In Reply: 2023 Update in ambulatory general internal medicine

We appreciate Ashley Lim’s close read of our review. Regarding the use of SGLT-2 inhibitors in patients without albuminuria, as we point out, the EMPA-KIDNEY trial¹ was the first large randomized trial of SGLT-2 inhibitors to enroll patients with chronic kidney disease without albuminuria. Two other large randomized trials of SGLT-2 inhibitors have evaluated patients with chronic kidney disease with or without diabetes, but both required some degree of albuminuria.^2,3 Thus, we conclude that there is currently no convincing evidence to support using SGLT-2 inhibitors to prevent kidney disease progression in patients with chronic kidney disease without significant albuminuria. Given the higher rates of cardiovascular disease among patients with chronic kidney disease, managing cardiovascular risk (eg, reducing systolic blood pressure in patients with hypertension or initiating statin therapy)⁴ should be prioritized over initiating SGLT-2 inhibitors for these patients until such evidence emerges.

Regarding the feasibility of recommending a Mediterranean diet over a low-fat diet for secondary prevention of major cardiovascular events, we share Lim’s concern that many patients are not able to access, afford, or implement such a diet. Additional measures available to participants of the Delgado-Lista et al study,⁵ including individual and group appointments with dietitians both in person and by telephone, are also unlikely to be available to the majority of patients who may benefit from a Mediterranean diet. Despite these limitations, we found that this study provides important insights into dietary recommendations that clinicians may use when counseling patients with previous cardiovascular disease.

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