From Guidelines to Ground Reality: High-Value Therapies Miss Eligible Patients

After a lean period that seemed to last forever, kidney protective therapies have emerged in the limelight over the last 10 years. This revolution was led by the introduction of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on the back of large outcome trials that showed clinically meaningful reductions in kidney disease progression and cardiovascular events. This led to their incorporation into guidelines as a core component of care for most patients with CKD, with eligibility extending to relatively low estimated glomerular filtration rate thresholds.

Clinical practice guidelines and evidence-based therapies offer a disciplined approach to chronic disease management where outcomes depend on sustained, longitudinal care. They support consistent decision-making across clinicians and facilities, reduce unwarranted variation, and help shift prescribing away from low-value or non-beneficial practices. Guideline-concordant care also strengthens health-system performance by prioritizing interventions with demonstrated outcome benefit, enabling quality improvement, and aligning decisions with therapies that deliver the greatest health and economic return.

Implementing clinical practice guidelines in routine care is often constrained by clinician, patient, organizational, and system-level barriers. Deficits in clinician awareness and attitudes, such as disagreement with recommendations or limited confidence in applying them to complex patients, and inertia of prior practice, can prevent consistent delivery of recommended therapies. Therefore, the challenge is no longer whether SGLT2i works, but whether health systems can translate trial evidence into routine practice at scale.

Against this backdrop, the article by Gopal and colleagues¹ and the Commentary by Rao and Chelappan² in this issue offer a timely Indian reality check. The observations resonate with broader Indian data on prescribing patterns and guideline-based care for chronic disease. In the Indian CKD (ICKD) cohort, only about half of the participants used RAAS blockers, and fewer than half reported statin use, while a substantial proportion received alternative or indigenous medicines.³ This pattern illustrates the coexistence of partial uptake of high-value therapies and persistent reliance on low-value or non-evidence-based treatments. Older prescribing audits provide compatible signals: a hospital prescription analysis in CKD⁴ described high pill burden and prominent use of vitamins and minerals, suggesting the drift of chronic disease prescribing toward supplements and symptomatic medications and weak or inconsistent application of pathways for prioritizing disease-modifying therapy.

Comparable implementation gaps are documented in Indian cardiovascular disease (CVD) and heart failure care. In stable coronary heart disease, a multi-level audit from Rajasthan⁵ reported substantial attrition in secondary prevention medication bundles at lower levels of care, with far fewer patients in primary care receiving the combination of recommended agents than those discharged from tertiary hospitals. In acute coronary syndromes, the Kerala ACS Registry⁶ reported delivery of “optimal” discharge medication package in <50% admissions. A national physician survey⁷ reported that many clinicians believed only a quarter of their patients with heart failure with reduced ejection fraction (HFrEF) receive guideline-directed medical therapy (GDMT), and a tertiary-care study reported a low proportion of patients receiving GDMT at recommended doses.⁸ These data highlight recurring obstacles: therapeutic inertia, discontinuity after discharge, limited dose titration, incomplete transition from specialist to longitudinal primary-care management, concerns about tolerability, and monitoring demands.

To be fair, this pattern is not limited to India; international reports have also documented slow uptake of SGLT2i even after guideline endorsement.

Improving outcomes in chronic diseases will depend not only on disseminating guideline statements but on strengthening delivery systems that make evidence-based care feasible across settings. The nephrology-specific implications include upstream action: CKD detection in diabetes and hypertension services, greater use of albuminuria testing, and clearer referral triggers; simple, standardized protocols embedded in outpatient workflows, supported by practical monitoring pathways and patient counselling and care models that reduce fragmentation, particularly in systems where patients often receive episodic specialty care.

Payers also need to pay attention. The Prime Minister Jan Arogya Yojana (PM-JAY) scheme does not cover long-term CKD/CVD prevention drugs. Private insurers have also historically focused on hospitalization, though OPD add-ons are expanding. We need sustained funding for outpatient cardio-renal bundles (labs, visits, SGLT2i/RAASi/statins), and audit of concordance of claims with guideline-based therapy. Finally, SGLT2i need to be included in the list of essential medicines and made widely available through the public healthcare system.

In conclusion, chronic disease outcomes in India will improve when evidence-driven and high-value therapies are prioritized early, maintained over time, and delivered through care pathways designed for continuity, monitoring, and affordability. It serves as a call-to-action for implementation-focused nephrology that links evidence to delivery.