Modern Management of CKM Syndrome: Use of GLP-1 Receptor Agonists in a Multidisciplinary Setting—Expert Group Recommendations from Kuwait

Abstract

Obesity, type 2 diabetes (T2D), cardiovascular disease (CVD), and chronic kidney disease (CKD) are overlapping conditions that drive premature morbidity and mortality worldwide. Care remains siloed and reactive despite shared risk factors and strong evidence for early intervention. To support integrated disease management, the American Heart Association (AHA) recently introduced the concept of cardiovascular–kidney–metabolic (CKM) syndrome, recognizing the bidirectional links between metabolic, kidney, and cardiovascular health. Kuwait faces one of the highest burdens of CKM-related diseases globally. Three-quarters of adults are overweight or have obesity, and 28% have diabetes, both of which are leading causes of mortality and health system strain. Yet multidisciplinary care remains limited, and innovative pharmacotherapies, including glucagon-like peptide-1 receptor agonists (GLP-1 RAs), are underused. A panel of Kuwaiti endocrinologists, cardiologists, and nephrologists convened to assess barriers to optimal CKM care and define practical recommendations. Discussions focused on current gaps in screening, care coordination, provider education, and access to therapies. Evidence on GLP-1 RAs was reviewed, considering the demonstrated benefits for weight loss, glycemic control, cardiovascular outcomes, and CKD progression. The expert group agreed that multidisciplinary, risk-stratified, and patient-centered approaches are urgently needed. Recommendations include earlier screening and diagnosis, improved integration across specialties, healthcare provider upskilling, public awareness campaigns, and broader access to GLP-1 RAs. Semaglutide was highlighted as a clinically valuable option owing to its broad efficacy and safety profile. Adopting a CKM care model tailored to Kuwait’s specific challenges, with appropriate use of GLP-1 RAs, can reduce disease burden, improve outcomes, and increase healthcare system efficiency. The local implementation of evidence-based, cross-specialty strategies is key to altering the trajectory of CKM syndrome in high-risk populations.

Key Summary Points

Cardiovascular–kidney–metabolic (CKM) syndrome has emerged as a concept to capture the close bidirectional relationship of obesity, type 2 diabetes, cardiovascular disease, and chronic kidney disease.

Despite their close links, care for these diseases is usually separate and reactive, missing opportunities for early intervention.

In Kuwait, there is a high burden of CKM-related diseases, which are a major cause of mortality and put strain on the healthcare system; yet coordinated, multidisciplinary care remains limited, and effective treatments, such as GLP-1 RAs, are underused.

A panel of endocrinologists, cardiologists, and nephrologists met to discuss the organization of care for CKM syndrome in Kuwait.

The experts recommend earlier screening and intervention, better integration across specialties, healthcare provider upskilling and training, public awareness campaigns, and broader access to GLP-1 RAs with proven benefits and safety, such as semaglutide.

Introduction

Cardiovascular–kidney–metabolic (CKM) syndrome encompasses a group of interrelated conditions, including obesity, type 2 diabetes (T2D), cardiovascular disease (CVD), and chronic kidney disease (CKD), significantly contributing to premature morbidity and mortality worldwide [1, 2]. Despite shared risk factors and pathophysiology, the management of these conditions remains fragmented and reactive, leading to delayed diagnoses and inadequate care [3–5]. In response, the American Heart Association (AHA) has introduced the concept of CKM syndrome to highlight the interconnections between metabolic, kidney, and cardiovascular health, facilitating integrated disease management [6, 7].

The AHA’s multistage model for CKM syndrome addresses both individuals at risk for CVD and those already affected [7]. This model is supported by similar guidance from other organizations, including the European Society of Cardiology (ESC) [8, 9], the American Diabetes Association (ADA), and the Kidney Disease: Improving Global Outcomes (KDIGO) global nonprofit organization, which developed a consensus report on managing diabetes in patients with CKD [10]. In the Gulf Region, experts from the  United Arab Emirates, Saudi Arabia, and Kuwait have convened to address concerns about CKM syndrome’s rising prevalence in younger populations [11].

The AHA’s framework treats CKM syndrome as a continuum, allowing for earlier and more targeted interventions as patients progress from metabolic risk to T2D and further complications such as CKD and CVD [6]. Modern glucose-lowering therapies, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs), align well with this approach owing to their benefits in glycemic control, weight loss, and reduced cardiovascular and kidney risks [12–15]. However, despite substantial evidence supporting their use, GLP-1 RAs are not consistently adopted in clinical practice [16]. For example, the multinational CAPTURE study revealed low utilization of GLP-1 RAs among adults with T2D, even those with existing CVD [17].

Kuwait faces a severe burden of CKM-related diseases, exacerbated by increasing obesity and diabetes rates that heavily impact the healthcare system [18–20]. Multidisciplinary care models are limited, and effective treatments such as GLP-1 RAs remain underutilized owing to barriers, including clinician unfamiliarity and inconsistent prescription practices, and systemic issues, such as fragmented care pathways and insufficient preventive strategies [16]. Consequently, many clinicians express a need for more precise guidance on the use of these agents and broader CKM management strategies.

This consensus paper aims to bridge this gap by offering evidence-based recommendations from a multidisciplinary panel of experts, focusing on a unified strategy to enhance CKM care in Kuwait. Emphasizing the importance of holistic management, earlier intervention, and appropriate use of GLP-1 RAs, this paper seeks to provide guidance on how to better respond to Kuwait’s unique healthcare challenges effectively.

Methods

In November 2024, a panel of experts from Kuwait, together with the President of the Central European Diabetes Association (CEDA), met to discuss the evolving landscape of CKM syndrome management. The panel included experts in cardiology, nephrology, and endocrinology. Novo Nordisk organized and funded the meeting.

Through structured discussion, the panel examined the unmet needs in the management of cardio-kidney and metabolic diseases within Kuwait. The discussion included how the concept of CKM health is perceived and accepted within the healthcare community, as well as the understanding of the link between CKM conditions such as obesity, CVD, T2D, and CKD. The experts further explored recommendations in current international treatment guidelines for people with T2D and at high risk for CVD and CKD, perceptions of CKM health as a concept recently motivated by the AHA Presidential Advisory [7], and the influence of existing barriers to early initiation and their impact on therapeutic management, together with optimal care, including integrated and multidisciplinary approaches.

Insights from the Kuwait Endocrinology, Cardiology, and Nephrology Expert Group panelists were synthesized and captured in a meeting report. One of the authors (M.R.) prepared the first version of the present document with the support of medical writers from the Last Mile agency. The document was subsequently extensively reviewed by all the co-authors and further validated in a follow-up meeting with the panel.

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Disease Burden In Kuwait

CKD, CVD, T2D, and obesity form an interconnected group of noncommunicable diseases (NCDs) known as CKM syndrome. Together, these diseases present a significant global health challenge, contributing to 75% of NCD-related deaths worldwide [21] and imposing heavy economic burdens [22]. In Kuwait, NCDs account for 65% of deaths and nearly 4% of GDP, with CVD responsible for a significant portion of healthcare spending [18]. The widespread prevalence of overweight and obesity and T2D in Kuwait, estimated to affect almost three-quarters and 28% of adults, respectively, exacerbates the healthcare challenges associated with CKM syndrome [19, 20]. Many individuals go undiagnosed until serious complications emerge, such as kidney damage or cardiovascular events [20, 23]. Even when diagnosed, disease management is frequently suboptimal owing to persistent hyperglycemia, poor adherence to treatment, and low patient awareness [24–26].

Obesity plays a central and compounding role. A high proportion of individuals living with diabetes in Kuwait also have obesity [26], which independently increases the risk of developing CKD and CVD [9]. High body mass index (BMI) is now a leading cause of death and disability globally [27], with childhood obesity contributing to a growing pipeline of future disease. Half of Kuwaiti schoolchildren are overweight or have obesity, and most carry that weight into adulthood [19, 28]. The long-term economic implications are stark: obesity-related healthcare costs in Kuwait are projected to increase more than 14-fold by 2060, from 2.29 billion US dollars in 2019 to 33.33 billion [29]. Early intervention in weight management can substantially improve insulin sensitivity and metabolic outcomes, particularly in high-risk populations, such as those in Kuwait [30, 31].

CKD further augments the burden. It not only worsens outcomes for people with diabetes and CVD but also significantly increases the risk of cardiovascular events and death from any cause [32, 33]. In Kuwait, more than half of moderate-to-severe CKD (stages 3–5) cases are attributable to diabetes [34]. Dialysis needs are rising steadily, with more than 2200 patients receiving treatment in 2019 alone [35], and renal replacement therapy (RRT) is placing a substantial strain on healthcare resources [36]. Despite the impact of CKD, there appears to be a shortfall in the number of people receiving regular nephrology follow-up, suggesting underdiagnosis or underutilization of available specialist care [34].

In Kuwait, the use of glucose-lowering therapies (GLP-1 RAs and sodium-glucose cotransporter-2 inhibitors [SGLT2is]) remains modest among people with T2D and established atherosclerotic cardiovascular disease (eASCVD) according to the PACT-MEA study [37]. Although SGLT2is are used more often than GLP-1 RAs—41.7% versus 25.0% among people with T2D, and 58.2% versus 26.9% among those with eASCVD—both classes remain underused [37]. This is notable, given that SGLT2is are fully accessible across all specialties and within primary healthcare settings in Kuwait.

Addressing CKM syndrome in Kuwait requires transforming how these interrelated diseases are managed, as the current division of care limits early intervention opportunities [36]. Disjointed care often leads to incomplete assessments, as patients may not receive comprehensive evaluation across metabolic parameters or suitable follow-up treatment [36]. For example, metabolic syndrome (MetS), which affects many Kuwaiti adults [38], remains under-recognized in clinical practice globally, further delaying timely intervention [6]. Promoting early detection and identification of shared risk factors, alongside the use of evidence-based, guideline-recommended therapies for disease management, is regarded as a fundamental practice across guidelines [7, 9, 10, 30]. These strategies have been shown to improve health outcomes, reduce complications, and lower healthcare costs [39, 40]. International guidance advises adopting an interdisciplinary approach that bridges specialties and fosters innovative collaborative pathways to ensure holistic patient care [41].

Modern Management of CKM Syndrome

Early and accurate identification of CKM syndrome is widely acknowledged as critical for minimizing complications related to cardiovascular, kidney, and metabolic disease [7, 9, 10, 30]. Leading frameworks, including the AHA’s CKM staging model and the Diabetes, Cardiorenal, and Metabolic (DCRM) 2.0 recommendations, offer structured guidance on disease prevention, staging, and personalized management that includes pharmacological intervention [7, 30]. These models promote continuous screening and risk stratification, highlighting the progressive nature of CKM syndrome and the increasing cardiovascular risk associated with advancing stages [7]. Furthermore, they recommend the early initiation of emerging therapies shown to reduce cardiovascular and kidney morbidity, reinforcing that intensified treatments yield the greatest benefit among patients at higher CKM risk [7].

GLP-1 RAs are recognized as novel therapies owing to their multifaceted benefits in targeting key drivers of CKM syndrome: hyperglycemia, excess weight, and cardio-kidney risk, while maintaining a favorable safety profile [14]. These agents address multiple pathological pathways simultaneously, enabling broad-spectrum modulation of the metabolic disturbances fundamental to CKM syndrome. The mechanism of action by which GLP-1 RAs work is to stimulate insulin release, inhibit glucagon release, and slow gastric emptying to slow glucose absorption [42]. These physiological effects translate into meaningful improvements in glycemic regulation and weight reduction, which are critical targets in managing T2D. There is now a robust evidence base supporting their efficacy in achieving sustained glycemic control and promoting weight loss in patients with T2D [43]. In September 2025, the World Health Organization (WHO) added GLP-1 RAs to its Essential Medicines List for managing T2D in high-risk groups [44]. The WHO has also released its first guideline for treating obesity as a chronic, relapsing disease in which there is a conditional recommendation stating that GLP-1 RAs may be used for long-term treatment for obesity [45]. Some GLP-1 RAs have further been shown to reduce cardiovascular events in patients with T2D who have eASCVD or severe target organ damage, independent of baseline HbA1c or concomitant glucose-lowering therapies [9, 14].

GLP-1 RAs demonstrate benefits across multiple disease domains and risk profiles, increasingly positioning them as a comprehensive treatment option suitable for patients with T2D, obesity, CKD, and elevated cardiovascular risk [46, 47] (Fig. 1). Their various formulations provide the flexibility needed to accommodate different patient needs and prescriber preferences. These agents can be administered either as once-daily or once-weekly injectables, and semaglutide is also available as an oral tablet, further expanding patient options [47, 48]. Furthermore, GLP-1 RAs are generally well tolerated, with gastrointestinal effects being the most common adverse events [49]. Nausea, vomiting, diarrhea, and constipation occur mainly during dose escalation and are generally mild to moderate and transient [49]. Some patients discontinue treatment owing to persistent gastrointestinal intolerance [49]. Rare but clinically relevant risks include gallbladder disease and pancreatitis, while hypoglycemia is uncommon unless combined with insulin or sulfonylureas [50, 51].

Fig. 1.

Summary of considerations for GLP-1 RA use [30]. This figure is adapted from the DCRM 2.0: Multispecialty Practice Recommendations for the Management of Diabetes, Cardio-Kidney, and Metabolic Disease. It is based on evidence in randomized controlled trials and observational studies. Deed-Attribution 4.0 International-Creative Commons (https://creativecommons.org/licenses/by/4.0/). GLP-1 RA glucagon-peptide receptor agonist, ASCVD atherosclerotic cardiovascular disease, GI gastrointestinal, LDL-C low-density lipoprotein cholesterol, TG triglycerides

Despite the advantages of GLP-1 RAs for weight loss and secondary prevention, their costs are still relatively high compared with other medications [52, 53]. The combination of these costs, side effects, and individual patient preferences contributes to high discontinuation rates [53]. Early discontinuation, in particular, limits the period during which patients derive health benefits [53]. For individuals with a body mass index (BMI) of 40 or higher who struggle to meet weight loss goals through lifestyle modifications alone, the AHA recommends bariatric surgery as a viable adjunctive option [7]. Bariatric surgery in individuals with a BMI equal to or greater than 35 can offer a lower one-time cost compared with the cumulative cost of GLP-1-RA-based therapy over time [54]. For enhanced obesity prevention and management, the AHA emphasizes the importance of ensuring that patients have access to and support for comprehensive obesity management strategies, which should include lifestyle and behavioral therapies, pharmacotherapy, and bariatric surgery [7].

CKM Risk Pathways and Intervention with GLP-1 RAs

The Cardiometabolic Continuum

Appropriate management of obesity is critical in stalling the development of CKM syndrome, as recently emphasized by a panel of 33 international experts [51]. This is because obesity is a complex chronic disease affecting nearly all organ systems and because it initiates a cascade of metabolic disturbances. The accumulation of excessive and metabolically impaired fat tissue triggers systemic inflammation, promotes insulin resistance, and impairs pancreatic β-cell function, regarded as fundamental processes leading to the development of T2D [55, 56]. Dysfunctional adiposity closely associates with components of metabolic syndrome, including hypertension, hypertriglyceridemia, and insulin resistance, which often cluster together, elevating the risk for progressive CKM pathology [57]. In other words, obesity is not merely a risk factor but a key driver in the pathogenesis of the CKM continuum, underpinning the necessity for early and targeted intervention.

Early intervention addressing obesity through lifestyle and pharmacological agents such as GLP-1 RAs can disrupt the obesity–T2D continuum, delaying or preventing downstream cardiovascular and kidney complications [30, 46]. For this reason, the DCRM 2.0 recommends initiating treatment promptly following diagnosis of obesity to maximize outcomes [30]. In alignment, AHA’s CKM syndrome model classifies excess weight and adiposity at an early stage (stage 1), defined by established criteria such as BMI and waist circumference, with no other metabolic risk factors at this stage [7]. Dysfunctional fat tissue may manifest as impaired glucose tolerance or prediabetes in individuals with overweight or abdominal obesity, reflecting early metabolic derangements [7].

The weight loss effects of GLP-1 RAs are well established across multiple clinical trials, and GLP-1 RAs are recommended for patients with obesity (BMI ≥ 30 kg/m²) or overweight individuals with weight-related comorbidities [46]. A systematic review and meta-analysis comprising 15 trials demonstrated that these agents significantly reduce body weight and improve cardiovascular risk factors, including systolic and diastolic blood pressure, as well as lipid profiles [58]. GLP-1 RAs also favorably modified triacylglycerol, total cholesterol, very low-density lipoprotein, and high-density lipoprotein levels, further supporting their role as a comprehensive treatment option [58]. In 2022, a panel of ten international experts highlighted the importance of personalized management of dyslipidemias in patients with T2D, also using innovative anti-diabetic agents [59].

Sustained weight loss not only improves metabolic parameters but also significantly increases the likelihood of maintaining normoglycemia. Evidence suggests that early intervention during less severe dysglycemia can prevent progression to T2D or even promote remission [60]. While lifestyle interventions remain effective in delaying or preventing T2D onset among people with prediabetes, long-term adherence poses considerable challenges. In contrast, pharmacologic therapies such as GLP-1 RAs have demonstrated efficacy in reducing the risk of progression from prediabetes to T2D during active treatment [61]. Therefore, GLP-1 RAs provide a practical adjunct or alternative to lifestyle change, especially where adherence barriers exist.

Reflecting this evolving understanding, various global expert groups, including a panel from eastern and southern Europe, are collectively calling for a paradigm shift away from traditional glucose-centric diabetes care and toward a more holistic approach that prioritizes obesity and cardiometabolic complications [46]. The high level of consensus around this shift highlights that it is imperative to integrate weight management therapies such as GLP-1 RAs early within the CKM management continuum to improve long-term outcomes.

Cardiovascular and Kidney Risk Assessment in T2D

The 2023 European Society of Cardiology guidelines for managing CVD in patients with T2D stress the close relationship between diabetes and CVD, calling for routine diabetes screening among patients with CVD and a thorough assessment of cardio-renal risk in individuals with diabetes [9]. People with T2D are at least twice as likely to develop CVD and related complications over their lifetime compared with those without the disease [62]. Complications can include coronary artery disease, stroke, heart failure (HF), and atrial fibrillation (AF), as well as peripheral artery disease (PAD) [63]. Moreover, many patients with CVD have undiagnosed T2D [9]. Proactively screening patients with CVD for diabetes and assessing cardiovascular risk in individuals with diabetes and evaluating them for cardiovascular and kidney disease at an early stage is especially important, considering that diabetes and CVD at a younger age have a major impact on prognosis [64].

Early and aggressive management of modifiable risk factors, hyperglycemia, hypertension, and dyslipidemia, through lifestyle change and combination pharmacotherapy, can delay or prevent the onset of CKD, ASCVD, AF, and HF [7, 10, 30]. Adopting this type of proactive approach aligns with global recommendations to break the interconnected cycles of metabolic and cardiovascular deterioration. GLP-1 RAs have shown consistent kidney benefits in major cardiovascular outcome trials involving patients with T2D. In the LEADER trial, liraglutide significantly reduced the risk of new or worsening nephropathy, primarily through reductions in macroalbuminuria [65]. Similarly, the SUSTAIN-6 and REWIND trials reported lower rates of kidney composite outcomes, including sustained estimated glomerular filtration rate (eGFR) decline and progression of albuminuria, among participants treated with GLP-1 RAs compared with placebo [66, 67]. The Harmony Outcomes trial with albiglutide also demonstrated favorable effects on kidney parameters [68]. These findings suggest that the kidney-protective effects of GLP-1 RAs extend beyond glucose lowering, potentially through mechanisms such as improved endothelial function, reduced oxidative stress, and anti-inflammatory actions [69]. There are several kidney-protective pathways, including direct antioxidant and anti-inflammatory actions that reduce kidney oxidative stress and attenuate signaling through the receptor for advanced glycation end-products, thereby decreasing reactive oxygen species production within the kidney [69]. GLP-1 receptor activation also reduces levels of angiotensin II, contributing to blood-pressure-lowering effects [70]. Furthermore, GLP-1 RAs inhibit the sodium–hydrogen exchanger isoform 3 (NHE3) in the proximal tubule, promoting natriuresis and leading to constriction of the afferent arteriole. This vascular effect reduces glomerular hyperfiltration and intraglomerular pressure, which are key contributors to kidney damage [70]. In particular, semaglutide has been shown to lower systolic but not diastolic blood pressure, indicating additional protective mechanisms that are independent of classic cardiovascular risk factors [70].

A large meta-analysis of eight cardiovascular outcome trials (CVOTs) (over 60,000 patients) found that GLP-1 RAs reduced [14]:

• Major adverse cardiovascular events (MACE) by 14%.

• All-cause mortality by 12%.

• Heart failure hospitalizations by 11%.

• Composite kidney outcomes by 21%.

These benefits occurred without significant increases in adverse effects such as hypoglycemia, retinopathy, or pancreatitis. While several CVOTs were performed with injectable GLP-1 RAs [46], the recent SOUL trial assessed the use of oral semaglutide, which was associated with a significantly lower risk of MACE than a placebo, without an increase in the incidence of serious adverse events, in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), CKD, or both [71]. Notably, the SOUL trial included 9650 participants who had undergone a median follow-up of 49.5 months [71]. Therefore, these recent findings complement and extend all the previous evidence gained over the years on the cardiovascular benefit of GLP-1 RAs [72].

In the Gulf Region, a panel of diabetes specialists, endocrinologists, and cardiologists developed consensus recommendations for managing cardiovascular risk in individuals with T2D in the UAE. They strongly advocate for the use of long-acting GLP-1 RAs for patients at increased risk of ASCVD, CKD, and heart failure, conditions that are often undiagnosed in primary care and pose a significant burden [73]. Semaglutide has also been proven as an effective treatment for patients with obesity-related heart failure, improving symptoms, physical limitations, and exercise capacity even in those without diabetes [74, 75]. The SELECT trial, which involved patients without diabetes with a BMI of 27 or higher and established CVD, demonstrated that a treatment dose of 2.4 mg significantly reduced MACE and heart failure composite endpoints compared with placebo [74]. The STEP-HFpEF trial, which focused on patients with heart failure and preserved ejection fraction who also had obesity, found that semaglutide (2.4 mg) resulted in greater reductions in symptoms, enhanced physical function, improved exercise capacity, and greater weight loss compared with placebo [75].

At present, semaglutide stands out as the sole GLP-1 RA approved for lowering the risks associated with worsening kidney disease, kidney failure, and CVD-related mortality in adults with T2D and CKD [76]. The approval is based on the pivotal FLOW phase 3b kidney outcomes trial results. It addresses a critical need for adults with T2D living with the common comorbidity of CKD [77]. The ADA/KDIGO consensus explicitly advises using GLP-1 RAs, which demonstrate cardiovascular benefits, for T2D and patients with CKD who do not achieve their personalized glycemic goals with metformin and/or SGLT2is, or who are unable to take these medications [10]. ADA/KDIGO further cautions that, given that multiple interventions are required for optimizing care for individuals with CKD, avoiding therapeutic inertia is crucial [10]. Many individuals with diabetes and CKD continue to face significant residual risks for CKD progression and cardiovascular events, even under treatment and when there are increasingly available strategies for risk reduction management [10]. Regular consultations may be necessary to identify and implement various therapies, some of which may interact with one another. A thorough care plan should be collaboratively developed by healthcare professionals and patients, incorporating lifestyle modifications and evidence-based pharmacological treatments to preserve kidney function and achieve intermediate targets for glycemia, blood pressure, and lipid management [10].

Emerging data highlight even broader advantages for semaglutide, such as decreasing systemic inflammation, improving liver function, including in metabolic-associated steatotic liver disease and steatohepatitis [78], and reducing risks associated with AF, osteoarthritis, and peripheral vascular disease [79–81]. On the basis of results from the phase 3 Essence trial that demonstrated significant liver improvements with semaglutide compared with placebo, the US Food and Drug Administration approved semaglutide as the first GLP-1 RA to treat adults with metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced liver fibrosis [82, 83]. Furthermore, the STRIDE trial showed enhanced walking capacity and quality-of-life benefits in individuals with PAD and T2D [81].

Practical and Implementation Considerations in Kuwait

CKM syndrome is an escalating public health challenge in Kuwait, fueled by high rates of obesity, T2D, CVD, and CKD. Despite strong clinical evidence and international guidance, translating these advances into routine patient care remains suboptimal. Many patients are diagnosed late, typically after complications have developed, and even fewer receive coordinated, guideline-based care. Persistent gaps include underdiagnosis, fractured care processes, inconsistent risk factor control, and restricted access to novel therapeutics such as GLP-1 RAs [17, 84].

For Kuwait to fully realize the benefits of modern therapies within CKM management, system-wide solutions are critical. These include the implementation of early detection initiatives; support for multidisciplinary, longitudinal care across specialties; and ensuring equitable access to evidence-based pharmacologic treatments. However, the feasibility of these strategies needs thorough evaluation through local implementation research and pilot programs. Engaging healthcare providers, patients, and policymakers will be crucial to tailoring interventions to the Kuwaiti setting and overcoming specific barriers. In light of these considerations, the Kuwait Endocrinology, Cardiology, and Nephrology Expert Group has proposed several recommendations for enhancing the management of CKM syndrome in Kuwait (Table 1).

Table 1.

The expert group’s recommendations

	Panel recommendation
Integrated, multidisciplinary care pathways
Kuwait’s current care organization does not consistently support early risk identification or integrated CKM management. Although some clinics have implemented structured pathways, these remain the exception. Patients often bypass primary care and access specialist services directly, which undermines comprehensive risk assessment and coordinated treatment. As a result, disease is frequently diagnosed late, and opportunities for risk modification are lost	Develop standardized clinical pathways to strengthen integration by linking primary care with cardiology, nephrology, and endocrinology. These should be supported by shared electronic health records and referral protocols to ensure continuity of care Empower primary care providers through clear guidance and system-level support to identify and manage CKM risk early in the disease continuum
Risk assessment and stratification
Given the complex interplay of obesity, T2D, CKD, and CVD, universal and systematic screening protocols are necessary to identify individuals across the full cardiometabolic risk spectrum. Utilizing structured risk assessments facilitates personalized treatment strategies corresponding to CKM stages, aligning with international best practice guidelines and maximizing clinical benefit	Implement routine screening for obesity, T2D, CKD, and CVD in high-risk adults and adolescents Promote recognition of the obesity–T2D continuum framework to facilitate timely intervention, including early identification, and optimize clinical outcomes Use validated structured risk assessment tools to guide timely, stage-specific interventions
Access to evidence-based therapies
While GLP-1 RAs are endorsed in multiple guidelines for patients with T2D, obesity, CKD, or CVD, their use in Kuwait remains suboptimal. Contributing factors include inconsistent supply, Ministry of Health budget allocation, lack of insurance coverage, and prescriber hesitancy, particularly among non-endocrinologists	Update national treatment protocols to reflect the full spectrum of GLP-1 RA benefits, including kidney and cardiovascular protection Expand insurance coverage and reimbursement policies to remove financial barriers and address access constraints through procurement strategies and policy-level interventions Develop clear, detailed clinical protocols addressing the combined use of GLP-1 RAs with other agents such as SGLT2is to guide prescribers, particularly non-endocrinologists, in safely treating complex patients
Workforce and system capacity
Effective CKM care depends on a trained, multidisciplinary workforce. However, Kuwait faces a notable shortage of dietitians, CKD nurses, diabetes educators, and other allied health professionals. This shortage hinders integrated care delivery and restricts long-term follow-up, particularly for patients with multiple comorbidities	Increase investment in workforce development, including targeted training programs and recruitment of allied professionals to CKM-focused clinics Facilitate colocation of multidisciplinary teams or implement structured virtual coordination platforms to enhance communication and continuity of care Introduce institutional incentives to encourage collaborative practice models focused on CKM management
Education for providers and patients
Clinical inertia, particularly in initiating and intensifying treatment, remains a significant obstacle to optimal CKM management. Many nonspecialist providers are unfamiliar with newer agents such as GLP-1 RAs, especially injectable formulations. Concurrently, low levels of patient awareness around CKM risk factors and treatment options contribute to poor adherence and delayed care-seeking	Implement comprehensive continuing medical education (CME) initiatives that focus on the practical aspects of GLP-1 RA use, risk stratification, and treatment planning Prioritize training for primary care providers and nonspecialist physicians to reduce clinical inertia Launch culturally relevant education materials and public awareness campaigns to encourage patients to adopt proactive health behaviors and engage in early care. Evidence suggests that educational interventions enhance both clinical outcomes and treatment adherence in populations with chronic diseases [85]
Outcome tracking and local evidence generation
Routine outcome measurement in CKM care remains limited to standard metrics such as HbA1c or body weight. Broader outcomes, such as eGFR decline, hospitalization rates, cardiovascular events, and patient-reported quality of life, are rarely captured, limiting the ability to assess impact or guide system improvement [30]	Define national indicators for CKM outcomes and invest in real-world data infrastructure to support the shift toward value-based care Use longitudinal patient registries and local implementation studies to help validate the effectiveness of guideline-based interventions and inform further protocol refinement

Conclusions

Empowering cardiologists, nephrologists, primary care physicians, and endocrinologists to confidently utilize GLP-1 RAs is essential for advancing comprehensive CKM syndrome management in Kuwait. These specialists play fundamental roles in early risk identification, guideline-based treatment initiation, and ongoing multidisciplinary care, ensuring that patients receive therapies that address both glycemic control and cardiovascular and kidney protection. Delivering such comprehensive care also requires close collaboration across sub-specialties—cardiology, nephrology, and endocrinology. Each discipline must remain mindful of the others to achieve truly integrated patient management. Strengthening provider education, updating national protocols, and enhancing access to GLP-1 RAs will empower clinicians to effectively incorporate these evidence-based agents. By fostering such capacity building alongside integrated care pathways, Kuwait can significantly reduce CKM-related morbidity and mortality and improve long-term health outcomes.

Limitations

This consensus reflects the views of a multidisciplinary expert panel in Kuwait but was not based on a formal Delphi process or structured stakeholder engagement, such as patient or caregiver input. Therefore, while the recommendations are grounded in clinical experience and current evidence, they may not capture the full spectrum of perspectives. The applicability of these recommendations across diverse healthcare settings in Kuwait warrants further validation. Future efforts should include implementation research and pilot programs to test feasibility, evaluate outcomes, and identify barriers to scale. Engaging patients, primary care providers, and health system leaders will be essential to refining and operationalizing these strategies effectively.

Author Contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this article. Waleed A. Aldahi, Abdullah Alenezi, Thamer Alessa, Rashed Alhamdan, Khaldoon A. Al-Humood, Ahmed Alqallaf, Torki Alotaibi, Heba Alrajab, Abdulmuhsen M. Alshammari, Anas M. Alyousef, Asrar Alsayed Hashem, and Manfredi Rizzo contributed to the concept, drafting, and critical revision of this article; take responsibility for the integrity of the work as a whole; and have given their approval for this version to be published.

Funding

Novo Nordisk organized and funded the panel meeting held with experts from Kuwait in November 2024. In addition, Novo Nordisk provided financial support for medical writing assistance, but had no role in the writing, revision, or submission of the present article. The Rapid Service Fee was funded by Novo Nordisk.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflict of Interest

The authors have given lectures, received honoraria and research support, and participated in conferences, advisory boards, and clinical trials sponsored by many pharmaceutical companies. However, no pharmaceutical company had any role in the scientific content of the present article, which has been written independently, and reflects only the opinion of the authors, without any role by the industry. The following conflicts of interest were reported: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events were received by Thamer Alessa from Eli Lilly, Sanofi, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, and Servier; Heba Alrajab from CSL Vifor, Bayer, Amgen, Novo Nordisk, and AstraZeneca (consulting fees were also received); Anas Alyousef from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Amgen, Bayer, and Vifor CSL. Waleed Aldahi and Asrar Alsayed Hashem received honoraria for lectures and presentations from Novo Nordisk, Eli Lilly, and Merck. Khaldoon Al-Humood has given lectures and received honorariums from Medtronic, Abbott, Boehringer Ingelheim, AstraZeneca, Pfizer, Bristol Myers Squibb (BMS), Novartis, and Servier. Dr. Alrajab has received payment for expert testimony from CSL Vifor and AstraZeneca. Dr. Alrajab received support to attend meetings and/or travel from ATC, Fresenius and Roche; and Dr. Alsayed Hashem and Dr. Aldahi received support for attending medical conferences and meetings by Novo Nordisk and Eli Lilly; and Dr Alessa by Novo Nordisk and Sanofi. Authors who participated on a Data Safety Monitoring Board or Advisory Board include Dr. Alessa for Novo Nordisk; Dr. Alrajab for CSL Vifor, Sobi – Swedish Orphan Biovitrum, and AstraZeneca; Dr. Alyousef for Sobi, and Vifor CSL; Dr. Alsayed Hashem for Algorithm. Dr. Alyousef is also President of the Kuwait Nephrology Association; he does not receive fees for this role. Dr. Alsayed Hashem is President of the Kuwait Obesity Association and Dr. Aldahi is the President of the Kuwait Diabetes Society. Both Dr. Alsayed Hashem and Dr. Aldahi have participated in public awareness campaigns for obesity and diabetes in Kuwait. Dr. Aldahi has participated in advisory boards for several companies, including Novo Nordisk. Dr. Alrajab has held a leadership or fiduciary role in other boards, societies, committees, or advocacy groups, paid or unpaid, with CSL Vifor, Sobi – Swedish Orphan Biovitrum, and AstraZeneca. Manfredi Rizzo has given lectures, received honoraria and research support, and participated in conferences, advisory boards, and clinical trials sponsored by many pharmaceutical companies, including Amgen, AstraZeneca, Biodexa, Boehringer Ingelheim, Kowa, Eli Lilly, Meda, Mylan, Merck Sharp & Dohme, Novo Nordisk, Novartis, Roche, Sanofi, and Servier. Manfredi Rizzo is an Editorial Board member of Diabetes Therapy. He was not involved in the selection of peer reviewers for the manuscript nor for any of the subsequent editorial decisions. Abdullah Alenezi, Rashed Alhamdan, Torki Alotaibi, Ahmed Alqallaf, and Abdulmuhsen Alshammari have nothing to disclose.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.