Semaglutide in type 2 diabetes and chronic kidney disease in Australia: practical clinical considerations from a multidisciplinary panel

Chronic kidney disease (CKD) and cardiovascular disease (CVD) are major causes of morbidity and mortality in people with type 2 diabetes (T2D). Contemporary CKD guidelines increasingly support incorporation of glucagon-like peptide-1 receptor agonists (GLP-1RAs) as an additional pillar of cardiorenal therapy alongside renin-angiotensin-aldosterone system (RAAS) blockade, sodium-glucose co-transporter 2 inhibitors (SGLT2i) and finerenone. Semaglutide is the first GLP-1RA with kidney-outcome data from a dedicated trial in T2D-CKD: the Evaluate Renal Function with Semaglutide Once Weekly (FLOW) study. In FLOW, once-weekly subcutaneous semaglutide 1 mg reduced major kidney disease events by 24%, major adverse cardiovascular events by 18% and all-cause mortality by 20% versus placebo on a background of guideline-directed therapy. Here a multidisciplinary expert panel summarises Australian Therapeutic Goods Administration indications and Pharmaceutical Benefits Scheme restrictions, highlights common access barriers and outlines approaches to shared care between primary and tertiary services for use of GLP-1RAs. Guidance is also provided on treatment sequencing of GLP-1RA alongside RAAS blockade, SGLT2i and finerenone. Evidence from key GLP-1RA trials, in addition to FLOW, is reviewed and translated into practical, implementable prescribing strategies for Australian clinicians. The panel also identified priority patient groups for GLP-1RA therapy, including those with residual albuminuria, heart failure with preserved ejection fraction, established CVD, obesity and Aboriginal and Torres Strait Islander peoples at high cardiorenal risk. Remaining evidence gaps, particularly for non-diabetic CKD, advanced CKD, dialysis and transplant populations and equity of access, are identified as priorities for future research and policy.