag: What does canagliflozin’s new indication for renal and cardiovascular outcomes in patients with type 2 diabetes mean?

Novak: What this means is it's a total game-changer for the management of diabetes. It's a game changer for the outcomes of our patients with diabetes. 

They usually have hypertension, dyslipidemia, chronic kidney disease, it all goes hand-in-hand with diabetes and the reason why these patients die, which is cardiovascular disease. So to have this indication, to have this class of drugs, it's just a great time to have diabetes, honestly, if you're going to have it.

MD Mag: Will the introduction of SGLT2 inhibitors to this patient population increase physician testing for renal risk in T2D?

Novak: I would hope that that would be the case. We definitely do need to do a better job with monitoring these patients. It's not enough just to look at the estimated glomerular filtration rate in our patients. We have to be looking for the presence or absence of albuminuria. It's actually the presence of albumin area regardless of where their GFR is—if they've got protein showing up in their urine, they are really at an increased risk for developing kidney disease, as well as cardiovascular disease. 

So I would hope that having new tools in our chest can only help providers look a little deeper and do those assessments on patients.

MD Mag: What is the benefit of SGLT2 inhibitors in this patient population?

Novak: The SGLT2 inhibitors, what we've seen across the class is this benefit to the kidneys, the reduction of albuminuria. Of course, they help with weight loss in our patients with diabetes. 

The great news is that for the glucose management of these patients using an SGLT2 inhibitors, they're effective with an EGFR of 45 or higher. However, what we're seeing with CREDENCE data and what we're starting to see in some of the other studies that we've done with SGLT2 inhibitors, is that despite not having glucose management effective when their EGFR is lower than 45, they are still achieving or receiving the benefit as far as kidney protection, cardiovascular.

So what's happening with the SGLT2 inhibitor class is just really remarkable. It's groundbreaking. It's changing the lives of our patients and it's changing how we as providers can help manage those patients.

MD Mag: What are the risk factors that need to be considered with this drug class?

Novak: We always have to worry about volume depletion when using a medication that uses a mechanism of action that includes volume depletion in some way. So, making sure that those patients stay well-hydrated. 

There's also an increased risk for mycotic infections in patients who use these agents again, because of the glucose urea. So, making sure that they stay hydrated, good hygiene practices and then any concerns that they may have, they should address with their providers right away. 

But by and large, these are a pretty good class of drugs—relatively well-tolerated. And there's some differences in between each drug that's in the class, but overall, what we're seeing as far as renal protection and cardiovascular protection is really remarkable.
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