Abstract
Introduction
The optimal positioning and sequencing of sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in adults with chronic kidney disease (CKD) with type 2 diabetes (T2D) and overweight/obesity is unclear. This Delphi panel aimed to establish expert consensus on the foundational versus adjunctive role of SGLT2is and GLP-1 RAs in this adult population.
Methods
A total of 114 participants across 10 countries participated in a two-round Delphi panel (9.7% drop-off rate between rounds). Statement development was guided by a systematic literature review and 12 global experts. Consensus was pre-defined as ≥ 75% agreement/disagreement. The Delphi panel took place between 29 August and 20 October 2025.
Results
Totals of 13/30 (43%) and 7/17 (41%) statements achieved consensus in Rounds 1 and 2, respectively. Panellists agreed that SGLT2is should be foundational therapy in adults with CKD and T2D, independent of body mass index (BMI). Consensus was also achieved that GLP-1 RAs should be considered as an add-on for those with BMI ≥ 35 kg/m2 and cardiometabolic complications and comorbidities [e.g. residual glycated haemoglobin A1c (HbA1c) elevation, atherosclerotic cardiovascular disease]. Combination therapy was considered appropriate for adults with persistent kidney disease progression, high cardiovascular risk or suboptimal metabolic control.
Conclusion
While treatment of adults with CKD and T2D should be holistic, SGLT2is should be prioritised as foundational therapy, independent of BMI, to reduce cardiorenal risk. Combination therapy with GLP-1 RAs was preferred for those with ongoing CKD progression and/or high cardiometabolic risk. Further clarity is required around the optimal timing of combination and sequential add-on therapy initiation.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12325-026-03618-z.
Keywords: Chronic kidney disease, Glucagon-like peptide-1 receptor agonist, Sodium-glucose co-transporter 2 inhibitor
Key Summary Points
| Why carry out this study? |
| Positioning of sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in chronic kidney disease (CKD) with type 2 diabetes (T2D) and obesity remains uncertain. |
| This modified Delphi panel gathered consensus from 114 international experts in CKD and T2D on the foundational versus adjunctive role of SGLT2is and GLP-1 RAs, with the consensus threshold for statements being pre-defined as ≥ 75% agreement/disagreement. |
| What was learned from the study? |
| While treatment of adults with CKD, T2D and overweight/obesity should be holistic and individualised, consensus was generated that supports the foundational use of SGLT2is, independent of body mass index (BMI). |
| GLP-1 RAs should be considered as an add-on to SGLT2i therapy for those with cardiometabolic complications with elevated glycated haemoglobin A1c (HbA1c), BMI ≥ 35 kg/m2 and comorbidities. |
| Further clarity is needed on the optimal positioning and sequencing of combination and sequential add-on therapy with both drug classes. |
Introduction
Chronic kidney disease (CKD) is associated with cardiovascular disease (CVD), acute kidney injury and kidney failure, and is predicted to be the fifth leading cause of premature death by 2040 [1–3]. The global prevalence of CKD is approximately 10% and is increasing, driven by rising rates of type 2 diabetes (T2D) and obesity [1, 4]. CKD prevalence is substantial among people with T2D (up to ~ 50%), and obesity is estimated to increase lifetime risk of CKD by 25% [5, 6].
In recent years, the therapeutic landscape in CKD management has expanded beyond traditional renin-angiotensin system (RAS) blockade to include sodium-glucose co-transporter 2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and non-steroidal mineralocorticoid receptor antagonists, such as finerenone [2, 7]. Among antihyperglycemic agents, SGLT2is are widely recognised for their early cardiorenal protection in CKD, including protection from and management of heart failure (HF), independent of glucose levels and ejection fraction. GLP-1 RA-based therapies confer cardiovascular benefits and favourable metabolic effects, such as weight loss [8, 9], with emerging evidence of kidney protection [8–12]. Most notably, the FLOW trial, the first dedicated GLP-1 RA kidney outcome trial, demonstrated that once-weekly semaglutide reduced the risk of sustained decline in estimated glomerular filtration rate (eGFR), kidney failure or cardiovascular death in people with CKD and T2D [9]. Both classes are recommended by guidelines [2, 7]. However, even in the context of recent clinical trials, there remains a lack of clear guidance on their foundational (i.e. first-line) versus adjunctive roles in the real-world management of adults with CKD and T2D [13, 14]. In contrast, the current Kidney Disease Improving Global Outcomes (KDIGO) 2024 guidelines clearly position non-steroidal mineralocorticoid receptor antagonists, including finerenone, as an adjunctive therapy, for adults with T2D and an eGFR > 25 ml/min/1·73 m2 despite maximum tolerated dose of RAS inhibitor and SGLT2i treatment, though emerging data suggest a possible future shift to co-foundational use [2, 15].
The lack of clear guidance on optimal positioning and sequencing of SGLT2is and GLP-1 RAs is, in part, due to limited direct comparative data on the two agents. This finding was supported by a recent systematic literature review (SLR) identifying evidence on comparisons, positioning or combinations of these two agents in adults with CKD and T2D with or without overweight/obesity [16]. This SLR identified only one study formally assessing treatment sequencing (RECAP), in which no significant difference in kidney outcomes was observed, based on whether SGLT2i or GLP-1 RA therapy was initiated first [17].
To address uncertainties around prescribing of SGLT2is and GLP-1 RAs in adults with CKD and T2D with or without overweight/obesity, an international Delphi panel was conducted to elicit consensus on the optimal treatment positioning and sequencing of these two classes, led by a multidisciplinary steering committee (SC) of 12 global experts. The findings from this Delphi study aim to help guide treatment decisions in adults with CKD and T2D with or without overweight/obesity, and can be adapted to suit local health system contexts to ultimately improve timely treatment and long-term outcomes for this population.
Methods
Steering Committee
An international, multidisciplinary SC of 12 healthcare professionals was convened (Supplementary Material Table S1).
The SC reviewed the Delphi panel protocol, approved key themes to explore, led the development and revision of Delphi panel statements and interpretation of the final survey results for this manuscript (Supplementary Material Figure S1). To avoid potential bias, the SC did not actively participate in the consensus process.
Delphi Panellists
Eligible panellists were actively practising healthcare professionals involved in treatment decision-making for adults with T2D and CKD in the following medical specialties: primary care, nephrology, endocrinology/diabetology, or internal medicine. Eligible panellists required a minimum of 5 years post-speciality clinical practice experience managing CKD and/or T2D and were based across 10 countries (Supplementary Material Table S2). Recruitment was designed to reflect real-world management, with particular emphasis on primary care physicians who frequently initiate and adjust therapies for CKD and T2D prior to, or alongside, nephrology referral. Invitations were sent in iterative rounds, to ensure adequate representation of countries and specialties.
In total, 257 panellists were invited via email and 144 confirmed they wished to participate in the Delphi panel (Supplementary Material Table S2). Panellists were not provided with honoraria for their participation.
Study Design
The Delphi methodology was selected as a widely recognised, systematic and robust process for eliciting expert consensus. The study was conducted and reported in line with ACcurate COnsensus Reporting Document (ACCORD) and Conducting and REporting DElphi Studies (CREDES) guidance [18, 19].
Statement types included multiple-choice, single-choice Likert, and a ranking statement used for evidence-generation purposes in Round 1. For Likert-scale statements, consensus was set at a pre-defined threshold of ≥ 75% respondents selecting “strongly agree”/“agree” or “strongly disagree”/“disagree”. “Slightly agree” and “slightly disagree” were categorised as neutral responses, along with “prefer not to answer”. Single- and multiple-choice statements were deemed to have reached consensus if ≥ 75% panellists selected the same option. Optional free-text boxes were available for panellists to contextualise their response to each question/statement.
Each survey round was distributed via an online bespoke web-app, and responses were collected individually for each panellist. Survey outputs were anonymised by the study co-ordinators, and each panellist was assigned a unique ID to facilitate analysis of results throughout the Delphi panel process.
Round 1 statement development was led by the SC and informed by an SLR (PROSPERO ID: CRD420251053598) to identify existing literature on the use of interventional therapies SGLT2is and GLP-1 RAs in adults with CKD and T2D with or without obesity [16]. Panellists were provided with a summary of SLR results prior to completing the Round 1 survey to ensure familiarity with the current available literature. Statements not reaching consensus in Round 1 were rephrased in Round 2, based on free-text responses received and SC input. New statements were added in Round 2 to build on Round 1 statements. Panellists were able to view the anonymised aggregated responses from the preceding round for any related statements.
Ethical Approval
No patients were involved in the study, which was not submitted for approval by an ethics committee or institutional review board. Participants gave informed consent to participate in the study before taking part and were made aware of the study objectives and the aim for publication of a manuscript. Participants remained independent throughout the Delphi panel, no honoraria were provided for their time or participation in the surveys, and their responses were anonymised from each other and the funder throughout the surveys.
Individual data were handled independently through an online, secure web-app; Costello Medical Consulting Limited was responsible for this website and protecting personal data provided by participants. Security measures were in place to prevent personal data from being accidentally lost, used or accessed in an unauthorised way, altered or disclosed. In addition, access to personal data through the website was limited to study co-ordinators, subject to a duty of confidentiality.
Results
The Round 1 Delphi survey was open from 29 August to 8 September 2025; Round 2 was open from 10 to 20 October 2025. Of the 144 panellists who agreed to take part in the survey, 114 completed Round 1. For Round 2, the survey was circulated to all 114 panellists who completed Round 1 and 103 responses were received (9.7% drop-off rate between rounds). Panellist demographics are presented in Table 1. Across both rounds, 20 statements reached consensus [13/30 (43%) in Round 1; 7/17 (41%) in Round 2]. A full list of statements and their progression across rounds, along with consensus grading according to the following percentage of respondents agreeing/disagreeing with a statement: U = 100%; A = 99–91%; B = 90–81%; C = 80–75%, is presented in Table 2. A summary of the key findings from the Delphi panel is shown in Fig. 1.
Table 1.
Delphi panellist demographics
| Number completing round 1, n (%) | Number completing round 2, n (%) | |
|---|---|---|
| Professional speciality | ||
| Endocrinology/diabetology | 56 (49·1) | 52 (50·5) |
| Primary care | 33 (28·9) | 28 (27·2) |
| Nephrology | 17 (14·9) | 16 (15·5) |
| Internal medicine | 8 (7·1) | 7 (6·8) |
| Panellist location | ||
| Australia | 12 (10·5) | 12 (11·7) |
| China | 5 (4·4) | 5 (4·9) |
| France | 14 (12·3) | 11 (10·6) |
| Germany | 11 (9·6) | 9 (8·7) |
| India | 1 (0·9) | 1 (1·0) |
| Italy | 18 (15·8) | 17 (16·5) |
| Japan | 12 (10·5) | 12 (11·7) |
| Spain | 15 (13·2) | 13 (12·6) |
| United Kingdom | 14 (12·3) | 12 (11·7) |
| United States | 12 (10·5) | 11 (10·6) |
| Years of experience in speciality | ||
| 5–10 years | 9 (7·9) | 10 (9·7) |
| 11–15 years | 18 (15·8) | 13 (12·6) |
| > 15 years | 87 (76·3) | 80 (77·7) |
| Proportion of practice dedicated to managing CKD or T2D | ||
| < 10% | 5 (4·4) | 4 (3·9) |
| 10–25% | 35 (30·7) | 24 (23·3) |
| 25–50% | 25 (21·9) | 30 (29·1) |
| > 50% | 49 (43·0) | 45 (43·7) |
CKD chronic kidney disease, T2D type 2 diabetes
Table 2.
Flowchart of Delphi panel statement progression across Rounds 1 and 2
Consensus was met when ≥ 75% of respondents selected ‘strongly agree/agree’ or ‘strongly disagree/disagree’ for Likert scale statements. Consensus was graded according to the following percentage of respondents agreeing/disagreeing with a statement: U = 100%; A = 99–91%; B = 90–81%; C = 80–75%. Any ‘slightly agree’ or ‘slightly disagree’ responses to Likert scale statements were considered neutral, as well as ‘do not wish to respond’. Percentages have been rounded to the nearest whole number. Green shading indicates statements that reached consensus
ASCVD atherosclerotic cardiovascular disease, BMI body mass index, CKD chronic kidney disease, CVD cardiovascular disease, eGFR estimated glomerular filtration rate, GLP-1 RA glucagon-like peptide-1 receptor agonist, HbA1c glycated haemoglobin A1c, HF heart failure, SGLT2i sodium-glucose co-transporter 2 inhibitor, T2D type 2 diabetes, UACR urine albumin-to-creatinine ratio
Fig. 1.
Summary of key findings from Delphi survey. ASCVD atherosclerotic cardiovascular disease, BMI body mass index, CKD chronic kidney disease, GLP-1 RAs glucagon-like peptide-1 receptor agonists, HbA1c glycated haemoglobin A1c, HF heart failure, SGLT2i sodium-glucose co-transporter 2 inhibitors, T2D type 2 diabetes
Treatment Goals in Adults with CKD and T2D
Panellists agreed that, while treatment of adults with CKD and T2D who have overweight/obesity should be holistic, reduction of cardiorenal risk should be prioritised (94% agree). Consensus was achieved that kidney protection should be optimised, particularly for adults with early CKD, T2D and overweight/obesity, even if metabolic targets such as weight or glycated haemoglobin A1c (HbA1c) are being met (96%). Trends in eGFR decline and urine albumin-to-creatinine ratio (UACR) reduction are more important indicators of long-term kidney protection than changes in HbA1c or body weight (85%). When considering trial data, composite kidney outcomes were considered to give a better overall measure of long-term kidney protection than any single kidney endpoint (91%).
Treatment decisions when prescribing SGLT2is and/or GLP-1 RAs in adults with CKD and T2D who have overweight/obesity are strongly influenced by tolerability and safety (88%). While consensus was not reached, panellists indicated that patient preference, and potential for improved adherence, also strongly influenced treatment choice (64% and 62%, respectively).
Prioritisation of Body Mass Index (BMI)
Results on the prioritisation of BMI as a driver of treatment choice were mixed. In Round 1, consensus was achieved that BMI is a clinical characteristic that strongly influences choice of first-line therapy for adults with CKD and T2D who have overweight/obesity (75%). However, there was only 63% agreement that BMI strongly influences treatment decisions regarding whether to prescribe SGLT2is versus GLP-1 RAs. In Round 2, 42% agreed that BMI is not the primary concern when considering whether to prescribe SGLT2is versus GLP-1 RAs as first-line therapy, whereas 24% disagreed (34% provided ‘neutral’ responses).
First-Line Therapy Decisions for Patient Profiles
When assessing consensus on first-line therapy decisions for patient profiles, panellists considered kidney function (eGFR, UACR; both 85%), and risk/history of HF (75%) as key factors [in addition to BMI (75%), for which inconsistent feedback was received, discussed above]. A clear consensus (93%) was achieved that SGLT2is should be included as part of foundational (first-line) therapy across BMI categories. This was explored further in Round 2 where a robust consensus was reached on SGLT2is being the preferred first-line therapy for mild and moderate CKD for adults with BMI < 35 in both generalised and specific patient profiles (Tables 3 and 4). HF was also a clear prompt for first-line therapy with an SGLT2i (86%). Panellist responses indicated a preference for GLP-1 RAs as first-line therapy in specific patient profiles with high metabolic risk (high BMI and high HbA1c) and established atherosclerotic cardiovascular disease (ASCVD) (Table 4). However, use of GLP-1 RAs as first-line did not achieve consensus in any generalised profile (mild CKD with uncontrolled hyperglycaemia and BMI ≥ 35 reached 73% agreement). There was clear consensus that GLP-1 RAs should be considered as add-on therapy to SGLT2is for those with BMI ≥ 35 kg/m2 and serious obesity-related complications and comorbidities (95%). Results further indicated that residual HbA1c elevation (78%), BMI elevation (84%), both HbA1c and BMI elevated in parallel (86%) and ASCVD development (76%) would drive decisions to prescribe add-on GLP-1 RAs to SGLT2is. Consensus was not reached on the impact of different frailty signs and symptoms on first-line treatment choice with SGLT2is versus GLP-1 RAs.
Table 3.
Generic patient profiles suitable for first-line treatment with SGLT2is or GLP-1 RAs
The definitions of mild and moderate CKD align to the Kidney Disease Improving Global Outcomes (KDIGO) 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. Mild CKD: Defined as eGFR 45–59 mL/min/1·73 m2 and albuminuria < 3 mg/mmol or eGFR ≥ 60 mL/min/1·73 m2 and albuminuria 3–30 mg/mmol. Moderate CKD: Defined as eGFR 30–44 mL/min/1·73 m2 and albuminuria < 3 mg/mmol, or eGFR 45–59 mL/min/1·73 m2 and albuminuria 3–30 mg/mmol. Controlled glycaemia: A HbA1c value of ≤ 7%. Uncontrolled glycaemia: A HbA1c value of ≥ 7%. Units for BMI are in kg/m2
Cells in green (*) show generic patient profiles where consensus was reached (≥ 75% agreement) on the suitable first-line therapy. Cells shared in orange (^) show generic patient profiles where consensus was not reached, but a considerable number of panellists agreed on the most suitable first-line therapy (65–74% agreement)
BMI body mass index, CKD chronic kidney disease, eGFR estimated glomerular filtration rate, GLP-1 RA glucagon-like peptide-1 receptor agonist, HbA1c glycated haemoglobin A1c, KDIGO Kidney Disease Improved Global Outcomes, SGLT2i sodium-glucose co-transporter 2 inhibitor
Table 4.
Specific patient profiles suitable for first-line treatment with SGLT2is or GLP-1 RAs
Units are as follows: BMI in kg/m2; eGFR in mL/min/1·73 m2; UACR in mg/g. Percentage values show the percentage of the 114 panellists who selected each therapeutic agent as the first-line therapy for each specific patient profile and therefore do not add up to 100%
Cells in green (*) show generic patient profiles where consensus was reached (≥ 75% agreement) on the suitable first-line therapy. Cells shared in orange (^) show generic patient profiles where consensus was not reached, but a considerable number of panellists agreed on the most suitable first-line therapy (65–74% agreement)
ASCVD atherosclerotic cardiovascular disease, BMI body mass index, eGFR estimated glomerular filtration rate, GLP-1 RA glucagon-like peptide-1 receptor agonist, HbA1c glycated haemoglobin A1c, HF heart failure, SGLT2i sodium-glucose co-transporter 2 inhibitor, UACR urine albumin-to-creatinine ratio
Sequencing and Combination use of SGLT2is and GLP-1 RAs
Panellists agreed that decisions relating to sequencing and combination use of SGLT2is and GLP-1 RAs should consider time to clinical benefit (85%), with SGLT2is providing the earliest kidney advantages (e.g. reduction in eGFR decline and/or UACR [97%]). Consensus was reached that combination therapy was appropriate for adults with persistent kidney disease progression, high cardiovascular risk or suboptimal metabolic control (96%). There was no consensus on whether initiation of combined therapy should be simultaneous (defined as within a 4-week interval) or sequential, and the optimal timing for add-on therapy.
Guideline Interpretation and Practice Gaps
When exploring consensus on guideline interpretation and practice gaps, panellists agreed on a need for an expert-endorsed treatment algorithm to support clinical decision-making for adults with CKD and T2D (81%). Panellists agreed that cost or reimbursement barriers related to GLP-1 RAs hinder implementation of guideline recommendations for this class (78%). However, no consensus was reached on barriers to implementing guideline recommendations regarding SGLT2is. Overall, there was strong consensus on the need for improved primary care practitioner awareness and education to overcome therapeutic inertia around prescribing these agents (95%).
Discussion
This Delphi study convened an international panel of > 100 clinical experts to address gaps in existing evidence and guidelines regarding the optimal treatment positioning and sequencing of SGLT2is and GLP-1 RAs in adults with CKD and T2D with or without overweight/obesity. The study did not evaluate other treatments for CKD, such as RAS inhibitors, finerenone or control of risk factors (e.g. hypertension).
SGLT2is as Foundational Therapy in Adults with CKD
There was a clear consensus that SGLT2is should be positioned as foundational therapy in adults with CKD and T2D, independent of BMI and in particular in the presence of HF, given their consistent kidney protective benefits and well-established mechanisms of action [20–22]. This finding is consistent with leading CKD treatment guidelines, where SGLT2is are recommended as first line in addition to RAS inhibition, metformin and statins [2, 7], and reflects the breadth of pivotal trial data (DAPA-CKD, EMPA-KIDNEY and CREDENCE) demonstrating earlier kidney and cardiovascular benefits (e.g. reduction in sustained decline in eGFR, kidney disease progression or end-stage kidney disease) and the tolerability of SGLT2is across the CKD spectrum [10–12]. The foundational role of SGLT2is in CKD management was also supported by the SLR findings underpinning this study [16], which showed that meta-analyses of randomised controlled trials consistently favoured SGLT2is over GLP-1 RAs for composite kidney outcomes.
Panellists favoured a holistic approach to the treatment of adults with CKD and T2D with or without overweight/obesity, with a strong consensus on kidney protection being optimised, even when metabolic targets are being met. However, within the context of holistic treatment, there was a lack of clarity regarding the relative importance of BMI as a driver of first-line therapy choice (SGLT2is versus GLP-1 RAs). Considerations around the relative prioritisation of BMI as a driver of treatment decisions are complex, with potential differences across regions, based on ethnicity and genetics contributing to varying clinical thresholds for obesity and risk of comorbidities such as HF and ASCVD [23].
Although consensus was not consistently achieved regarding the prioritisation of BMI when choosing between SGLT2is and GLP-1 RAs, BMI was still recognised as one of the clinical factors that influences decision-making. The SC agreed that weight should be managed independently of CKD, while acknowledging the weight-loss benefits observed with GLP-1 RAs, especially among those with obesity [24–26]. Furthermore, the Delphi statements and patient profiles predominantly focused on adults with normal or elevated BMI, reflecting the high prevalence of overweight/obesity in T2D and CKD. However, patients with a low BMI (e.g. BMI < 20 kg/m2) were not explicitly addressed, and the SC recognise that cautious, individualised clinical judgement is required in such individuals, given that SGLT2is and GLP-1 RAs exert differing weight-loss effects on visceral fat versus lean body mass.
Positioning of GLP-1 RAs as Add-On Therapy to SGLT2is
Data providing direct comparisons between SGLT2is and GLP-1 RAs to allow assessment of optimal positioning and sequencing of these agents are very limited. In the wider literature, established evidence from randomised controlled trials, albeit in non-CKD populations, generally support GLP-1 RAs (notably once-daily semaglutide over 52 weeks) for HbA1c and weight benefits, owing to the strength of evidence demonstrating their role in body weight, glycaemic and blood pressure reduction [25, 27]. Furthermore, dedicated cardiovascular outcome trials (LEADER, SUSTAIN-6, REWIND)[26, 28, 29] have demonstrated consistent reduction in major adverse cardiovascular events with long-acting GLP-1 RAs, particularly in people with established ASCVD. The FLOW trial notably demonstrated a reduction in the risk of major adverse cardiovascular events, death from cardiovascular causes and all-cause mortality with semaglutide in adults with CKD and T2D, with prespecified analyses suggesting that these outcomes were consistent in patients across BMI groups and with/without prior SGLT2i use [9].
Despite this, GLP-1 RAs only achieved consensus as the preferred first-line therapy when assessing specific patient profiles, but not when assessing broader patient categories (Tables 3 and 4). This is likely due to the more established CKD-specific evidence base available for SGLT2is [10–12], and the fact that FLOW evaluated semaglutide in patients receiving prior guideline-directed standard of care, limiting generalisability to GLP-1 RAs more broadly as a first-line therapy [8, 9].
Panellists did agree with prioritising GLP-1 RAs as an add-on therapy to SGLT2is in adults with BMI ≥ 35 kg/m2 to achieve weight loss goals. However, participants in the FLOW study had a mean BMI of 32 kg/m2, therefore suggesting the benefits of semaglutide are not limited to those with severe obesity, supporting the role for GLP‑1 RAs beyond weight reduction alone. Consensus was also reached that cardiometabolic complications and comorbidities, including residual HbA1c elevation, BMI elevation and ASCVD development, could drive a decision to add GLP-1 RA to SGLT2i therapy, tailored to individual patient characteristics and preference. As patient preference may potentially be influenced by recent media attention on GLP-1 RAs, communicating the importance of early kidney protection will be crucial to ensure informed shared decision-making. The importance of individualised, holistic treatment in the context of complex clinical decisions was also highlighted by the lack of consensus regarding use of SGLT2is versus GLP-1 RAs in frailty, with differing preferences depending on specific risks or symptoms, requiring clinical judgement to balance efficacy and safety.
Sequencing and Combination Use of SGLT2is and GLP-1 RAs
There was agreement that sequential or upfront combination therapy with SGLT2is and GLP-1 RAs is appropriate for individuals with ongoing kidney progression, high cardiovascular risk or suboptimal metabolic control. This aligns with SLR results, highlighting early signals of additive efficacy and the potential value of combined therapy [16].
Despite agreement on the benefit of combination therapy for certain patient profiles, uncertainty remained concerning the definition of combination therapy and whether this is understood as upfront combination, or add-on therapy or both. There was no consensus on the optimal timing of GLP-1 RA add-on therapy after initiating an SGLT2i, nor on the feasibility of initiating both therapies within a 4-week interval (referred to as ‘simultaneous’). No clear trends were identified when data were analysed by country, pointing to potential variability across different health settings (e.g. state versus private, primary versus secondary) rather than geographies.
The lack of consensus on optimal timing of combination therapy with SGLT2is and GLP-1 RAs may have been influenced by the absence of clinical data to support this. The SLR underpinning this study did not identify any formal sequencing studies or direct comparisons of SGLT2is versus GLP-1 RAs [16]. RECAP was the only study to explore order of initiation, showing no significant difference in kidney outcomes based on whether GLP-1 RA or SGLT2i therapy was initiated first [17]. It should be noted that this post hoc subgroup analysis used a small sample size, only including 438 participants with CKD (GLP-1 RA-first group, n = 223; SGLT2i-first group, n = 215) from the 643 participants with T2D in the RECAP study. Furthermore, the KDIGO 2024 guidelines cover combination therapy from the perspective of SGLT2is being first-line therapy, and long-acting GLP-1 RAs being an add-on in adults with CKD and T2D who have not achieved individualised glycaemic targets despite use of metformin and SGLT2is, or who are unable to use those medications [2]. However, the guidelines were published before the first kidney outcome study with a GLP-1 RA (FLOW) [9]. Overall, further evidence is needed to define the optimal sequencing of these two agents in adults with CKD and T2D with or without overweight/obesity.
Guideline Interpretation and Practice Gaps
Overall, there was no consensus around whether current guidelines provide clear recommendations on prioritisation of SGLT2is versus GLP-1 RAs in CKD. The dissent in responses remained when results were broken down by country. Free-text responses highlighted that the American Diabetes Association (ADA) guidelines provide clear recommendations on the prioritisation of SGLT2is versus GLP-1 RAs for adults with CKD and T2D; however, adults rarely have CKD and T2D in isolation, often also experiencing ASCVD, which is where guidance becomes unclear. Further to this, local guidelines may not always directly align to KDIGO and ADA guidelines. Together, the lack of clear recommendations can result in differences in care received by patients, with inadequacies and inequities in the management of diabetic CKD care in primary care highlighted in the UK [30]. Within this Delphi panel, improved primary care practitioner awareness and education were considered crucial to overcoming therapeutic inertia around prescribing SGLT2is and GLP-1 RAs. However, panellists also agreed that, in the absence of evidence and clear, consistent guidance, there is a need for an expert-endorsed treatment algorithm, to support clinical decision-making for adults with CKD and T2D.
The most frequently cited barrier to implementing guideline recommendations regarding the prescription of GLP-1 RAs in practice was cost or reimbursement barriers, reaching consensus across Europe, the United States and Asia-Pacific. Although cost-effectiveness studies comparing the two classes in the CKD setting are not yet available, SGLT2is have been shown to be more cost-effective than GLP-1 RAs for T2D [31]. However, the potential reduction in healthcare resource use across both classes suggests a combination of both SGLT2is and oral GLP-1 RAs may confer long-term cost savings compared to SGLT2is and standard of care alone [32, 33].
No consensus was reached globally to signify the top barriers to implementing guideline recommendations regarding prescription of SGLT2is in clinical practice, owing to divergence in the options selected. Upon further analysis by country, lack of prescriber confidence, and concern regarding adverse events associated with medication, both reached consensus regarding prescribing SGLT2is in the United Kingdom, though there was still considerable uncertainty across other countries. Lack of consensus on the barriers to prescribing these agents likely reflects differences in healthcare settings, both nationally and internationally, and the extensive range of challenges faced when prescribing these agents globally.
Strengths and Limitations of This Modified Delphi Panel
Delphi panels, unlike standard surveys, require ongoing time commitments from panellists, which can result in survey attrition. Attrition was minimised by ensuring the rounds took place in quick succession (< 2 months) to maintain panellist engagement. This approach resulted in high panellist retention rates, with 103 of 114 eligible panellists completing Round 2.
Statements within Delphi surveys may be open to different interpretation due to potential language barriers and limited context. However, the international SC reviewed statements to minimise this risk. Including pooled Round 1 results in Round 2 further reduced misinterpretation bias by allowing reinterpretation in light of the group's responses.
Furthermore, this Delphi panel assessed expert consensus regarding the broad drug classes: SGLT2is and GLP-1 RAs. However, it should be noted that not all individual SGLT2is and GLP-1 RAs are equal regarding kidney, cardiovascular, and metabolic outcomes. This may have limited nuanced interpretation of the statements by panellists.
Conclusion
This Delphi study has provided international expert consensus on treatment goals, first-line therapy choice and positioning and combination use of SGLT2is and GLP-1 RAs in the real-world management of CKD and T2D in adults with or without overweight/obesity. The consensus from this study highlights that SGLT2is should be foundational therapy, independent of BMI, emphasising kidney protection as an early treatment goal. GLP-1 RAs should be considered as an add-on to SGLT2i therapy for those with cardiometabolic complications with elevated HbA1c, BMI ≥ 35 kg/m2, and comorbidities. Treatment decision-making should focus on individualised holistic treatment, requiring clinical judgement to balance the efficacy and safety of treatments with confounding health factors. Further clarity is needed on the optimal positioning and sequencing of combination therapy.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank all the participants of this study for providing their expert insights and perspectives. Corresponding author Prof. Peter Rossing confirms that permission has been obtained from all acknowledged below. The following people completed both rounds of the Delphi panel, contributing to the results presented here (see Supplementary Material Table S2 for more information): Australia: Roger Chen; Gary Deed; Elif Ekinci; Charlotte Hespe; Kean-Seng Lim; Richard MacIsaac; Tamara Milder; Anita Munoz; Daniel O'Hara; Eugenia Pedagogas; Carol Pollock; Georgia Rigas. China: Dafa Ding; Jing Ding; Chen Nan; Kan Sun; Qing Tian. France: Beatrice Duly Bouhanick; Nicolas Chevalier; Emannuel Cosson; Dominique Delsart; Julia Fidry; Pierre Gourdy; Kavitha Loganathan; Louis Potier; Pierre Jean Saulnier; Damien Tomasso; Philippe Zaoui. Germany: Anja Gabert; Jan Görtzen-Patin; Carsten Hafer; Tilo Hanfstingl; Werner Kalbfleisch; Michael Malt; Ricardo Mauser; Marcel Roos; Petra Sandow. India: Subhajyoti Ghosh. Italy: Angelo Avogaro; Roberto Baratta; Ilaria Barchetta; Paolo Di Bartolo; Riccardo Candido; Salvatore Corrao; Olga Disoteo; Katherine Esposito; Fabrizio Febo; Andrea Giaccari; Sandro Inchiostro; Ernesto Maddaloni; Maria Ida Maiorino; Mario Manunta; Mario Morieri; Raffaele Napoli; Emanuela Setola. Japan: Masahiro Fukuda; Masato Furuhashi; Kazuki Haraguchi; Keizo Kanasaki; Shinji Kume; Yoshifumi Saisho; Masahiro Takihata; Hideaki Tanaka; Tomohiro Tanaka; Yasuo Terauchi; Jun Wada; Toshimasa Yamauchi. Spain: Pilar Alonso Álvarez; Virginia Bellido; María Isabel Egocheaga Cabello; Ana Cebrián Cuenca; Jose Carlos Fernandez; Francisco Manuel Adán Gil; Noemí Pérez León; María Marqués; Cristobal Morales; Pedro Rozas Moreno; Oscar Moreno-Perez; Alberto Ortíz; Antonio Hormigo Pozo. United Kingdom: Lavan Baskaran; Eimear Darcy; Ketan Dhatariya; Ahmet Fuat; Roy Hamilton; Iskandar Idris; Philip Kalra; Maarten Taal; Waqas Tahir; Raj Thakkar; Kristin Veighey; John Wilding. United States: Robert Busch; Gates Colbert; Daniel Edmonston; Aidar Gosmanov; Csaba Kövesdy; Christos Mantzoros; Kevin Pantalone; Athena Philis-Tsimikas; Anthony Provenzano; Sylvia Rosas; Neil Skolnik. Individual written consent of the Delphi panel participants listed above was secured when circulating email invitations to participate in the study.
Medical Writing/Editorial Assistance
The authors acknowledge Alice Knapton, PhD, Noa Chapman, MSc, and Arianna Psichas, PhD from Costello Medical, UK, for management of the Delphi panel, data analysis, medical writing, and editorial assistance based on the authors’ input and direction. Support for third-party writing assistance for this article, provided by Costello Medical, was funded by AstraZeneca in accordance with Good Publication Practice (GPP2022) guidelines (http://www.ismpp.org/gpp-2022).
Author Contributions
Substantial contributions to study conception and methodology: Yehuda Handelsman, Alice Cheng, Gian Paolo Fadini, Pam Kushner, Fabrice Bonnett, Paola Fioretti, Takashi Kadowaki, Naresh Kanumilli, Xavier Cos, Thomas Frese, Linong Ji, Peter Rossing; substantial contributions to analysis and interpretation of the data: Yehuda Handelsman, Alice Cheng, Gian Paolo Fadini, Pam Kushner, Fabrice Bonnett, Paola Fioretti, Takashi Kadowaki, Naresh Kanumilli, Xavier Cos, Thomas Frese, Linong Ji, Peter Rossing; drafting the article or revising it critically for important intellectual content: Yehuda Handelsman, Alice Cheng, Gian Paolo Fadini, Pam Kushner, Fabrice Bonnett, Paola Fioretti, Takashi Kadowaki, Naresh Kanumilli, Xavier Cos, Thomas Frese, Linong Ji, Peter Rossing; final approval of the version of the article to be published: Yehuda Handelsman, Alice Cheng, Gian Paolo Fadini, Pam Kushner, Fabrice Bonnett, Paola Fioretti, Takashi Kadowaki, Naresh Kanumilli, Xavier Cos, Thomas Frese, Linong Ji, Peter Rossing; agreed to be accountable for all aspects of the work: Yehuda Handelsman, Alice Cheng, Gian Paolo Fadini, Pam Kushner, Fabrice Bonnett, Paola Fioretti, Takashi Kadowaki, Naresh Kanumilli, Xavier Cos, Thomas Frese, Linong Ji, Peter Rossing.
Funding
This study was funded by AstraZeneca. Authors received honoraria for their role as SC members and their guidance of the Delphi panel process; no honoraria were received for the development of the manuscript. All associated publication costs, Rapid Service and Open Access Fees, were funded by AstraZeneca. AstraZeneca reviewed Delphi panel statements and this manuscript for technical accuracy and regulatory compliance. AstraZeneca were not involved in the distribution of the Delphi survey, or the collection and analysis of responses. The authors had full editorial control of the manuscript and provided their final approval of all content.
Data Availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Conflict of Interest
All authors have declared any relevant competing interests. Yehuda Handelsman: Received research grants, consultant and speaker honoraria from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Corcept, Eli Lilly, Ionis, Merck, Novo Nordisk, Regeneron, Sanofi, Verdiva Bio; Alice Cheng: Received consulting and speaking honoraria from Abbott, Astellas, Aspen, AstraZeneca, Amgen, Bausch, Bayer, Biomea Fusion, Boehringer Ingelheim, Dexcom, Eisai, Eli Lilly, GSK, HLS Therapeutics, Insulet, Medtronic, Merck, MSD, Novo Nordisk, Pfizer, Sandoz, Sanofi, and Vertex; Gian Paolo Fadini: Received grants, honoraria or lecture fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Guidotti, Mundipharma, Novartis, Novo Nordisk, Servier, and Sanofi; Pam Kushner: Received honoraria for consulting or advisory boards for AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Novo Nordisk and Verdiva Bio; Fabrice Bonnett: No competing interests; Paola Fioretto: Received fees as consultant and speaker for AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly and Novo Nordisk; Takashi Kadowaki: Received research grants from Nippon Boehringer Ingelheim Co., Ltd. and Sumitomo Pharma Co., Ltd.; receiving consulting fees from Taisho Pharmaceutical Co., Ltd., Eli Lilly Japan K.K. and Novo Nordisk Pharma Ltd.; receiving honoraria for lectures from Nippon Boehringer Ingelheim Co., Ltd., Sumitomo Pharma Co., Ltd., Teijin Pharma Ltd., MSD Corporation, Eli Lilly Japan K.K., Mitsubishi Tanabe Pharma Corporation, Taisho Pharmaceutical Co., Ltd. and Novo Nordisk Pharma Ltd; Naresh Kanumilli: No competing interests; Xavier Cos: No competing interests; Thomas Frese: Received payments from Astra Zeneca and Boehringer Ingelheim; Linong Ji: No competing interests; Peter Rossing: Received consultancy and/or speaker fees (to his institution) from Abbott, AstraZeneca, Amgen, Bayer, Boehringer Ingelheim, Eli Lilly, Gilead, Novo Nordisk and Roche; research grants from AstraZeneca, Bayer and Novo Nordisk; study drugs from AstraZeneca, Bayer Lexicon and Novo Nordisk.
Ethical Approval
No patients were involved in the study, which was not submitted for approval by an ethics committee or institutional review board. Participants gave informed consent to participate in the study before taking part and were made aware of the study objectives and the aim for publication of a manuscript. Participants remained independent throughout the Delphi panel; no honoraria were provided for their time or participation in the surveys, and their responses were anonymised from each other and the funder throughout the surveys.
Footnotes
Prior Presentation: Findings from this Delphi panel were presented at the World Congress of Nephrology 2026 (28–31 March), Yokohama, Japan, poster number P362 (Handelsman et al. in WCN26-6543 defining the roles of sglt2is and glp-1 ras in the management of chronic kidney disease with type 2 diabetes and overweight/obesity: a Delphi consensus. World Congress of Nephrology, 2026).
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Change history
6/24/2026
The original article was revised due to update in Funding Information.
References
- 1.Kidney Research UK. Kidney disease: a UK public health emergency. 2023. https://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf. Accessed May 2025.
- 2.KDIGO. 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4s):S117-s314. 10.1016/j.kint.2023.10.018. [DOI] [PubMed] [Google Scholar]
- 3.National Institute for Health and Care Excellence. Chronic kidney disease: what are the complications? 2024. https://cks.nice.org.uk/topics/chronic-kidney-disease/background-information/complications/. Accessed May 2025.
- 4.Prasad R, Jha RK, Keerti A. Chronic kidney disease: Its relationship with obesity. Cureus. 2022;14(10):e30535. 10.7759/cureus.30535. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Friedman AN, Kaplan LM, le Roux CW, Schauer PR. Management of obesity in adults with CKD. J Am Soc Nephrol. 2021;32(4):777–90. 10.1681/ASN.2020101472. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Fenta ET, Eshetu HB, Kebede N, Bogale EK, Zewdie A, Kassie TD, et al. Prevalence and predictors of chronic kidney disease among type 2 diabetic patients worldwide, systematic review and meta-analysis. Diabetol Metab Syndr. 2023;15(1):245. 10.1186/s13098-023-01202-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.American Diabetes Association Professional Practice C. 11. Chronic kidney disease and risk management: standards of care in diabetes. Diabetes Care. 2025;48(1 Suppl 1):S239–51. 10.2337/dc25-S011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Mann JFE, Rossing P, Bakris G, Belmar N, Bosch-Traberg H, Busch R, et al. Effects of semaglutide with and without concomitant SGLT2 inhibitor use in participants with type 2 diabetes and chronic kidney disease in the FLOW trial. Nat Med. 2024;30(10):2849–56. 10.1038/s41591-024-03133-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Perkovic V, Tuttle KR, Rossing P, Mahaffey KW, Mann JFE, Bakris G, et al. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med. 2024;391(2):109–21. [DOI] [PubMed] [Google Scholar]
- 10.Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJ, Charytan DM, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295–306. [DOI] [PubMed] [Google Scholar]
- 11.Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436–46. 10.1056/NEJMoa2024816. [DOI] [PubMed] [Google Scholar]
- 12.Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117–27. 10.1056/NEJMoa2204233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bae JH. SGLT2 inhibitors and GLP-1 receptor agonists in diabetic kidney disease: evolving evidence and clinical application. Diabetes Metab J. 2025;49(3):386–402. 10.4093/dmj.2025.0220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Madero M, Chertow GM, Mark PB. SGLT2 inhibitor use in chronic kidney disease: supporting cardiovascular, kidney, and metabolic health. Kidney Med. 2024;6(8):100851. 10.1016/j.xkme.2024.100851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Agarwal R, Rossing P, Mann JFE. Finerenone with empagliflozin in chronic kidney disease and type 2 diabetes. N Engl J Med. 2025;393(17):1755. 10.1056/NEJMc2513088. [DOI] [PubMed] [Google Scholar]
- 16.Handelsman Y, Cheng A, Fadini GP, Kushner P, Bonnet F, Fioretto P, et al. Evidence-based positioning of sodium-glucose co-transporter protein 2 inhibitors and glucagon-like peptide-1 receptor agonists in the management of chronic kidney disease with type 2 diabetes and overweight or obesity: a systematic literature review. Adv Ther. 2026. 10.1007/s12325-026-03559-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Tsukamoto S, Kobayashi K, Toyoda M, Tone A, Kawanami D, Suzuki D, et al. Effect of preceding drug therapy on the renal and cardiovascular outcomes of combined sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonist treatment in patients with type 2 diabetes and chronic kidney disease. Diabetes Obes Metab. 2024;26(8):3248–60. [DOI] [PubMed] [Google Scholar]
- 18.Gattrell WT, Logullo P, van Zuuren EJ, Price A, Hughes EL, Blazey P, et al. ACCORD (ACcurate COnsensus Reporting Document): a reporting guideline for consensus methods in biomedicine developed via a modified Delphi. PLoS Med. 2024;21(1):e1004326. 10.1371/journal.pmed.1004326. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Junger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on conducting and reporting DElphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review. Palliat Med. 2017;31(8):684–706. 10.1177/0269216317690685. [DOI] [PubMed] [Google Scholar]
- 20.Apperloo EM, Neuen BL, Fletcher RA, Jongs N, Anker SD, Bhatt DL, et al. Efficacy and safety of SGLT2 inhibitors with and without glucagon-like peptide 1 receptor agonists: a SMART-C collaborative meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol. 2024;12(8):545–57. 10.1016/S2213-8587(24)00155-4. [DOI] [PubMed] [Google Scholar]
- 21.Upadhyay A. SGLT2 inhibitors and kidney protection: mechanisms beyond tubuloglomerular feedback. Kidney360. 2024;5(5):771–82. 10.34067/KID.0000000000000425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Yamada T, Wakabayashi M, Bhalla A, Chopra N, Miyashita H, Mikami T, et al. Cardiovascular and renal outcomes with SGLT-2 inhibitors versus GLP-1 receptor agonists in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and network meta-analysis. Cardiovasc Diabetol. 2021;20(1):14. 10.1186/s12933-020-01197-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Misra A. Ethnic-specific criteria for classification of body mass index: a perspective for Asian Indians and American Diabetes Association position statement. Diabetes Technol Ther. 2015;17(9):667–71. 10.1089/dia.2015.0007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ozbek L, Abdel-Rahman SM, Unlu S, Guldan M, Copur S, Burlacu A, et al. Exploring adiposity and chronic kidney disease: clinical implications, management strategies, prognostic considerations. Medicina. 2024;60(10). 10.3390/medicina60101668. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Ma H, Lin YH, Dai LZ, Lin CS, Huang Y, Liu SY. Efficacy and safety of GLP-1 receptor agonists versus SGLT-2 inhibitors in overweight/obese patients with or without diabetes mellitus: a systematic review and network meta-analysis. BMJ Open. 2023;13(3):e061807. 10.1136/bmjopen-2022-061807. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Marso SP, Daniels GH, Brown-Frandsen K, Kristensen P, Mann JF, Nauck MA, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311–22. 10.1056/NEJMoa1603827. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Rodbard HW, Rosenstock J, Canani LH, Deerochanawong C, Gumprecht J, Lindberg SO, et al. Oral semaglutide versus empagliflozin in patients with type 2 diabetes uncontrolled on metformin: The PIONEER 2 trial. Diabetes Care. 2019;42(12):2272–81. 10.2337/dc19-0883. [DOI] [PubMed] [Google Scholar]
- 28.Gerstein HC, Colhoun HM, Dagenais GR, Diaz R, Lakshmanan M, Pais P, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet. 2019;394(10193):121–30. 10.1016/S0140-6736(19)31149-3. [DOI] [PubMed] [Google Scholar]
- 29.Marso SP, Bain SC, Consoli A, Eliaschewitz FG, Jodar E, Leiter LA, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834–44. 10.1056/NEJMoa1607141. [DOI] [PubMed] [Google Scholar]
- 30.Brown P. Diabetes distilled: ABCD–UKKA concise recommendations for management of CKD in type 2 diabetes. Diabetes Prim Care. 2024;26:223–6. [Google Scholar]
- 31.Franchi M, Pellegrini G, Avogaro A, Buzzetti G, Candido R, Cavaliere A, et al. Comparing the effectiveness and cost-effectiveness of sulfonylureas and newer diabetes drugs as second-line therapy for patients with type 2 diabetes. BMJ Open Diabetes Res Care. 2024;12(3). 10.1136/bmjdrc-2023-003991. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Niu S, Bhatt P, Puyat V, Cohen J, Erickson K, editors. 1066-P: Cost-effectiveness of SGLT2i plus GLP-1RAs vs. SGLT2i in patients with chronic kidney disease. American Diabetes Assocation, 85th Scientific Sessions; 2025; Chicago, Illinois.
- 33.Rossing P, Lindhardt M, Tikkanen CK, Menon J, Cattin J, Hunt B, et al., editors. 782-P: Once-weekly semaglutide versus placebo for the treatment of type 2 diabetes and chronic kidney disease in Denmark: a long-term cost-effectiveness analysis based on FLOW. 85th Scientific Sessions of the American Diabetes Association; 2025; Chicago. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.