Concurrent use of SGLT-2 inhibitors and RAS blockers

Jürgen Floege, MD, is a professor of medicine, director of the Division of Nephrology and Clinical Immunology at the University Hospital RWTH Aachen, Germany, and Distinguished Fellow of the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA).

In the context of the latest data on the efficacy of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in chronic kidney disease (CKD), do you think that an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) must always be used first, or can an SGLT-2 inhibitor be the upfront treatment?

A very good question. Should one start sequentially or should we start with an SGLT-2 inhibitor together with a renin–angiotensin system (RAS) blocker?

And I must say that I’ve recently changed my practice. I no longer wait for the RAS blocker to work and then start the SGLT-2 inhibitor. I start them in parallel and I believe, given that they have a synergistic action, there’s no reason not to do this.