Guideline-directed medical therapy adoption for diabetic kidney disease remains low among Thai T2D patients
Background
Diabetic kidney disease (DKD) is a severe complication of Type 2 Diabetes (T2D), often leading to end-stage renal disease. The "pillar approach" emphasizes holistic management using multiple guideline-directed medical therapies (GDMTs) to slow progression and improve outcomes. Despite robust evidence for agents like SGLT2i, GLP-1 RA, RASi, and finerenone, real-world implementation remains a challenge. The Theptarin Diabetes Staging (TDS) system offers a structured way to monitor T2D progression, highlighting the need to assess how effectively these therapies are being deployed in clinical practice to prevent advanced DKD stages.
Study Design
Researchers conducted a retrospective review of 206 medical records from T2D patients with DKD in Thailand, specifically those categorized under TDS stage 4Ka (moderately increased persistent albuminuria), 4Kb (severely increased persistent albuminuria), and 5Ka (eGFR <45 mL/min/1.73 m2). The study prospectively evaluated the rates of use for RASi, SGLT2i, GLP-1 RA, and finerenone from 2021 to 2025. Additionally, the achievement of metabolic targets and the stability or improvement of TDS stages were assessed, comparing patients receiving GDMT ≥3 classes versus <3 classes.
Results
The review of 206 patient records (mean age 64.1 ± 10.3 years, A1C 7.3 ± 1.2%, mean eGFR 71.6 ± 24.5 mL/min/1.73 m2) revealed initial GDMT adoption rates in 2021: RASi was used by 78.2%, SGLT2i by 51.5%, and GLP-1 RA by 13.6% of all patients. By 2025, these rates showed modest improvement: RASi use reached 79.7%, SGLT2i 59.3%, GLP-1 RA 19.8%, and finerenone 2.8%. Despite these increases, a significant gap in comprehensive care persisted.
Only 1.1% of all patients in 2025 received all four guideline-directed medical therapies (RASi, SGLT2i, GLP-1 RA, and finerenone). Patients who received
GDMT ≥3 classesdemonstrated more stable or improved TDS stages (96.2%) compared to those receiving<3 classes(78.8%,P-value = 0.036), highlighting the clinical benefit of multi-drug regimens.
Key Findings
- In 2021, RASi use was 78.2%, SGLT2i 51.5%, and GLP-1 RA 13.6% among DKD patients.
- By 2025, GDMT rates improved to RASi 79.7%, SGLT2i 59.3%, GLP-1 RA 19.8%, and finerenone 2.8%.
- Only 1.1% of patients received all four guideline-directed medical therapies by 2025.
- Patients on
GDMT ≥3 classeshad significantly more stable/improved TDS (96.2%) vs.<3 classes(78.8%,P=0.036).
Why It Matters
This real-world data underscores a critical gap in the implementation of comprehensive guideline-directed medical therapies (GDMT) for diabetic kidney disease (DKD), even with the availability of highly effective agents. Clinicians must prioritize and actively improve the adoption of multi-drug GDMT regimens for T2D patients with DKD. The finding that only 1.1% of patients received all four recommended therapies by 2025 indicates a substantial opportunity for intervention. Proactive strategies, including regular patient reviews, feedback mechanisms, and educational initiatives, are crucial to enhance adherence to guidelines. This could significantly improve the attainment of treatment targets, slow DKD progression, and ultimately lead to better clinical outcomes for patients, moving beyond single-agent approaches to truly holistic care.
diabetic kidney disease
type 2 diabetes
gdmt
sglt2i
glp-1 ra
ras inhibitor