To the Editor:
Singapore has the second-highest per capita prevalence of chronic kidney disease (CKD) in the world (11.4%).1 Sodium/glucose cotransporter 2 inhibitors (SGLT2is) have shown significant efficacy at delaying CKD progression and reducing cardiovascular mortality in patients.2 Despite being available to primary care in 2017, recommended by local guidelines since 2022, and further subsidized starting in 2023, SGLT2i prescription rates in Singapore still indicate underprescription.3 Although a study identified factors affecting SGLT2i underprescription in CKD patients,4 its global extent remains unknown.
Given the aging population and increasing CKD prevalence, initiating SGLT2is is vital for effective management and reducing systems burden. Primary care physicians’ perspectives on SGLT2i prescription can inform practical strategies to slow CKD progression, given their role in patient-centered care, early diagnosis, management, and care coordination.5 Therefore, this study aimed to investigate factors influencing SGLT2i prescription among primary care physicians, identify concerns, and determine what interventions would be welcomed to optimize CKD management.
We developed a 38-item online questionnaire (Item S1) informed by the study by Ng et al4 adopting the Theoretical Domains Framework, which underwent content and face validation by domain experts and primary care physicians (Item S2). From April to August 2024, the anonymous survey was administered nationwide via a secure digital platform. The National University of Singapore Institutional Review Board (NUS-IRB-2024-268) approved the study as minimal risk research. See Item S2 for detailed methods.
Results
Two hundred primary care physicians responded, with 49.5% from the private sector, with a median 13 years’ experience, 62% practicing full-time, and 69% accredited as family physicians (Table S1). Of them, 31% were unaware of the association between persistent albuminuria and CKD, while 46.5% did not know that SGLT2is can be initiated without first maximizing angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment. Despite this, 47.5% believed that they did not need further evidence of the benefits of SGLT2is. Of the respondents, 46.5% thought an SGLT2i was not necessary if albuminuria was controlled by angiotensin-converting enzyme inhibitors/angiotensin receptor blockers alone, and 34.5% still had safety concerns (Fig 1). While most (81.5%) were more likely to use SGLT2is when benefits were clear, they were cautious when starting SGLT2is for advanced CKD (36%) and elderly patients (54.5%), for which public physicians showed more caution than private practitioners (P = 0.02). Public physicians face more operational challenges, such as time constraints and competing priorities (P = 0.01). Conversely, private physicians are more likely to be deterred by costs (P < 0.001). Overall, 79% of physicians felt that the long-term benefits of SGLT2is justified the costs (Table S2).
Figure 1.
Barriers in SGLT2i prescribing identified by primary care physicians. Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CKD, chronic kidney disease; DKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemic state; SGLT2i, sodium/glucose cotransporter 2 inhibitor; UTI, urinary tract infection.
The interventions most welcomed were clearer guidelines, price reduction, and continuing medical education (Fig 2). Private physicians were more likely to value continuing medical education (P = 0.03), in-clinic visual prompts (P = 0.04), and audit and feedback dashboards (P = 0.02) (Table S3).
Figure 2.
Interventions welcomed by primary care physicians.
Discussion
Our study generally aligned with existing literature on physician perspectives toward SGLT2is. Our results confirmed primary care physicians’ role and comfort in SGLT2i initiation and acknowledged its benefits.6 Patient complexity and high costs were common barriers to initiation, echoing previous research.7
Primary care physicians demonstrated adequate knowledge of SGLT2is, but struggled to apply it in specific clinical scenarios, such as diagnosing CKD and maximizing angiotensin-converting enzyme inhibitor/angiotensin receptor blocker doses before SGLT2i initiation. Notably, many physicians lacked awareness that persistent albuminuria is CKD, highlighting a concerning gap between perceived and actual knowledge. Delayed or inaccurate CKD diagnosis can hinder timely initiation of guideline-recommended therapies, and coupled with patient-related obstacles, this exacerbates SGLT2i prescribing inertia, highlighting the need for targeted interventions. Informatics tools, such as computerized decision supports and automated best practice alerts, could enhance SGLT2i prescribing.8 Continued patient activation, engagement, and individualized care is key. As evidence grows, SGLT2is will become integral to chronic disease management, emphasizing their vital role in cardiovascular care.
Physicians exhibited caution when prescribing SGLT2is for elderly and advanced CKD patients. In the elderly, concerns included polypharmacy-related drug interactions, limited studies conducted in the elderly, and complex comorbid conditions, which can lead to diminishing benefits and increased mortality.9 For advanced CKD patients, caution may be driven by increased risk of adverse effects, including hypotension, electrolyte disturbances, and worsening kidney function. Targeted education to enhance physicians’ confidence in managing these scenarios is needed.
Our study contributed uniquely by comparing knowledge, attitudes, and practices between private and public physicians, revealing system barriers that differentiated these groups. Private practitioners face higher drug costs due to smaller economies of scale, passing costs to patients and increasing inertia. Public physicians juggle with time and resource constraints, managing socioeconomically disadvantaged patients with multimorbidity. Emerging solutions such as generics, innovative care delivery, and physician enablers can help overcome these barriers.10
This study’s strengths are its diverse sample of primary care physicians, representing private and public sectors. Limitations include convenience sampling, reliance on physician-reported data, and potential social desirability bias, impacting generalizability and accuracy.
In conclusion, physician knowledge gaps, patient, and system barriers limit SGLT2i use in primary care despite high access, governmental support, and experience. Customized solutions for public and private practitioners are crucial to enhance utilization and improve CKD outcomes.
Article Information
Authors’ Contributions
Conceptualization and methodology: SWCK, HSJC, CLYN; data acquisition and validation: SWCK, MYL, CKL; data curation, formal analysis, visualization: JL; writing (original draft): SWCK, MYL, CLYN; writing (review and editing): CKL, JL, HSJC; supervision and mentorship: HSJC, CLYN. Each author contributed important intellectual content during article drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
None.
Financial Disclosure
All the authors declare that they have no relevant financial interests.
Acknowledgements
Dr V. Vien Lee (SingHealth Centre for Population Health Research and Implementation, Singapore) for her inputs to our survey questionnaire.
Data Sharing Statement
The data supporting this study’s findings are not publicly available due to privacy concerns related to research participants. However, they can be obtained from the corresponding author (SWCK) on reasonable request, subject to appropriate safeguards and agreement.
Peer Review
Received November 11, 2024. Evaluated by 1 external peer reviewer, with direct editorial input from an Associate Editor and the Editor-in-Chief. Accepted in revised form March 10, 2025.
Footnotes
Item S1: Detailed methods.
Item S2: Questionnaire.
Table S1: Summary of Physicians’ Demographics.
Table S2: Summary of Physicians’ Questions, and Responses.
Table S3: Summary of Top Interventions Welcomed by Physicians.
Table S4: Summary of Physicians’ Suggestions Related to Effective Interventions to Increase Prescription of SGLT2 Inhibitors for Patients with CKD in Primary Care.
Supplementary Materials
Item S1, S2; Table S1-S4.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Item S1, S2; Table S1-S4.