2025 Southeastern Residency Conference

Submission Type: Resident Poster
Submission Category: Research-In-Progress
Submission Topic: Primary Care
Title: 
Pharmacist-Led Optimization of Sodium-Glucose Cotransporter-2 inhibitors in Veterans with Chronic Kidney Disease and Type 2 Diabetes Mellitus at the Carl Vinson VA Medical Center  
Purpose: 
Sodium-Glucose Cotransporter-2 inhibitors (SGLT2i) have been shown to reduce Chronic Kidney Disease (CKD) progression and cardiovascular events in patients with type 2 diabetes mellitus (T2DM) and comorbid CKD. Use of SGLT2i are recommended by both the American Diabetes Association (ADA) and Kidney Disease – Improving Global Outcomes (KDIGO). At the Carl Vinson VA Medical Center (CVVAMC), it is estimated that only 35% of Veterans with T2DM and CKD are prescribed a SGLT2i. The purpose of this project is to optimize the usage of SGLT2i in Veterans diagnosed with T2DM and CKD via a pharmacist-led medication management model. 
Self Assessment Question:
Which component of the nephron do SGLT2 inhibitors exert their mechanisms of action?
A. Loop of Henle
B. Distal convoluted tubule
C. Proximal tubule
D. Collecting duct
Methods:  
This performance improvement project was approved by the local P&T Committee on 01/24/25. The primary objective will be to increase the percentage of Veterans with T2DM and CKD who are prescribed an SGLT2i. Veterans will be identified via the National Academic Detailing Diabetes dashboard and contacted by a clinical pharmacist practitioner (CPP) to provide education about the benefits of SGLT2i; the CPP will offer and prescribe SGLT2i using shared-decision making.  Veterans will be included using the following criteria:  Diagnosis of T2DM and CKD, Primary Care Assignment at Dublin Main Campus,  Veteran resides in an area considered rural and high poverty, and male sex at birth.  Veterans will be excluded if they have Type 1 Diabetes Mellitus, active prescription for any SGLT2i (empagliflozin, dapagliflozin, canagliflozin), documented allergy or contraindication to a SGLT2i including frequent urinary tract or genital yeast infections, active prescription for foley catheter or diapers, receiving hemodialysis, or EGFR <20 ml/min/1.73m2. Empagliflozin is on the VA National formulary and will be the preferred SGLT2i. If the Veteran agrees to empagliflozin trial, the prescription will be mailed and they will be scheduled with a CPP within 4-6 weeks to monitor change in renal function and symptoms of urinary tract/genital yeast infections. 
Results:
A total of 243 Veterans were reviewed between July 2024 and March 2025. Of the 243, the majority were white (55.5%) with an average age of 74 years old.  Out of the 243 eligible veterans, 82 were eligible to receive treatment. The veterans were excluded for the following reasons: 14 veterans had an eGFR < 20 ml/min, 45 veterans did not have an active diagnosis of CKD, 22 veterans did not have an active diagnosis of Type 2 Diabetes Mellitus, 31 veterans had an anion gap value > 12, 7 veterans had a documented allergy to an SGLT2, 9 had urinary issues, 11 veterans were deceased, and 17 veterans were initiated on an SGLT2i prior to review. Of the 82 veterans eligible for treatment, 20 veterans were initiated on treatment (24.39%). Veterans were not initiated on treatment for the following reasons: primary care providers not agreeable to initiation, unable to reach, hypotension, dual care and following non-va providers, and declining treatment due to shared decision making. Empagliflozin was well tolerated in those in which it was initiated, and no adverse effects have been reported to date.
Conclusion:
This pharmacist-led performance improvement project met its primary objective by increasing the usage of SGLT2i in Veterans diagnosed with T2DM and CKD. Upon completion of the project 38.5% of patient were on SGLT2i which is an increase from the start of the project (35%).  The modest increase in the percentage of patients initiated on empagliflozin is attributed to the relatively low number of patients who met inclusion criteria for the project and the unscheduled nature of initial contact.