Fig. 5
The clinical inertia crisis: a manifesto. a Our manifesto for change. We have set out needed actions to tackle clinical inertia in T2D in a ‘manifesto’ to change practice, including seven steps that colleagues can adopt to change local prescribing habits, so that more lives are saved and cardiorenal events avoided with appropriate use of SGLT2i and GLP-1 RA. b Rethinking treatment algorithms to separate the management of cardiorenal risk from HbA1c targets. Central to our manifesto is a wider adoption of the new approach taken by ADA, EASD and ESC guidelines [36, 50, 51] to treatment algorithms of antidiabetic agents. Rather than only add on treatments when HbA1c targets are exceeded, updated guidelines recommend that ASCVD, HF and renal risks should be considered independently of HbA1c. For patients with established ASCVD or presenting indicators of high ASCVD risk, the treatment regimen should be adapted by add-on or switch to incorporate a SGLT2i or GLP-1 RA with proven CV benefits. For patients with HF, notably HFrEF with LVEF < 45%, or CKD, an SGLT2i with proven benefit should be incorporated by add-on or switch, so long as not contraindicated e.g. due to renal function lower than indicated in prescribing information. CKD can be defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 and/or urinary albumin–creatinine ratio (UACR) > 30 mg/g (and especially if > 300 mg/g). Among SGLT2i, according to current European Union prescribing information, dapagliflozin, empagliflozin and ertugliflozin should not be initiated below 60 ml/min/1.73 m2 (and stopped if persistently below 45 ml/min/1.73 m2), while canagliflozin should only be used below 45 ml/min/1.73 m2 for patients with UACR ˃ 300 mg/g, and should not be initiated below 30 ml/min/1.73 m2. Prescribing information in the United States has some differences; ertugliflozin is not recommended in patients with an eGFR below 60 ml/min/1.73 m2, while canagliflozin, dapagliflozin and empagliflozin may be initiated below 60 ml/min/1.73 m2, but should be discontinued if persistently below 45 ml/min/1.73 m2 (with the exception of dapagliflozin in patients with HFrEF, with or without T2D, where use is supported for eGFR ≥ 30 ml/min/1.73 m2). If SGLT2i cannot be used, a GLP-1 RA with proven benefit should be considered to improve renal outcomes for patients with CKD