ASHP Midyear: Pharmacists Play Key Role in Managing Chronic Kidney Disease With Emerging Therapies

Chronic kidney disease (CKD) is a growing public health concern with significant clinical and economic impacts. Denise Kelley, PharmD, BCPS, FASHP, clinical assistant professor at the University of Texas at Austin College of Pharmacy and clinical pharmacy specialist of internal medicine at the Dell Seton Medical Center, emphasizes the wide-ranging consequences of CKD beyond just fluid and toxin regulation, including anemia, mineral bone disorders, metabolic acidosis, and cardiovascular complications. Uncontrolled diabetes and hypertension are major drivers of CKD, and pharmacists can play a vital role in helping patients manage these conditions to prevent or delay CKD progression. Until recently, options for slowing CKD were limited, but a surge of new therapies like SGLT2 inhibitors, finerenone, and emerging data on GLP-1 agonists have created an exciting time with more opportunities to intervene. Pharmacists must stay up-to-date on guidelines and emerging evidence to effectively educate providers and patients on leveraging these novel treatments, particularly for diabetes patients with CKD where SGLT2 inhibitors are now recommended.

Pharmacy Times: What are some of the health outcomes associated with CKD, and how can this affect a patient’s quality of life?

Denise Kelley: So the incidence of [chronic kidney disease (CKD)] continues to rise and contributes to a major public health burden and economic impacts on our country and worldwide, and so while many people think of the kidneys as associated with volume regulation and clearance of toxins, we know there's really so much more than that. So, of course, patients with CKD can develop anemia, which can directly impact quality of life for patients, can also impact mineral bone disorders, leading to conditions like osteopenia, and then additionally, there's consequences with metabolic acidosis. Also beyond that, we're learning more and more about the cardiovascular consequences that we're seeing and having a correlation between CKD and cardiovascular outcomes, and so really, a lot more is impacted with CKD than what maybe most people would initially think.

Pharmacy Times: How can pharmacists help patients manage key modifiable and non-modifiable factors of CKD progression?

Kelley: Most of the time, when patients develop CKD, some of the driving causes are uncontrolled diabetes and uncontrolled hypertension, and I think pharmacists play a large role in managing those conditions, and can have an impact in helping educate patients that these conditions, if uncontrolled, have a higher chance of leading to the patient developing CKD. I think most patients would feel that they, you know, don't want to become dialysis dependent in the future, and so if they can correlate that gaining good control of these conditions like diabetes and hypertension might prevent them from getting to that point, and there might be some added motivation and incentive from their part, and I think pharmacists can help with that.

Pharmacy Times: What are the primary classes of medications used to slow CKD progression?

Kelley: So until recently, the only answer to that would have basically been [angiotensin-converting enzyme (ACE)] inhibitors or ARBs—angiotensin receptor blockers—and so for the last few decades, that's really all we had and our options to help slow CKD progression. However, in the last few years, we've seen a surge of options that exist, making this an exciting time for opportunities to slow CKD progression. The first drug class that kind of shed light for this were the SGLT2 inhibitors, specifically the ones that have been FDA-approved are canagliflozin, approved for diabetic kidney disease, and empagliflozin and dipagliflozin, approved for chronic kidney disease in general. Beyond those, there's a new drug class, somewhat new, the finerenone, which is a non-steroidal mineralocorticoid receptor antagonist, so similar to spironolactone, and eplerenone, but slightly different being a non-steroidal and then, while the next one I'm about to mention hasn't formally been FDA approved for slowing CKD progression, the drug, semaglutide, one of our [glucagon-like peptide (GLP)-1] receptor agonists has had some emerging data that suggests it might have a benefit in this space as well.

Pharmacy Times: What are the specific considerations for managing diabetes in patients with CKD?

Kelley: Basically, any person with diabetes and CKD should really be started on an SGLT2 inhibitor, according to the American Diabetes Association, as long as their EGFR is greater than 20. Particularly, we're seeing greater benefit in those patients with significant albuminuria. So otherwise, having that on board as kind of a pillar of diabetes management in patients with CKD, I think, is important. Beyond that it is important to keep in mind that patients with CKD might have impaired clearance and impaired reactions to some of the other therapies we use for diabetes. So always being mindful of which drug therapies might need to be adjusted or dose reduced in someone with CKD. The other drugs I had mentioned previously that have a role or that we're starting to discuss for slowing CKD progression could be used or are finerenone, for example, has been approved for diabetic kidney disease. However, it's not going to have an impact on glycemic control, per se, it's something that could be added to someone's regimen specifically to try to delay CKD progression. Semaglutide could always be used for someone with diabetes, whether they have CKD or not. It's just we are now starting to see some emerging data that would suggest it might also be having benefit at slowing CKD progression.

Pharmacy Times: How can pharmacists help optimize glycemic control and reduce the risk of diabetic kidney disease?

Kelley: I'm staying up to date on just all that's changing in this field, knowingwhat the guidelines are recommending, what drug therapies should be included, and again, educating providers and educating patients that glycemic control is imperative to try to slow CKD progression, but also some of the drug therapies we're using may not directly affect glycemic control, right? But we know they're needed, or could be valuable at still slowing CKD progression in patients with diabetes.

Pharmacy Times: Is there anything else you would like to add?

Kelley: I think just that this is an exciting time to have new options available to us, and encourage pharmacists to kind of stay up to date as these are continuously having emerging data out there on what options might be useful and where these new therapies might have a place in managing patients across the spectrum, both, diabetes, patients without diabetes, who have CKD, and really trying to serve as those experts to educate other providers and patients on on how to best leverage some of these new options.