The SGLT2 inhibitors have had a profound effect on chronic disease management, in particular, in those living with chronic kidney disease, heart failure, or seeking to reduce cardiovascular risk in type 2 diabetes.

There has been a quiet but profound shift in how we understand and use them. What began as a class of glucose-lowering agents has become central to the management of chronic kidney disease and heart failure. Most clinicians now recognize their role in slowing kidney decline and reducing cardiovascular events.

And yet, when kidney function falls into the low 20s – or below – many of us still hesitate.

That hesitation is not unreasonable. It reflects how these drugs were originally studied and how their use was first framed. But it is increasingly at odds with what we now understand about how they work and where their benefits lie.

How the Threshold Entered Practice

The commonly cited eGFR “floor” for SGLT2 inhibitors comes from the major clinical trials – CREDENCE, DAPA-CKD, and EMPA-KIDNEY.

Each of these studies required a minimum eGFR for enrollment, generally in the range of 20 to 30 mL/min/1.73 m². That decision has often been interpreted as implying that the drugs are ineffective or unsafe below those levels.

In reality, those thresholds were pragmatic. At the time these trials were designed, SGLT2 inhibitors were still largely viewed through a glycemic lens, and there was understandable caution about introducing them in advanced CKD. Trial populations also need to be bounded to allow for interpretable results.

Over time, however, those entry criteria have taken on a life of their own. What began as a study design choice has come to feel like a biological boundary.

What the Trials Actually Tell Us

One detail that tends to receive less attention is what happened after patients entered these trials.

Kidney function did not remain static. Many participants experienced progressive decline in eGFR, often falling well below the initial enrollment threshold. In general, however, they were not required to discontinue therapy as this occurred. Regulatory summaries of these trials now make this explicit, noting that patients in studies such as DAPA-CKD and related programs continued therapy even as eGFR declined below the entry criteria.

Importantly, there was no signal that benefit disappeared once a patient crossed an arbitrary eGFR value. Nor was there a late-emerging safety concern specific to lower levels of kidney function.

This creates a situation that is difficult to reconcile clinically. A patient who began treatment at an eGFR of 28 and has since declined to 17 is typically continued on therapy without much debate. A patient who first presents at an eGFR of 17, however, may be considered a less appropriate candidate to start.

The physiology in these two situations is the same. The difference lies in how the evidence was generated, not in how the drug behaves.

Moving Beyond the Glycemic Frame

Part of the persistence of this threshold comes from the way these drugs were originally conceptualized.

It remains true that the glucose-lowering effect of SGLT2 inhibitors diminishes as eGFR falls. With less filtered glucose, there is less glycosuria, and HbA1c reductions become modest.

But the outcomes that have driven their widespread adoption in CKD are not primarily related to glycemic control.

The more relevant mechanism is hemodynamic. By inhibiting sodium reabsorption in the proximal tubule, these agents increase sodium delivery to the macula densa, restore tubuloglomerular feedback, and reduce intraglomerular pressure. This results in a functional “unloading” of the glomerulus.

That mechanism does not appear to switch off at a specific eGFR. It is active in moderate CKD and, based on both physiology and trial experience, likely remains operative in more advanced stages as well.

Once one accepts that the benefit is largely independent of glucose lowering, the rationale for a strict lower threshold becomes less clear.

Interpreting the Early Rise in Creatinine

The initial rise in serum creatinine that accompanies SGLT2 inhibitor initiation continues to generate concern, particularly in patients with more advanced CKD.

At lower baseline eGFR, even a modest increase can feel consequential. It is often interpreted, understandably, as a sign that the kidney is being harmed.

However, in most cases, this early change reflects a reduction in intraglomerular pressure rather than structural injury. The same principle underlies the rise in creatinine seen with initiation of ACE inhibitors or ARBs – a phenomenon that is now widely accepted as part of their renoprotective effect.

Seen in that light, the early “dip” in eGFR is less a complication than an expected physiological response. It requires clinical judgment, particularly in patients at risk of volume depletion or other competing insults, but it should not automatically be viewed as a reason to avoid or discontinue therapy.

Where the Benefit May Be Greatest

Another important consideration is how treatment effect translates into clinical benefit across different levels of kidney function.

Meta-analyses, including large collaborative work led by David Neuen, suggest that relative risk reductions for kidney outcomes are broadly consistent across eGFR strata. However, because baseline risk is substantially higher in patients with more advanced CKD, the absolute benefit may be greater in this group.

In practical terms, a modest slowing of decline at an eGFR of 20 may translate into a meaningful delay in the need for dialysis. That is often of greater consequence to patients than a similar relative effect earlier in the disease course.

This raises an important question: are we withholding therapy from the very patients who stand to gain the most?

The Evolving Position of Guidelines

Guidelines have begun to reflect this shift in understanding.

KDIGO recommends SGLT2 inhibitors in patients with diabetes and CKD down to an eGFR of 20 mL/min/1.73 m² and explicitly notes that the reversible fall in eGFR after initiation is generally not a reason to stop therapy.

Diabetes Canada (2025 update) supports their use in patients with eGFR 20–45, even in the absence of significant albuminuria in many cases.

American Diabetes Association similarly recommends SGLT2 inhibitors for patients with CKD down to an eGFR of 20 for kidney and cardiovascular protection.

At the same time, regulatory labeling remains somewhat heterogeneous. For example, Jardiance (empagliflozin) does not specify a strict lower eGFR threshold for heart failure indications, whereas Farxiga (dapagliflozin) continues to advise against initiation below eGFR 25 while permitting continuation if kidney function later declines.

Taken together, this reflects a field in transition. The conceptual model has shifted, but the practical boundaries have not fully aligned.

A Practical Way to Approach the Patient at Low GFR

When considering whether to initiate an SGLT2 inhibitor in a patient with advanced CKD, it may be helpful to reframe the question.

Rather than focusing primarily on whether the patient meets the entry criteria of a particular trial, one might ask:

• Is the underlying mechanism of benefit still relevant at this level of kidney function?

• Is there evidence, direct or indirect, that benefit persists as eGFR declines?

• Would I be comfortable continuing this therapy if the patient had already been on it?

If the answer to the last question is yes, it is worth examining why initiation feels different.

That difference may be more reflective of how the evidence was generated than of any meaningful change in biology.

Conclusion

SGLT2 inhibitors are no longer best understood as glucose-lowering drugs. Their primary role in CKD is to modify intraglomerular hemodynamics and reduce the downstream consequences of hyperfiltration and injury.

The eGFR thresholds that continue to shape prescribing patterns originated as pragmatic decisions in clinical trial design. Over time, they have been interpreted as markers of biological effectiveness.

As evidence accumulates and guidelines evolve, that interpretation is becoming harder to sustain.

For clinicians, the challenge is not simply to follow thresholds, but to understand where they came from – and when it may be reasonable to look beyond them.

References

1. de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2022;102(5):974-989. doi:10.1016/j.kint.2022.08.012.

2. Herrington WG, Staplin N, Wanner C, et al; EMPA-KIDNEY Collaborative Group. Empagliflozin in Patients with Chronic Kidney Disease. N Engl J Med. 2023;388(2):117-127. doi:10.1056/NEJMoa2204233.

3. EMPA-KIDNEY Collaborative Group. Effects of Empagliflozin on Progression of Chronic Kidney Disease: A Prespecified Secondary Analysis from the EMPA-KIDNEY Trial. Lancet Diabetes Endocrinol. 2024;12(1):39-50. doi:10.1016/S2213-8587(23)00321-2.

4. Nuffield Department of Population Health Renal Studies Group; SGLT2 inhibitor Meta-Analysis Cardio-Renal Trialists’ Consortium. Impact of Diabetes on the Effects of Sodium Glucose Co-Transporter-2 Inhibitors on Kidney Outcomes: Collaborative Meta-Analysis of Large Placebo-Controlled Trials. Lancet. 2022;400(10365):1788-1801. doi:10.1016/S0140-6736(22)02074-8.

5. Neuen BL, Fletcher RA, Anker SD, et al. SGLT2 Inhibitors and Kidney Outcomes by Glomerular Filtration Rate and Albuminuria. JAMA. 2026;335(3):233-244. doi:10.1001/jama.2025.20834.

6. Chatur S, Fletcher RA, Yeung E, et al. SGLT2 Inhibition in Patients With Type 2 Diabetes and CKD Experiencing a Deterioration in Estimated Glomerular Filtration Rate to <20 mL/min/1.73 m². J Card Fail. 2026. doi:10.1016/j.cardfail.2026.01.020.

7. Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018.

8. American Diabetes Association Professional Practice Committee. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes – 2026. Diabetes Care. 2026;49(Suppl 1):S246-S260. doi:10.2337/dc26-S011.

9. Diabetes Canada Clinical Practice Guidelines Expert Committee. Chronic Kidney Disease in Diabetes: 2025 Update. Diabetes Canada Clinical Practice Guidelines. 2025.

10. Cherney DZI, Odutayo A, Aronson R, Ezekowitz J, Parker JD. Sodium Glucose Cotransporter-2 Inhibition and Cardiorenal Protection: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;74(20):2511-2524. doi:10.1016/j.jacc.2019.09.022.

Medication coverage in British Columbia is meant to ensure everyone can get the drugs they need. Yet, in my experience, many patients still face barriers. In this post, I’ll explain how BC’s PharmaCare system works, why middle-income patients often fall through the cracks, and what solutions exist or should be considered to make prescription drugs more accessible.

Understanding BC’s Fair PharmaCare Deductible System

BC’s Fair PharmaCare program is the province’s income-based drug coverage plan. In simple terms, the less your family’s adjusted net income is, the more assistance you get with prescription costs. Coverage is determined by annual deductibles (the amount you pay out-of-pocket each year before PharmaCare starts paying) and family maximums (the limit after which PharmaCare covers all eligible costs for the rest of the year). Here’s a quick breakdown:

• Lowest incomes (e.g., adjusted net family income below approximately $20,000) – No deductible; PharmaCare covers 100% of eligible prescription costs right away.

• Moderate incomes – A deductible applies, which is a percentage of your adjusted net family income. After this deductible, PharmaCare typically covers 70% of eligible costs (or 75% for families with a senior member born before 1940) until a family maximum is reached, then 100%.

• Higher incomes – A higher deductible (proportional to income) must be paid out-of-pocket before coverage kicks in. After the deductible, PharmaCare typically covers 70% of eligible drug expenses (or 75% for families with a senior member born before 1940) for the rest of the year (until the family maximum is met, after which it covers 100%).

The intent of this system is to protect families from catastrophic drug costs while asking those with higher incomes to contribute more. It works well for many: families with very low incomes pay nothing for eligible prescriptions, and those with very high incomes can generally afford their costs or have private insurance. However, many patients in the middle – not ultra-poor, but not wealthy – encounter serious challenges under this system.

Middle-Income Patients Caught in the Middle

For patients of modest or middle income, the annual deductible can be a significant hurdle. In Metro Vancouver (with its high cost of living), I’ve met patients who simply cannot afford to spend hundreds or thousands of dollars on medications early in the year, even though they would get coverage later in the year once their deductible is met.

Ironically, these are often working people or seniors on fixed pensions who don’t qualify for zero-deductible assistance but also don’t have the spare cash that higher-income families do.

To illustrate, consider a family with a combined income that gives them a $1,200 annual deductible. If their medication costs are about $200 a month, they will pay full price for roughly the first six months of the year (until they’ve paid $1,200) before PharmaCare coverage kicks in. During those first six months, this family gets no help at all, even though by year’s end they will have paid the same $1,200 out-of-pocket whether it was spread out or lumped at the start.

For a family living paycheque-to-paycheque, front-loading all their drug expenses in the first half of the year is a heavy burden – some end up delaying or forgoing medications in those early months simply because they can’t afford the upfront cost. In effect, the deductible system can be unfair to those with limited cash flow or savings, even if their total annual drug expense may be manageable over 12 months.

Not Filing Taxes – No Coverage

Another hidden issue is that PharmaCare eligibility relies on filing income taxes. The program checks your reported income (from two years prior) to set your deductible each year. If you haven’t filed a tax return, PharmaCare has no income info for you – meaning you may be treated as if you have the highest income. In fact, if income data isn’t available, PharmaCare assigns a default $10,000 deductible (essentially no effective coverage at all). Many vulnerable patients – for example, those who are homeless, dealing with mental health issues, or new immigrants unfamiliar with the system – do not file taxes and thus miss out on PharmaCare coverage they should be eligible for.

Even some low-income seniors fall through the cracks by not filing; as BC’s Seniors Advocate noted, it’s distressing that people with very low incomes are “forgoing hundreds or thousands of dollars in benefits that depend on filing tax returns” – and Fair PharmaCare is one of those key benefits.

What can be done? For patients in this situation, the first step is often help with filing taxes. There are community programs and free clinics that will do tax returns for low-income individuals at no charge. The Canada Revenue Agency’s Community Volunteer Income Tax Program operates free tax clinics across the country for those with modest incomes.

In BC, health authorities and non-profits regularly host such clinics – “There are free tax clinics that can help. Ask your patient to Google ‘free tax clinic’.” as one Vancouver Coastal Health guide advises doctors. Even the provincial government has a help line: the Ministry of Social Development and Poverty Reduction will assist people in getting ID and filing their taxes so they don’t miss out on benefit.

Crucially, if a patient was exempt from filing Canadian taxes (e.g., new resident, worked overseas, or a minor with no income), they can submit a Fair PharmaCare Proof of Income Affidavit to report their income directly to PharmaCare and establish their coverage.

Bottom line: filing that tax return or submitting an affidavit can open the door to PharmaCare coverage, and free help is available to do it if patients know where to look.

A Solution to the Deductible “Cash-Flow” Problem

If a family knows they’re likely to spend enough on prescriptions to meet their deductible each year, there is a little-known option that can prevent the mid-year coverage gap.

BC PharmaCare offers a Monthly Deductible Payment Option (MDPO). Under the MDPO, instead of paying your whole deductible out-of-pocket before getting coverage, you arrange to pay it in equal monthly installments throughout the year. As soon as you enroll in MDPO, PharmaCare acts as if you’ve met your deductible – meaning you get immediate coverage of eligible prescriptions right from January 1st. You then pay your portion at the pharmacy and also pay your fixed monthly payment toward the deductible to the government. By the end of the year, you will have paid the same amount, but your costs are spread evenly each month, which is much more manageable for people on a fixed budget.

For example, the family with the $1,200 deductible could enroll in MDPO and pay $100 per month. PharmaCare would start covering 70% of their prescription costs immediately, so they’d only pay 30% at the pharmacy all year. Note: the exact amount covered (e.g., 70%) depends on a family’s income level and PharmaCare’s coverage rules.

This does remove that six-month “no coverage” window and ensures they aren’t forced to delay treatments early in the year. It essentially turns a large yearly bill into a predictable monthly expense.

How to enroll: You must be registered for Fair PharmaCare and have a deductible greater than $0 to qualify.

It’s important to note that you cannot be enrolled in MDPO if you have private health insurance with a drug benefit plan, as this can complicate or delay your private health benefits if PharmaCare processes claims as primary payer.

To sign up, you fill out a one-page form (the MDPO enrolment form, code HLTH 5303) and mail or fax it to PharmaCare.

Note: If you plan to use the MDPO for the current year, you need to enroll by late September of that year to spread payments; otherwise you can enroll for the next calendar year. Once enrolled, your monthly payment can be set up as an automatic bank withdrawal or you can pay via monthly invoices. PharmaCare will provide tax receipts so you can claim the deductible payments as medical expenses on your income tax later.

The MDPO isn’t widely known, but it can be a lifesaver for middle-income patients who struggle with upfront medication costs. One of my aims in writing this is to raise awareness of this option – it makes the PharmaCare system a bit fairer for those who have the income “on paper” but not in their wallets on January 1st.

When Private Insurance Creates Additional Hurdles

It’s not only the uninsured or middle-class who have issues – paradoxically, even patients with private drug insurance plans can hit roadblocks to accessing medications.

Many extended health benefit plans in BC are designed to work in coordination with PharmaCare (often called a “PharmaCare tie-in”). In practice, this means if a prescription is expensive or falls under certain categories, your insurance will only cover it after you’ve gone through the PharmaCare approval process for that drug.

Typically, these are medications that PharmaCare covers only under special conditions – for example, expensive brand-name drugs or biologics that require a doctor to certify that certain criteria are met. Under a PharmaCare tie-in, the doctor must submit a “Special Authority” request to BC PharmaCare on the patient’s behalf, and only if PharmaCare grants approval (or at least acknowledges the request) will the private insurance plan pay its share.

The rationale is that this ensures the drug is being used appropriately and that the insurance isn’t paying for something the provincial plan would cover. From a system cost perspective it makes sense – but for patients and doctors, it’s yet another layer of bureaucracy.

The real-world impact: I’ve seen patients caught in limbo waiting weeks (sometimes months) for a Special Authority approval and processing of such approval.

As of August 2026, B.C. reports that regular Special Authority requests take approximately four weeks; eForms are often processed faster.

With the current doctor shortage, getting the forms filled out can be challenging – doctors are extremely busy, and paperwork may not be prioritized. Some physicians are even reluctant to complete the forms or charge the patient an extra fee to do so (since form-filling isn’t an insured service).

While physicians should generally not charge patients for Special Authority forms that are a prerequisite for PharmaCare coverage of eligible drugs, some clinics may charge an administrative fee for completing forms, particularly if requested by a third-party insurer.

From the patient’s perspective, this is a double barrier: a form that might be delayed or cost money to have completed. Meanwhile, the clock is ticking and the patient cannot get coverage for the medication until the paperwork goes through.

In many cases, people simply give up and don’t start a potentially beneficial drug therapy because the process is too onerous or they can’t afford to pay out-of-pocket during the delay. It’s a frustrating situation where having insurance doesn’t actually guarantee timely access to medication. What can be done here? For now, patients should know their rights: if a physician does charge a fee for a Special Authority form, many insurance plans will reimburse that fee as part of health benefits. (For example, Pacific Blue Cross explicitly advises that any fees for Special Authority forms “are covered, and should be submitted to PBC” for reimbursement.) That at least removes the financial sting of the form for the patient, though it requires the patient to pay upfront and navigate another claim.

System-Level Improvements

• Streamline the Special Authority process.

  BC PharmaCare has moved some forms online (Special Authority eForms are generally faster), but more integration with doctors’ electronic medical records could help. If it was faster and easier for prescribers to complete these requests (or if certain criteria could be pre-approved), it would reduce delays.

  The province could also allocate more resources to process approvals faster – a few years ago when a large employee group was moved onto PharmaCare-linked coverage, Special Authority wait times ballooned to 2–3 months, a delay which is simply unacceptable when someone needs medication. Shortening that turnaround time is critical.

• Allow other healthcare professionals to assist.

  Pharmacists, for example, might be empowered to initiate Special Authority requests or help coordinate the paperwork, especially for straightforward cases. Some pharmacists already help by suggesting covered alternatives or generics to bypass the need for special approval. Expanding their role could take pressure off doctors and speed up patient access.

• Re-examine insurance policy.

  Do all these cases truly need prior PharmaCare approval? In some instances, the requirement could be waived if the patient’s physician provides direct justification to the insurer.

  Insurers could implement their own timely prior authorization review (many do for drugs that aren’t tied to PharmaCare) so that patients aren’t left waiting on a government process. Alternatively, insurers might offer interim coverage for a month or two of therapy while a PharmaCare decision is pending, so at least the patient isn’t without treatment.

• No patient left unsupported.

  As a policy goal, neither government nor insurers should design systems that leave a patient in the lurch. If we value public health, we should consider universal pharmacare or at least tighter coordination between public and private drug plans to eliminate these gaps.

  The federal Advisory Council on Pharmacare pointed out that one in five Canadians struggles to afford their prescriptions and many suffer worse health outcomes as a result.

  We can do better, even within our provincial program, to ensure that having insurance (public, private, or both) actually translates into getting your medications without undue hassle.

Moving Forward: Making PharmaCare Truly Fair

BC’s PharmaCare system has laudable aims and does help thousands of families afford life-saving drugs. But as I’ve outlined, there are several gaps that hit hardest on those in the middle – people with limited cash flow, or those facing bureaucratic obstacles. From the patient who didn’t file a tax return and unknowingly misses out on coverage, to the senior who can’t afford their pills until mid-year when their deductible is finally met, to the individual whose insurance insists on an approval that’s stuck on a doctor’s crowded to-do list – these are all fixable problems. What are the solutions? On a practical level, we should:

• Connect patients with tools and supports (like free tax clinics, the Proof of Income Affidavit, and the MDPO payment plan) so they can access the benefits already in place.

• Increase awareness among both the public and healthcare providers about these issues – many patients don’t know why they suddenly have a $10,000 deductible or that they could spread their payments monthly; many doctors may not realize the financial strain their patients are under early in the year or the importance of that Special Authority form.

• Advocate for policy changes: for example, consider automatically enrolling all residents in PharmaCare when they get their BC Services Card/MSP by facilitating consent for income verification, so no one is unknowingly uncovered. The government could also consider lowering deductibles or co-pays for middle-income brackets to lessen the upfront burden (even if it means slightly higher co-insurance later in the year). And as discussed, streamlining the special approval process or coordinating it better with private insurers would remove a needless barrier to care.

As a doctor, I hate to see a patient’s health suffer because of an inability to pay for or navigate the system for their prescriptions. Medications only work if you can actually get them. BC has a strong foundation with PharmaCare, but by addressing these gaps – making sure everyone files their taxes or provides income proof, smoothing out deductibles over the year, cutting red tape between insurers and PharmaCare – we can ensure that “PharmaCare” truly provides care, and not just in name. It’s about fairness and compassion: no patient should have to choose between paying the rent and taking the medication that keeps them healthy.

Sources:

• BC Ministry of Health – Fair PharmaCare coverage and deductibles

• BC Ministry of Health – Tax filing requirements for PharmaCare

• BC Ministry of Health – Fair PharmaCare Proof of Income Affidavit

• Vancouver Coastal Health – Guide for physicians on helping patients afford meds

• BC Ministry of Health – Monthly Deductible Payment Option (MDPO) details

• BC Ministry of Health – current MDPO enrolment form

• Pacific Blue Cross – Prior authorization and PharmaCare Special Authority (and relevant FAQs about fee reimbursement)

• BC Ministry of Health – Special Authority (SA) Turnaround Times

• Canada Revenue Agency – Community Volunteer Income Tax Program 

Canada is well-known for its universal healthcare system, which provides all citizens and permanent residents with access to medically necessary hospital and physician services without direct charges at the point of care.

Yet, when it comes to prescription medications, the picture is somewhat different. While Canada has lower drug prices than many countries, some Canadians still face significant out-of-pocket expenses.

Fortunately, several strategies and programs are available to help Canadians reduce the cost of pharmaceutical drugs. This article will summarize some of the primary methods Canadians can use to access medications at reduced or subsidized prices.

1. Provincial and Territorial Drug Benefit Programs:

Each province and territory in Canada has its drug benefit program to help cover the costs of prescription drugs for specific populations, often based on age or income. For instance:

• Ontario offers the Ontario Drug Benefit (ODB) program, which covers eligible drug costs for seniors, individuals residing in long-term care homes, and those on social assistance.
• British Columbia has the PharmaCare program, which offers income-based assistance to residents. To take advantage of these programs, residents typically need to apply and meet certain eligibility criteria.

2. Private Insurance:

Many employers offer private health insurance as part of their benefits packages. These insurance plans can cover a portion of prescription drug costs, reducing out-of-pocket expenses for the insured. It’s essential to understand the specifics of your plan, including co-pays, deductibles, and the list of covered medications.

3. Patented Medicine Prices Review Board (PMPRB):

The PMPRB is a federal agency responsible for ensuring that the prices of patented medicines sold in Canada are not excessive. While consumers do not interact directly with the PMPRB, its work indirectly benefits Canadians by keeping drug prices in check.

4. Generic Drugs:

Generic drugs are bioequivalent versions of brand-name drugs that usually come at reduced cost. When a prescription is written, Canadians can ask their pharmacists if a generic version of the medication is available. In many cases, switching to a generic can result in significant savings without compromising on treatment efficacy.

5. Patient Assistance Programs:

Several pharmaceutical companies operate patient assistance programs that offer certain medications at reduced prices or even for free to qualifying individuals. These programs are often designed for patients without insurance or those who cannot afford their medications due to financial hardships. It’s worth checking the drug manufacturer’s website or contacting them directly to see if such a program is available for a specific medication.

6. Bulk Purchasing:

Some provinces have formed alliances to negotiate and buy drugs in bulk, achieving better prices due to the higher purchasing volume. As a result, patients in these provinces may benefit from lower prices on certain medications.

7. Comparison Shopping:

Prices for the same drug can vary between pharmacies. Before filling a prescription, it might be worthwhile to compare prices at different pharmacies. Some online platforms and apps can help Canadians compare drug prices and find the best deals.

8. Tax Deductions:

Canadians can claim the cost of prescription drugs as a medical expense on their income tax return, which can result in tax savings. Ensure you keep all receipts and consult with a tax professional about eligible expenses.

9. Private Health Service Plans

Private Health Services plans (PHSPs) allow business owners and incorporated professional to use business income to pay for the personal medication costs of the business owner (as well as their employees). The medications are payed for without the owner/employee  paying any extra taxes for the benefit, and the business can claim the healthcare expenses as tax deductions. Providers such as CarbonFibre Financial offer self-administered private health services plans. 

10. National Pharmacare:

There’s ongoing debate and advocacy for the establishment of a national pharmacare program in Canada, which would offer universal drug coverage to all Canadians, similar to the existing healthcare system. If such a program is implemented in the future, it could significantly reduce or eliminate out-of-pocket expenses for prescription medications.

In Conclusion:
While Canada boasts a healthcare system that is the envy of many countries, prescription drug costs remain a concern for many citizens. However, by being informed and proactive, Canadians can utilize several avenues to reduce their medication expenses. Whether through provincial programs, exploring generic options, or tapping into patient assistance programs, a combination of strategies can help ensure that necessary medications remain accessible and affordable.

In Canada (and elsewhere) we are facing unprecedented barriers in accessing physicians (both primary care & specialty care) & other healthcare providers.

Many barriers exist, but lack of time is a major contributor to lack of physicians access. There are only so many hours in the day. 

There is a huge opportunity to enhance & modify IT processes to give healthcare providers back time that can then be reinvested in patient care. HCP time is a zero-sum game.

Time we lose gets taken from another source – usually patient care.

If doctors are wasting 15% of their time on low value/no-value activities (a very conservative estimate), should this time be recaptured, it could be invested back into patient care. In a fee-for-service model, this is a win-win opportunity. We improve access to doctors without recruiting while doctors remain incentivized by the fee for service model. 

I work in Fraser Health, BC’s largest health authority and will share ideas on how IT could help find more time for HCPs in its 12 hospitals. For all these ideas, let’s assume privacy & security will be sorted out. Many of these suggestions are essentially MEDITECH suggestions (the EHR used in FHA) but many could be implemented quite simply.

1. Achieve faster boot up and login for hospital computers running on Windows

Hospital computers are painfully slow to load with many processes running at boot up/login. For a consultant seeing 25 patients in a day, if it takes 3 minutes to reboot/login to each computer, that’s 1h and 15 minutes spent waiting for a computer to turn on, while literally staring at a blank screen.

Let’s get this down to 5 seconds per login.

If someone else is already logged in to a computer, allow a new user to login without having to do a 6 minute computer restart. We have to share computers. That feature is available, but locked out.

2. Create & share custom patient lists on MEDITECH

For those not MRP but still following patients, eg all consultants, currently no ability to easily track or find location of ones patients.

When patients move to a new location, the clinician doesn’t know and often wastes time walking to the wrong location & searching for your patient.

How about working with MEDITECH to create an “add to my list” feature.

Then be able to share these lists so that members of the same team (or colleagues covering on call) can easily share patient care.

3. Push notifications

It’s 2022 and mobile devices are here to stay.

Push notifications (PNs) are a powerful solution to be alerted to time sensitive results.

When waiting for lab/imaging results, clinicians have no idea when or if an important result is available, unless they manually search for it repeatedly throughout the day.

How about tagging results that you want PNs for?

Waiting for a CBC or creatinine before discharging a patient? Get the PN and then discharge once patient is stable.

Or get a PN with critical results so the ward staff don’t need to wasted tracking down the MD.

For implementation, obviously no PHI in the PN, just deep link into a secure mobile portal. And create algos to avoid excess noise.

4. Missing lab tests

MEDITECH does not allow one to differentiate if blood tests are just pending in the lab vs not actually drawn. Make this more clear so that missing tests can drive action. Currently, one doesn’t generally clue in that “pending” results are never coming.

5. Who’s caring for which patient?

At present, there is no clear solution to determine who is looking after each patient. Even if we sorted this out for the daytime hours, healthcare is a 24h operation. MRP coverage can changes 1-2 time per 24h period. Each patient can have multiple consultants, and eachh consulting service can change covering MD 1-2 time per 24h period. If you get the name of the appropriate MD, it is then cumbersome to get their contact info. And then unclear how to find that person through secure messaging/phone. Let’s solve this in the EHR or an integrated solution.

6. Create workflow & standardized communication for urgent & emergent medical imaging

At present, if urgent imaging is required, it can be very time consuming to figure out who to talk to. Most physicians will have to physically walk to the radiology department to find a radiologist to speak with. Many just order enter and hope it gets done in a timely fashion. Neither option is efficient.

Must create a solution to connect via digital devices (voice/messaging) with the correct radiologist. Can be asynchronous but must be fast/efficient.

Of course, also need solution for automated alerting when the desired images have been taken, rather than logging into a computer and reloading repeatedly.

7. Vital signs

Clinicians spend an incredible amount of time trying to find handwritten vital signs. They likely spend 3-6 minutes per patient looking for vital signs. For a consultant seeing 25 patients in a day, that’s ≥ 1h and 15 min spent wandering around looks for vital signs.

Often, HCPs give up and never review them.

This also applies to any other bedside records (glucose monitoring, weights, med administration, etc)

The feature already exists but is not used widely within the organization.

8. Smartphone access

It’s 2022. Provide app-based access to EHR and all process issues described in this list. We spend too much time hunting for free computers and waiting to login, yet everyone has a smartphone in their pocket.

If we do make smartphones part of our workflow, batteries will die. Wired and wireless recharging must be ubiquitous.

9. Facilitate seamless inpatient to outpatient care

Patients being discharged are at high risk of readmission and often need close outpatient followup. However, there is no seamless method to arrange follow up in a private MD office, and have pending imaging/labs forwarded to the outpatient setting. Current methods are prone to error, time consuming and allow patients to slip through the cracks.

10. Getting/replacing hospital ID

Hospital ID cards are required for opening most doors and accessing the computer system. It’s effectively impossible to work in the hospital if one loses an ID card. Currently take days to weeks to replace an ID card and impossible to solve outside regular business hours. However, hospitals run 128 h/week outside of regular business hours.

Hotels can replace a card in 60 seconds. Need to change processes so that in the unlikely event of a lost card, we don’t lose a clinician for hours to days. The temporary card replacement solution in place has significant barriers and effectively doesn’t work. It must be fast & work after regular hours.

This is a highly subjective list, but these trials have been included as they have had a meaningful impact on guidelines, patients and clinicians at a global scale.

1. IDNT: Irbesartan Diabetic Nephropathy Trial

A randomized, blinded, placebo-controlled trial designed to assess whether irbesartan or amlodipine slow the progression of nephropathy in patients with type 2 diabetes, independent of effects on systemic blood pressure (BP) lowering.

The primary outcome, a composite of doubling of serum creatinine, onset of end-stage renal disease, serum creatinine ≥6.0 mg/dl, or death from any cause, was reduced by 23% compared to the amlodipine group (32.6% vs. 41.1%, p=0.006).

The authors found that the angiotensin-II–receptor blocker irbesartan is effective in protecting against the progression of nephropathy due to type 2 diabetes. This protection is independent of the reduction in blood pressure it causes.

https://www.nejm.org/doi/full/10.1056/nejmoa011303

2. RENAAL: Reduction in End Points in NIDDM with the Angiotensin II Antagonist Losartan study

In this study, it was shown that losartan reduced the incidence of a doubling of the serum creatinine concentration and end-stage renal disease. The benefit exceeded that attributable to changes in blood pressure.

It was published at the same time as the IDNT study.

https://www.nejm.org/doi/full/10.1056/nejmoa011161

3. The Effect of Angiotensin-Converting-Enzyme Inhibition on Diabetic Nephropathy

This was a randomized, controlled trial comparing captopril with placebo in patients with type 1 diabetes mellitus who had protein in the urine of ≥ 500 mg per day.

This was an important study as it showed that captopril treatment was associated with a 50 percent reduction in the risk of the combined end points of death, dialysis, and transplantation. Notably, it was significantly more effective than blood-pressure control alone.

https://www.nejm.org/doi/full/10.1056/NEJM199311113292004

4. CREDENCE: Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy

The first study to show that an SGLT2i can reduce kidney outcomes in patients with diabetes and kidney disease.

This study showed that in patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group.

https://www.nejm.org/doi/full/10.1056/nejmoa1811744

5. DAPA-CKD: Dapagliflozin in Patients with Chronic Kidney Disease

The first study to show that an SGLT2i can reduce kidney outcomes in both people with and people without diabetes.

Specifically, the authors found that among patients with chronic kidney disease, regardless of the presence or absence of diabetes, the risk of a composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes was significantly lower with dapagliflozin than with placebo.

https://www.nejm.org/doi/full/10.1056/NEJMoa2024816

6. FIDELIO: Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes

While MRAs, including finerenone (a nonsteroidal, selective mineralocorticoid receptor antagonist) had been shown to reduce albuminuria in short-term trials involving patients with chronic kidney disease (CKD) and type 2 diabetes, long-term benefits on kidney and cardiovascular outcomes were unknown.

This was the first study that showed that in patients with CKD and type 2 diabetes, treatment with finerenone resulted in lower risks of CKD progression and cardiovascular events than placebo.

https://www.nejm.org/doi/full/10.1056/NEJMoa2025845

7. EMPA-KIDNEY: Empagliflozin in Patients with Chronic Kidney Disease

The first study to show that an SGLT2i can reduce kidney and cardiovascular outcomes in both people with and people without diabetes, independent of whether albuminuria is present.

Specifically, the authors found that among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin led to a lower risk of progression of kidney disease or death from cardiovascular causes.

https://www.nejm.org/doi/full/10.1056/NEJMoa2204233

EMPA-KIDNEY was a clinical trial testing whether taking a single pill of empagliflozin every day prevents worsening of kidney disease or deaths from heart disease in people who have chronic kidney disease (CKD). The trial was stopped early due to evidence of efficacy and was reported in November 2022 at the American Society of Nephrology ‘Kidney Week’ meeting and simultaneously published in the New England Journal of Medicine

1. Further solidifies SGLT2 inhibitors as the standard of care in managing CKD

Based on CREDENCE and DAPA-CKD, guidelines already recommend SGLT2i in chronic kidney disease. The American Diabetes Association and Diabetes Canada clinical practice guidelines recommend the use of SGLT2 inhibitors in people living with T2D and CKD as Grade A, Level 1 evidence.

The 2022 KDIGO (Kidney Disease Improving Global Outcomes) guidelines recommend the use of SGLT2 inhibitors when eGFR is ≥20 ml/min. This trial should further solidify this position.

2. Increase comfort starting SGLT2i treatment with a GFR as low as 20 ml/min

In the trial, patients were eligible for the study if they were adults with eGFR of at least 20 ml per minute (notably, regardless of the level of albuminuria)

Clinicians remain hesitant to start SGLT2i at lower GFRs so this study should help reassure the safety and efficacy at lower values.

3. Increase comfort continuing an SGLT2i below a GFR of 20 ml/min, even all the way down to dialysis initiation.

Like the CREDENCE and DAPA-CKD trials, EMPA-KIDNEY had patients remain on treatment all the way down to dialysis

Many clinicians get worried about continuing an SGLT2i when GFR is < 20 ml/min. There are now 3 kidney trials showing this strategy is both safe and effective.

4. Adds Empagliflozin as an SGLT2i with primary evidence of benefit in chronic kidney disease

Prior to EMPA-KIDNEY, we knew from primary outcome trials that dapagliflozin and canagliflozin had kidney protective effects. Empagliflozin has now been added to this list.

5. SGLT2i will be more widely used in patients without diabetes

This is now the 2nd major trial (after DAPA-CKD) which shows benefit in CKD whether or not someone has diabetes.

6. SGLT2 inhibitors may have beneficial effects even in the absence of protein in the urine

EMPA-KIDNEY included patients with CKD but without albumin in the urine (albuminuria). The primary outcome was not remarkably impacted in this subgroup, though this isn’t entirely surprising as the trial was stopped early and events are just less common in patients without albuminuria. There was, however, an impact on slope of GFR – this suggests there may be more impact on kidney outcomes over a longer period of time.

7. Another argument why SGLT2i may be the statins of the 21st century

Dr. Eugene Braunwald has called the SGLT2i class ‘the statins of the 21st century’ (Eur Heart J, 2022, qxmd.com/r/34741610/). This study showed impressive reductions in cardiovascular events, a repeated finding in multiple studies of SGLT2 inhibitors.

The SPRINT trial made waves in the field of hypertension, showing evidence for reduced hard clinical endpoints (a combined outcome of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes) in those patients with a BP target of 120 mm Hg systolic.

At the same time, it was clearly shown that more intensive blood pressure control drove increased risk of adverse events, including hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure.

The challenge with randomized clinical trials is that the results, while considered valid for the total population studied, may not apply to individual patients who simply meet the enrolment criteria for the study.

Some of those patients would derive more benefit and less harm, while others will see more harm and fewer benefits.  As the world moves towards personalized medicine, it would be ideal to be able to individualize how we apply the results of a clinical trial.

The CREBP Journal Club reviewed SPRINT and made the comment (which they shared in their PubMed Commons post):

Whether the interventions are beneficial for an individual patient appears to be dependent on the individual clinical circumstances and the preferences of the patient. We would strongly recommend the development of methods for improving shared decision making with patients on this topic before recommending this intervention be part of routine practice.

Well, enter the SPRINT data analysis challenge, and researchers like  Noa Dagan, MD, MPH, the head of data at Clalit Research Institute, Rahul Aggarwal, Boston University School of Medicine, and Joseph Rigdon, PhD from Stanford University.

Researchers like these re-analyzed the SPRINT data, made available by the NIH and its researchers, in order to derive more specific recommendations for individual patients.

Each researcher had a unique approach to personalizing the trial to individual patients or subgroups of patients.  Perhaps most fascinating was the approach taken by contest winner Dr. Dagan and her group, where they adapted the concept of the Number Needed to Treat (NNT) and calculated iNNT – the individualized number needed to treat (or harm).  Unlike the NNT which suggests how many all-comers would need to be treated to see a benefit of treatment, the iNNT represents the number of people, identical to the person in front of you, who would need to be treated to see one of them benefit.

Attempts to individualize treatment recommendations based on the balance of benefit vs harm obviously requires some subjective evaluation of how much real patients might value a potential benefit versus fear a potential harm.

It is clear that this type of analyses will require more patient input on the values, wishes and beliefs which would determine acceptability of treatment.  That being said, it is exceptionally exciting to see raw clinical trial being opened to the public, with researchers finding novel ways to personalize the applicability of a landmark clinical trial.

See the winning presentations at the SPRINT Data Analysis Challenge.

On a personal note, as medical director of QxMD, I’m eager to collaborate with researchers doing this type of work to adapt personalized decision support tools into the app Calculate by QxMD, so that we can make the results of this work accessible to the 1.5 million clinicians who use our platform every year.

SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26;373(22):2103-16. PMID: 26551272.

At last week’s Medicine rounds at the Royal Columbia Hospital, I presented the results from the recently published SPRINT trial.

SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26;373(22):2103-16. PMID: 26551272.

In short, my thoughts are that this is a very well done study with no concerning methodologic issues that affect the validity of the results.

With a clinically and statistically significant reduction cardiovascular outcomes and mortality, the benefits of a systolic BP target of <120 mm Hg appear to be quite meaningful in the population studied, despite the high NNTs.

It should be clearly noted that this study excludes those with prior stroke, diabetes, nursing home residents, among others.

That being said, it appears to be broadly applicable (with ~17 million Americans fitting the enrollment criteria), including the elderly and many with chronic kidney disease.

As a nephrologist, I was really encouraged to see that almost 30% of patients enrolled had CKD (with GFR 20-60 ml/min, with the exclusion of PKD, GN requiring immunosuppression, and proteinuria > 1 gm/day).  My clinical practice is certainly made up of plenty of patients who would satisfy the inclusion and exclusion criteria of the study.

Caution should be taken before applying the findings of this study to all patients who meet the enrollment criteria given the increased rate of serious adverse events in the intensive BP control arm (<120 mm Hg systolic), especially given that in the real world, adverse events can be higher than in clinical trials.

I take particular note that worsening GFR and acute kidney injury were more common in the intensive BP control arm, though chronic dialysis was not increased.  The rates of temporary dialysis in AKI were not reported, and it would be important to ensure this was not significantly increased in the intensive BP arm.

It’s also important to point out that in real world clinical practice (ie outside a clinical trial), even achieving a BP target of  <140 mm Hg can be quite hard (with at least 1/3 of hypertensive Americans above target), so shooting for a target of  <120 mm Hg may not be achievable in many patients.

All this being said, in those patients who I feel I can safely monitor and follow closely, I will be offering intensive BP control, after reviewing the risks, benefits and alternative.  As with any therapy that offers both potential advantages and risks, a decision on which BP target to use will require a careful discussion with our patients.

For those interested, here are my slides: