SGLT2 Inhibitors Benefit Frail Adults With T2D, Remain Underused

News | Articles | October 25, 2026 Two Kidney Week 2026 analyses tie SGLT2 inhibitors to kidney, CV, and survival gains in T2D, yet over half of patients with diabetic CKD receive neither. Sodium-glucose cotransporter 2 (SGLT2) inhibitors were associated with lower risks of kidney and cardiovascular (CV) events in older adults with type 2 diabetes (T2D), including those who are frail, according to a real-world analysis from South Korea that will be presented at the American Society of Nephrology’s Kidney Week 2026 in Denver, Colorado.

A second nationwide cohort study in the same poster session found that more than half of patients with T2D and albuminuria received neither an SGLT2 inhibitor nor a glucagon-like peptide-1 receptor agonist (GLP-1 RA). The largest gaps were among women, older adults, and patients with advanced chronic kidney disease (CKD).

1,2 Frailty Did Not Erase the Benefit Concerns about dehydration and loss of muscle mass have made SGLT2 inhibitors a harder call in frail older adults, and randomized trials often exclude people with severe frailty, the investigators noted. Sung Jin Moon, PhD, professor at Catholic Kwandong University International St.

Mary’s Hospital in Incheon, South Korea, and colleagues used the Korean National Health Insurance Service-Senior cohort to emulate a target trial. The cohort included adults aged 60 years or older who were taking first-line metformin and started either an SGLT2 inhibitor or another second-line glucose-lowering drug.

Frailty was assessed with 5 validated claims-based indices. 1 Of 151,134 patients, approximately 14.0% were classified as frail. In that group, SGLT2 inhibitor use was associated with a 30% lower risk of a composite kidney outcome and a 19% lower risk of major adverse cardiovascular events (MACE) compared with other second-line agents.

Patients who were not frail showed comparable benefits; however, the kidney benefit in frail patients lost statistical significance when frailty was defined by electronic or global frailty scores. The authors said this warrants careful monitoring and individualized treatment planning.

1 Combination Therapy Linked to Lowest Risk In the second study, Keren Cohen-Hagai, MD, clinical associate professor at Tel Aviv University, and colleagues, including Kamyar Kalantar-Zadeh, MD, MPH, PhD, of The Lundquist Institute in Torrance, California, analyzed 240,734 patients with T2D and a urinary albumin-to-creatinine ratio above 30 mg/g.

The primary composite outcome was death from any cause or end-stage kidney disease. 2 Overall, approximately 55.1% of patients received neither drug class, 18.3% received a GLP-1 RA alone, 13.8% received an SGLT2 inhibitor alone, and 12.8% received both. Among those with an estimated glomerular filtration rate (eGFR) above 30 mL/min/1.73 m 2 , adjusted hazard ratios (HRs) for all-cause death were about 0.33 (95% CI, 0.32-0.34) with an SGLT2 inhibitor alone, 0.46 (95% CI, 0.44-0.48) with a GLP-1 RA alone, and 0.26 (95% CI, 0.25-0.28) with both.

In patients with an eGFR below 30 mL/min/1.73 m 2 , the corresponding HRs were 0.24 (95% CI, 0.19-0.29), 0.55 (95% CI, 0.48-0.61), and 0.17 (95% CI, 0.13-0.23). 2 Caution vs Undertreatment Older age, female sex, lower eGFR, and cerebrovascular disease were associated with receiving neither agent.

2 In an interview with Pharmacy Times , Kalantar-Zadeh said the gap is not simply clinical inertia. “I believe this reflects a combination of legitimate clinical concerns and appropriate risk aversion,” he explained. “In older adults, polypharmacy can cause harm, including volume depletion, gastrointestinal adverse effects, and acute kidney injury.” Patients with eGFR below 25 mL/min/1.73 m 2 “have limited renal reserve and are especially vulnerable to poorly considered prescribing decisions,” according to Kalantar-Zadeh.

“The challenge is distinguishing appropriate caution from avoidable undertreatment.” Current guidance favors treatment. The American Diabetes Association 2026 Standards of Care recommend an SGLT2 inhibitor or a GLP-1 RA for patients with T2D and CKD (level A evidence), and they prefer a GLP-1 RA in advanced CKD (level B evidence).

The standards also position both classes as core risk-reduction strategies regardless of hemoglobin A 1C . 3,4 Where Pharmacists Fit Kalantar-Zadeh sees pharmacists as central to closing the gap. “We need embedded pharmacists in every CKD clinic,” he said.

“As integral members of the clinical team, pharmacists can optimize medications, educate patients, monitor adverse effects, reinforce sick-day precautions, and help navigate insurance coverage and affordability.” He also pointed to dosing practice. “I also value pharmacists’ attention to creatinine clearance and drug-specific dosing recommendations, rather than relying exclusively on body surface area–indexed eGFR,” he said.

“This distinction is particularly important in patients with advanced CKD, where individualized medication decisions and preservation of residual kidney function are paramount.” REFERENCES 1. Moon SJ, Lee JH, Park JT. Kidney and cardiovascular outcomes of SGLT2 inhibitors as add-on therapy to metformin in frail patients with type 2 diabetes.

Abstract SA-PO0405. Presented at: ASN Kidney Week 2026; October 24, 2026. 2.

Cohen-Hagai K, Zitman-Gal T, Kalantar-Zadeh K, et al. Bridging the treatment gap: SGLT2 inhibitors and GLP-1 receptor agonists and outcomes in patients with diabetes and CKD. Abstract SA-PO0406.

Presented at: ASN Kidney Week 2026; October 24, 2026. 3. Type 2 diabetes guideline side-by-side: ADA Standards of Care 2026 vs AACE 2026 algorithm.

Guideline Central. September 3, 2026. Accessed October 16, 2026. https://www.guidelinecentral.com/insights/sep-2026-type2diabetes-guideline-sidebyside/ 4.

Dixon D, Halpern L. ADA 2026: The 2026 ADA Standards—a pharmacist's guide to cardiorenal risk reduction. Pharmacy Times.

June 5, 2026. Accessed October 16, 2026. https://www.pharmacytimes.com/view/ada-2026-the-2026-ada-standards-a-pharmacist-s-guide-to-cardiorenal-risk-reduction Related to this article