Christopher Granger, MD: Integration, Value of SGLT2 Inhibitors in Practice


Dr. Granger discusses the current underuse of these agents and the steps cardiologists need to take to increase prescription rates and uptake for patients.

Within the fast moving field of cardiology, evidence has shown the proven benefits of sodium-glucose co-transporter 2 (SGLT2) inhibitors for patients with cardiovascular disease (CVD), as well as those with diabetes and athersclerotic CVD.

In an interview with HCPLive, Christopher Granger, MD, Professor of Medicine, Duke University School of Medicine, discussed his recent presentation on integrating SGLT2 inhibitors in practice at the 30th Beaumont Annual Cardiovascular Conference at Beaver Creek.

Granger pointed to data from the EMPA-REG study on empagliflozin showing substantial benefit in reducing heart failure events, as well as all-cause mortality and other CV outcomes leading SGLT2i’s to become a class 1A recommendation for patients with diabetes and ASCVD.

He additionally noted the DAPA-HF trial in chronic heart failure with low ejection fraction where all CV outcomes were improved and confirmed with empagliflozin.

Then, Granger highlighted the EMPEROR-Preserved, which looked at empagliflozin for patients with chronic heart failure and ejection fraction of ≥45% as one of the most recent and exciting trials.

“In that population, there was also substantial benefit,” Granger said. “This is really the first trial ever, to show important substantial benefits of a drug for patients with half path with heart failure with preserved ejection fraction. So, this has really totally changed the landscape.”

All in all, Granger noted the data showed impressive, improved outcomes, but the agents are substantially underused in the population for whom there’s proven benefit.

“One of those barriers is simply that cardiologists have not yet fully embraced these drugs,” Granger said. “Probably my main point at the Beaver Creek conference with respect to these drugs, is that cardiologists need to take the ball, they need to feel empowered, enabled, and responsible for use of these drugs, because they're not diabetes drugs. They're really cardiovascular drugs, that's their main benefit.”

He also discussed the cost being a barrier, as the drugs are quite expensive. But, just like DOACs, sacubitril valsartan, and PCSK9 inhibitors, Granger noted a need for a mechanism that helps patients get pre-authorized through insurance and finding other opportunities to make drugs affordable for patients.

“To close that gap, we really need to address three sets of barriers, one of those at the level of the clinician, another at the level of the patient, and the third at the level of the system,” Granger said.

He further highlighted COORDINATE-Diabetes, a cluster randomized trials of cardiology clinics in the US working to address the barriers and move the needle on getting agents like SGLT2 inhibitors and GLP-1 receptor agonists used more consistently in practice.

As for the timeline of when more patients might be using the drugs, Granger hoped the rate would substantially increase from around 20% now to 50% over the next couple of years.

“The only way we're going to get there is through a lot of education, through engaging cardiologists, and primary care doctors, those are the doctors and the providers who see these patients and prescribe for them,” he said. “It's not the endocrinologist, so we can't defer this to the diabetes care specialists, we have to take this up ourselves.”

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