The SGLT2 inhibitor gap: why are we missing opportunities in primary care?

BACKGROUND

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have evolved from glucose-lowering agents to cornerstone therapies for cardiovascular disease (CVD), chronic kidney disease (CKD), and heart failure (HF). The National Institute for Health and Care Excellence now recommends their use in people with type 2 diabetes and cardiorenal disease, and for all with symptomatic HF or CKD, irrespective of diabetes status. Despite this, uptake in UK primary care remains low.

AIM: The aim was to explore barriers contributing to the under-prescription of SGLT2 inhibitors in UK general practice.

METHOD: Recent UK prescribing data, national surveys, and qualitative studies examining GP perspectives on SGLT2 inhibitors were reviewed.

RESULTS

Despite guideline endorsement, prescribing remains inconsistent. Paradoxically, patients with CVD are less likely to receive an SGLT2 inhibitor (9.8%) than those without (13.8%). Barriers were identified at prescriber, patient, and system levels. Prescribers cited unfamiliarity with newer agents, concerns about adverse effects, difficulty keeping pace with emerging evidence, and therapeutic inertia when HbA1c appears 'controlled'. Access to specialist input also influenced behaviour - where endocrinology support is accessible, initiation is often deferred. Patient-related factors included polypharmacy, perceived side effects, and low motivation. System-level barriers such as restrictive formularies and prescribing budgets further limited uptake.

CONCLUSION

SGLT2 inhibitors are now central to evidence-based management of common primary care conditions. Closing this evidence-practice gap requires better dissemination of trial data, enhanced prescriber confidence, and supportive health system structures.