Unmasking patients insight into SGLT2 inhibitors- a collaborative quality improvement project to enhance patient education and safety
Authors: Saad L , Saha P , Mohamed M , Kuehl M , Banerjee P , Tran P 
Published: October 2024

Abstract

Background
Sodium-glucose cotransporter 2-inhibitors (SGLT2i) are increasingly prescribed for patients with type 2 diabetes (T2DM) and heart failure (HF) across the spectrum of ejection fraction, due to their cardiorenal and metabolic benefits (1). Amidst the considerable pill burden in this patient population, understanding its drug indication is imperative to maintain compliance. SGLT2i drugs are not without risks. Real-world data suggest a three-fold increase in genital and urinary tract infections (UTI) risk among SGLT2i users (2), while a meta-analysis revealed slightly elevated risks of diabetic foot complications with canagliflozin (3). Hence, to promote medication adherence and self-management, it is imperative to enhance patient awareness of the drug indication and potential side-effects.

Methods
We conducted a face-to-face patient survey involving 100 consecutive inpatients receiving SGLT2i at two hospital sites. The survey, comprising eight questions, explored patient understanding of drug indication, awareness of potential adverse effects including risk of UTI, sick-day rules and if applicable, diabetic ketoacidosis (DKA). The survey also served as a drug counselling opportunity as part of routine clinical care. Findings were communicated to the medicines optimisation team across primary and secondary care settings to drive the development of a concise patient information leaflet (PIL).

Results
Among the 100 patients receiving SGLT2i (mean age 72.5±12.8 years, 75% male), 53 were prescribed for HF (including 16 with HF with preserved ejection fraction) and 47 primarily for T2DM. Dapagliflozin constituted the majority of prescriptions (60%) followed by empagliflozin (40%). 69% were unclear why they were on SGLT2i and only 12% read the manufacturer’s PIL. Understanding of adverse effects were limited, with only 5% aware of sick-day rules and 12% knowledgeable about the risks of UTI. Among patients with diabetes (n=54), awareness of euglycaemic ketoacidosis risks and potential foot complications were low, at 11% and 5.6%, respectively. Patient comprehension did not significantly differ between HF and T2DM-initiated groups (Figure 1). However, a disproportionately higher rate of hospitalisation due to SGLT2i-related adverse effects occurred amongst T2DM-initiated individuals (Figure 1, last row). Notably, 98% felt that it was important to receive such information about drug side-effects from their prescribing clinician. Consequently we collaborated with the medication optimisation team to develop a one-page PIL, made available on the regional formulary website, with updates disseminated to the local diabetic and HF teams (Figure 2).

Conclusion
This quality improvement project highlighted substantial gaps in patient understanding and awareness of SGLT2i therapy. To ensure sustained improvements in patient awareness and adherence, collaborative efforts were initiated to develop a concise SGLT2i information leaflet for patients.