A clinical pharmacist-led outreach intervention significantly increased uptake of SGLT2 inhibitors among patients with type 2 diabetes (T2D) and chronic kidney disease (CKD), although it did not improve clinical outcomes.

“While there were no between-group differences in clinical outcomes during the follow-up period, this intervention may represent a strategy to improve uptake of guideline-recommended therapies, such as SGLT2 inhibitors, without adding burden to primary care teams for drug initiation and initial monitoring,” the authors reported in research published in JAMA Network Open.

Addressing a Persistent Prescribing Gap

The benefits of SGLT2 inhibitors in patients with CKD, including slowing progression to kidney failure and improving survival, have been demonstrated in recent large, randomized trials. Current guidelines recommend their use in T2D, CKD, and an estimated glomerular filtration rate (eGFR) of ≥ 20 mL/min/1.73 m².

The drugs represent a “significant paradigm shift in the management of CKD,” the authors noted.

Despite those recommendations, prescribing rates remain low. A 2024 analysis of 28 US health systems found that none had an SGLT2 inhibitor prescribing rate above 25% among patients with a Class 1A recommendation for the therapy.

Investing a Pharmacist-Led Strategy

To evaluate whether pharmacists could help improve the use of and adherence to recommended medications, investigators conducted a quality improvement study involving 8658 eligible patients (mean age, 78.7 years; 96.7% men) at eight Veterans Affairs health systems in the Midwestern US. Participants had T2D and CKD, with an eGFR between 25 and < 60 mL/min/1.73 m².

Patients were assigned to one of two groups. Those in the intervention group (50.8%) received a mailed letter describing the benefits of SGLT2 inhibitors and were scheduled for a 30-minute telephone consultation with a pharmacist. Patients deemed appropriate candidates were prescribed empagliflozin.

Patients in the usual care group (49.2%) did not receive the outreach interventions but remained eligible to receive SGLT2 inhibitors in the course of their normal care.

At 12 months, 864 patients in the intervention group (19.6%) filled an SGLT2 inhibitor prescription compared with 415 patients (9.7%) in the usual care group (hazard ratio, 1.91; P < .001).

However, there were no significant differences between groups in the composite clinical outcome of time to all-cause mortality, kidney failure, heart failure, myocardial infarction, and stroke, nor in any of these outcomes individually (P = .54).

Why Clinical Outcomes Failed to Improve

The authors suggested several reasons why increased medication uptake did not translate into measurable clinical benefit.

“Because only about one quarter of assigned patients received the intervention in this study and patients in the usual care arm continued to have access to a new SGLT2 inhibitor prescription via their usual practitioners, this dilutes the ability to assess clinical impact,” they wrote.

Furthermore, many studies demonstrating clinical benefits with SGLT2 inhibitors followed patients for 2-3 years or longer, considerably longer than the 1-year follow-up in the current study.

Senior author Areef Ishani, MD, of Minneapolis VA Health Care System in Minnesota, told Medscape Medical News that the findings nevertheless offer valuable insights into improving SGLT2 inhibitor uptake.

For instance, “a number of veterans declined starting the medication because they wanted to talk to their primary care provider first,” Ishani said. “Therefore, strategies that integrate or incorporate the primary care team in the outreach could be tested to evaluate if this leads to increased uptake.”

He also suggested that alternative pragmatic interventions could further improve prescribing rates.

“Different types of educational materials sent to patients before outreach may lead to greater uptake in starting the medication,” Ishani said.

In addition, many veterans reported that they were reluctant to add another medication to their regimen, suggesting a potential role for different motivational interviewing techniques or other strategies designed to address treatment hesitancy.

Despite the lack of short-term clinical benefit, the findings shed light on the potential value of pharmacist-led interventions.

“Compared with usual care, patients that received the pharmacist outreach intervention were nearly twice as likely to receive a prescription for an SGLT2 inhibitor and twice as likely to be filling their prescription after 12 months,” the authors wrote.

“Future work should explore strategies to optimize patient engagement and medication adherence and evaluate longer-term clinical and economic outcomes,” they added.

Interdisciplinary Effort May Be Key

Commenting on the study, Charmaine D. Rochester-Eyeguokan, PharmD, of the Department of Practice, Sciences, and Health Outcomes Research and the Center for Innovative Pharmacy Solutions at the University of Maryland School of Pharmacy in Baltimore, agreed that such interventions can help address barriers that prevent patients from receiving beneficial therapies.

“Despite the numerous advantages associated with SGLT2 inhibitors, patients frequently exhibit reluctance to incorporate additional pharmacological agents into their treatment regimen,” Rochester-Eyeguokan told Medscape Medical News.

“This hesitancy often stems from the necessity of consulting with their healthcare providers, as well as concerns regarding the augmentation of their existing medication burden.”

In a 2025 study, Rochester-Eyegoukan and colleagues found that a pharmacist-led intervention improved A1c levels and reduced institutional costs.

“However, we observed only modest and not clinically significant changes in clinical markers, including a reduction in estimated glomerular filtration rate, urine albumin to creatinine ratio, and blood pressure,” Rochester-Eyeguokan noted.

“These markers are also associated with a decrease in adverse outcomes of CKD, heart failure, and myocardial infarction or stroke.”

Notably, adherence to SGLT2 inhibitors or GLP-1 receptor agonists was more favorable among patients who received the intervention.

“This increased adherence can be attributed to the initial communication and referral by their healthcare providers, which fostered a greater likelihood of cooperation and engagement with the program,” she said.

Ultimately, efforts by ambulatory care pharmacists to improve medication uptake should be a part of a broader collaborative approach.

“This should be an interdisciplinary effort with prescribers to eliminate patient hesitancy,” Rochester-Eyeguokan said.

The study was funded by the VA Strategic Initiatives program. Ishani and Rochester-Eyeguokanreported no relevant disclosures.