2025 Southeastern Residency Conference

Title: Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitor Prescribing in Black/African American Veterans with Chronic Kidney Disease (CKD) and Type 2 Diabetes Mellitus (T2DM) Living in a Rural Area   

Authors: Madison Barrier, Camille Robinette, Meghan Mark, Allison Strain  

Objective: Evaluate and initiate SGLT-2 inhibitors in Black/African American Veterans with T2DM and CKD 

Self-Assessment Question: 
Which patient should be initiated on an SGLT-2 inhibitor?
A: 50 year old with T1DM and CKD, eGFR 45
B: 70 year old with T2DM and CKD, eGFR 15
C: 67 year old with T2DM and CKD, eGFR 35
D: 59 year old with T2DM and CKD, on dialysis

Background: SGLT-2 inhibitors reduce intraglomerular pressure and improve tubuloglomerular feedback resulting in delayed CKD progression in Veterans with and without T2DM.  Approximately 1 in 3 adults with T2DM also have CKD with higher rates of Black/African American individuals experiencing CKD. Based on the 2022 Kidney Disease Improving Global Outcomes (KDIGO) guidelines, an SGLT-2 inhibitor is recommended for Veterans with CKD, T2DM, and eGFR greater than or equal to 20 mL/min/1.73m2. 
Many Veterans at the Salisbury Veterans Affairs Health Care System (SVAHCS) are impacted by both T2DM and CKD. Approximately 20% of Veterans served by the SVAHCS live in rural areas and may have challenges accessing care. Offering telephone visits and mailing educational materials to rural Veterans may improve access to preventative healthcare without the need for traveling to a physical location.  

Methods: This quality improvement project will be conducted by enrolling Veterans via chart review to conduct telephone visits for SGLT-2 inhibitor education, prescribing, and follow-up. Veterans will be identified using the VA Academic Detailing Diabetes Patient Report with parameters for rurality, race, disease states (T2DM and CKD), and exclusion criteria. Veterans identified will be reviewed and assessed for inclusion in the project. Veterans will be contacted for an introduction to the population health clinic, project intention, and scheduling an initial visit with a pharmacist. The initial population health clinic visit will be conducted via telephone by a pharmacist to provide patient education and initiation of an SGLT-2 inhibitor, empagliflozin, in accordance with VA national formulary. A telephone follow-up scheduled for approximately one month after SGLT-2 inhibitor initiation will be used to assess tolerability and medication adherence. Further follow-up and management will be transitioned back to the Veterans’ established primary care teams.  

Results: A total of 45 Veterans were contacted based on the initial chart review, 20 agreed to appointments with a pharmacist to discuss the use of SGLT-2 inhibitors for CKD and T2DM and were subsequently included in the quality improvement project. The majority of patients were male 19 (95%) with an average eGFR of 51.85 mL/min/1.73m2 and A1c of 6.9%. During the initial visit with a pharmacist, 11 (55%) Veterans agreed to starting an SGLT-2 inhibitor. During all scheduled appointments, Veterans were provided verbal medication counseling, offered a pill box and/or testing supplies to assist with T2DM care if needed, and educational material was mailed after the conclusion of the visit for further review. Of the 11 patients who initiated an SGLT-2 inhibitor, 10 reported medication adherence (missing 2 or fewer days per week). At the time of follow-up, one Veteran reported an adverse effect (urinary tract infection) that resolved at subsequent follow-up.  Follow-up renal function testing was performed between weeks 3 and 10 from medication initiation. Average eGFR decreased by 2.1 mL/min/1.73m2 as expected based on documented literature.  

Conclusion: Based on the results of this quality improvement project, many Veterans are willing to initiate an SGLT-2 inhibitor for CKD and T2DM management. The most common reason for declining initiation was patient preference, followed by patients wanting to discuss with their primary care provider.  Due to the small sample size and limited project duration, no direct therapeutic effect was measured in the results of this project.