OBJECTIVES: The nephroprotective effect of antidiabetic medications is emphasized in guidelines for diabetic kidney disease (DKD) but evidence of real-world utilization and renal effectiveness is limited. This research aims to demonstrate the prescription patterns of antidiabetic medications by drug class and examine the subsequent renal outcomes among patients with DKD.

METHODS: Diabetic patients with stable antidiabetic treatment and incident estimated glomerular filtration rate (eGFR)<60 were identified from Taiwan's National Health Insurance datasets between 2016-2018. Baseline renal function was classified by eGFR as 45-59 (stage 3a), 30-44 (stage 3b), 15-29 (stage 4) and <15 (stage 5). Prescription patterns of anti-diabetic agents were presented as the exposure by drug class after stratifying the Diabetic Complications Severity Index (DCSI) and baseline renal function. Renal outcome was defined as a drop in eGFR stages or initial kidney replacement therapy (KRT). Patients receiving sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and dipeptidyl peptidase-4 inhibitors (DPP4i) were compared for renal effectiveness by survival analysis.

RESULTS: A total of 47,568 DKD patients were identified, 59.82% were stage 3a, 22.20% were stage 3b, 9.04% were stage 4 and 8.95% were stage 5. The increased trends were presented in insulin use (23 to 33%), DPP4i use (50 to 58%) and total number of antidiabetic medications as renal function deteriorated. In contrast, the decreased proportions were reported in the exposure of metformin (60 to 14%) and SGLT-2i (2.31 to 0.51 %). Compared with DPP4i, SGLT-2i had better survival benefits in extending time to renal progression and KRT no matter individual use or combination with other antidiabetic agents.

CONCLUSIONS: This real-world data revealed the prescription pattern of antidiabetic agents according to the renal function and diabetes severity. Our finding is also consistent with previous studies that SGLT2i slows the decline in eGFR and delays the onset of KRT.