Identifying Barriers to SGLT2 Inhibitor Use in Patients with CKD: A Qualitative Analysis

Background: Despite clearly stated guidelines by KDIGO recommending Sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in CKD, prescription of SGLT2is among providers remains suboptimal. In this study, we aimed to understand the utilization patterns of SGLT2is and to identify barriers hindering their broader implementation. Methods: We conducted semi-structured interviews with providers from January to April 2024 in a large academic center in New Haven, CT. Participants were asked open-ended questions about their experiences with prescribing SGLT2is, what factors facilitated or limited their use, and ideas on future directions to promote SGLT2i utilization. Each interview was recorded and transcribed. We used a hybrid approach of deductive and inductive content analysis using NVIVO analytic software. Results: A total of 8 providers participated in the semi-structured interviews. Providers included cardiologists, nephrologists and internal medicine physicians and nurse practioners. The median age of providers was 33 (range: 29-63) years. The cohort consisted of 50% women, with 15% identifying as Black and 29% as Hispanics. Provider comfort level and preference to defer to a specialist were mentioned most frequently as barriers to prescription. Other barriers included side effects, medication costs, and polypharmacy. Most providers believed that SGLT2is were well-tolerated and had significant benefits in slowing CKD progression, but most reported that KDIGO guidelines were not promoted in their workplace. The most common solutions provided by participants to overcome barriers to using SGLT2is were education for providers and patients, EPIC pathways to guide provider decision, and cost assistance for patients. Conclusion: While most providers agreed that SGLT2is are essential in the treatment of CKD, there exists a need and opportunity to improve education and comfort around their use among providers and patients.