Date of Award

12-7-2023

Document Type

Dissertation

Degree Name

Doctor of Medical Science (DMSc)

Department

Department of Physician Assistant Medicine

First Advisor

Justin M. Gambini, DMSc, PA-C, DFAAPA

Abstract

Introduction:

Needs Assessment:

Originally used as antidiabetic medications, later clinical trial data showed beneficial effects in reducing the onset and progression of renal complications in people with and without diabetes. 13 Randomized clinical trials and ‘real world’ observational studies involving mostly type 2 diabetes patients showed that SGLT2-i can slow the decline in glomerular filtration rate (GFR), and reduce the onset of microalbuminuria and slow or even reverse the progression of proteinuria.13 Additionally, with diabetes being one of the many chronic conditions still primarily managed by primary care providers (PCP), it falls upon these professionals to have the knowledge and role to initiate this disease-modifying drug. Furthermore, black individuals have a disproportionate cardiovascular and chronic kidney disease (CKD) burden, and the adoption of novel therapeutics has been slower among black patients than among white patients. 4 African Americans (AA) outrank other ethnic groups in the United States in prevalence, early onset, and severity of hypertension4. It is also well known that African ancestry has attenuated response to drugs inhibiting the renin-angiotensin system and to β-adrenergic blockers. 5 Therefore, angiotensin-converting enzyme (ACE) inhibitors should be avoided as an initial therapeutic option in treating hypertension in African Americans. 5 This is problematic because ACE inhibitors have significantly decreased cardiovascular mortality, myocardial infarction (MI), and hospitalizations for heart failure (HF) and its ineffectiveness restricts the treatment option for the African American patient population. 5 There are currently 4 FDA-approved SGLT2-i medications, canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, for adult patients with type 2 diabetes mellitus (DM).1 These novel drugs have been shown to reduce cardiovascular mortality among patients with HF. 4 Yet, these medications are not being utilized in this specific patient population. 12

Objectives:

  • Impact of Early Initiation of SGLT2-i on delaying progression of diabetic kidney disease (DKD)

  • Impact of SGLT2-I on blood pressure.

  • Identify current data on SGLT2-i efficacy regarding the prevention of kidney disease progression, acute kidney injury, and heart failure mortality.

  • Identify the role of SGLT2-i in treating African Americans (AA) with heart failure compared to angiotensin-converting enzyme inhibitors (ACE inhibitors) and Angiotensin II receptor blockers (ARBs) in reducing mortality rates.

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