SGLT2 Inhibitors for CKD in UK Primary Care 2026: What NICE TA1075 Means in Practice

One change has quietly widened the SGLT2 story well beyond diabetes. In July 2025, NICE technology appraisal TA1075 recommended dapagliflozin for chronic kidney disease in adults — including those without type 2 diabetes — replacing the narrower TA775. The drug class that moved to first-line for diabetes is now a kidney-protection therapy for a much larger population, and most of those patients sit on a primary-care CKD register.

This post is the practical UK primary-care picture: who is now eligible, what dapagliflozin is added to, the eGFR dip that catches clinicians out, the thresholds for starting and stopping, what to monitor, and how to find the patients who qualify but are not yet treated. It is written for UK GPs, GP registrars, GP pharmacists, advanced clinical practitioners, and trainees. The NICE guidance and the BNF entry for each agent remain the authoritative references; this post summarises and links, it does not substitute for clinical judgement.

For the diabetes side of the same drug class, see our companion guide on SGLT2 inhibitors in UK primary care.

What changed in 2025

Dapagliflozin for CKD now includes people without diabetes. NICE TA1075, published 2 July 2025, recommends dapagliflozin as an option for chronic kidney disease in adults, added to optimised standard care. The earlier appraisal, TA775, was more restrictive. The headline of the update is that eligibility is defined by kidney function and albuminuria — not by whether the patient has type 2 diabetes.

Empagliflozin is already recommended for CKD too. Empagliflozin was recommended for chronic kidney disease under NICE TA942 in 2023. Where both agents are suitable for a patient, NICE advises using the least expensive. For most practices, local-formulary preference settles the choice.

Neither appraisal changes the foundations of CKD care. Blood-pressure control, RAAS blockade, cardiovascular risk management, and the usual lifestyle advice still come first. What has changed is that an SGLT2 inhibitor now sits alongside them as a routine part of slowing progression — for a wider group than before.

Who is now eligible

TA1075 defines eligibility by two simple bands. Dapagliflozin is an option for adults with:

• an eGFR of 20 to less than 45 ml/min/1.73m² — no further criteria needed; or
• an eGFR of 45 to 90 ml/min/1.73m² — with either a urine albumin-to-creatinine ratio (uACR) of 22.6 mg/mmol or more, or type 2 diabetes.

In both cases the drug is added to the highest tolerated licensed dose of an ACE inhibitor or ARB, unless those are contraindicated.

The practical consequence is worth stating plainly. In the higher eGFR band, uACR is the gatekeeper — and it is the test most often missing. A patient with an eGFR of 60 and no recorded uACR is invisible to this pathway, not because they do not qualify but because nobody has measured the one value that decides it. The single highest-yield action on a CKD register is often not a prescribing decision at all; it is sending the urine.

Why this is a primary-care job

Most people with CKD in the UK are identified and followed in general practice, through eGFR and uACR monitoring, long before they ever see a nephrologist. The trial evidence behind these appraisals — slowing the decline in kidney function and reducing cardiovascular events — applies squarely to that primary-care population.

So the work lands with GPs, GP pharmacists, and the wider primary-care team: identify eligible patients on the register, check the missing uACR, optimise RAAS blockade, and initiate. Specialist referral remains appropriate for rapidly progressing disease, very low eGFR, diagnostic uncertainty, or where local pathways direct it — but the routine identification and initiation is a general-practice task.

The early eGFR dip that catches people out

Expect a fall in eGFR shortly after starting an SGLT2 inhibitor. It is the single most common reason the drug gets stopped when it should not be.

The dip is haemodynamic — a change in intraglomerular pressure, not kidney injury — and it typically stabilises rather than progressing. The long-term effect of the drug is to slow CKD progression; the early dip is part of how it works, not a sign of harm. UK Kidney Association guidance is to read an early fall as an expected drug effect, not a reason to stop. A large or sustained drop is different and warrants review.

The operational point: set the expectation at initiation, and do not discontinue on the first lower number. A routine early blood test is not needed just because the drug has started (see monitoring requirements below). A clinician who panics at the expected dip removes a patient from a treatment that protects their kidneys.

Prescribing in practice: thresholds, licence and monitoring

Dapagliflozin has three eGFR rules, from three sources. They answer different questions, which is why they do not match.

Minimum eGFR: starting, and when to stop

Starting. NICE TA1075 recommends dapagliflozin from an eGFR of 20 in people who meet its criteria. The licence is wider. The SmPC advises against starting below 15, and notes limited experience of starting below 25. The UK Kidney Association suggests a start below 20 can be considered, as a weaker, grade 2B suggestion. So a start between 15 and 20 is licensed, but it falls outside TA1075 and is not a routine primary-care start. It should generally involve renal specialist advice and your local prescribing guidance.

Continuing. A declining eGFR is not, by itself, a reason to stop dapagliflozin. The UK Kidney Association recommends continuing SGLT2 inhibitors until kidney replacement therapy is required, provided treatment remains appropriate and tolerated (grade 1A). The SmPC's eGFR threshold is for starting treatment. It does not set one for stopping.

In type 2 diabetes, the glucose-lowering effect fades with kidney function. It is reduced below an eGFR of 45 and likely absent in severe impairment. The kidney benefit does not depend on it. Below 45, consider adding other glucose-lowering treatment, rather than stopping dapagliflozin for that reason.

What the licence covers

Dapagliflozin (Forxiga) is licensed for chronic kidney disease in adults. The CKD indication sets no eGFR band, no albuminuria threshold and no diabetes requirement. Those criteria come from NICE.

The dose is 10 mg once daily, with no adjustment for renal function. In severe hepatic impairment, start at 5 mg and increase to 10 mg if tolerated. Dapagliflozin should not be used in people with type 1 diabetes, because of the increased risk of diabetic ketoacidosis.

Treatment started before TA1075 was published in July 2025, outside its criteria, can continue.

Before you start

• An ACE inhibitor or ARB at the highest tolerated licensed dose, unless contraindicated.
• A recent eGFR and uACR. In the 45 to 90 band, the uACR decides eligibility.
• Correct hypovolaemia first. In anyone at high risk of it, consider an early clinical review and, if appropriate, a lower diuretic or antihypertensive dose.
• Check the feet. Avoid starting with active foot disease: infection, ulceration or ischaemia.
• In type 2 diabetes on a sulfonylurea or insulin, the UK Kidney Association recommends considering a dose reduction in selected people: by 50% for a sulfonylurea or 20% for insulin, where HbA1c is under 58 mmol/mol and eGFR is above 45. It is not an automatic adjustment. Base it on the person's glycaemic control, hypoglycaemia risk and degree of insulin deficiency.
• In type 2 diabetes with risk factors for ketoacidosis, start with caution and discuss with the diabetes team.
• Women who could become pregnant: counsel before conception, and stop if pregnancy is planned, suspected or confirmed.

Monitoring requirements

There is no fixed blood-test schedule for dapagliflozin itself. The BNF entry has no monitoring section, and the SmPC sets no routine renal check. Routine bloods follow the CKD. Clinical review follows the person's risk.

• No routine early blood test just because it has been started. The UK Kidney Association advises that kidney function and potassium do not routinely need checking soon after initiation. People at higher risk of hypotension, dehydration or volume depletion may need an earlier clinical review.
• Read an early eGFR fall as expected. If eGFR is checked in the first few weeks, a modest fall is the expected haemodynamic effect, not an automatic reason to stop. Creatinine may rise at first, and the rise is generally transient.
• Glucose control in type 2 diabetes as eGFR falls below 45 (see above).
• Volume status during intercurrent illness, such as gastroenteritis. Pause dapagliflozin if volume depletion develops, until it is corrected.
• Sick-day rules at every medication review, not just at initiation (see the cautions below).
• In hospital: for major surgery or acute serious illness, interrupt treatment and monitor ketones, preferably in blood. Restart once ketones are normal and the patient is stable.

Ongoing CKD surveillance carries on as before, whether or not dapagliflozin is started. NICE NG203 sets a minimum frequency of eGFR checks for each CKD stage, while ACR monitoring is individualised. Calcium, phosphate and PTH are checked as appropriate for the stage.

Urine tests positive for glucose throughout treatment, which matters when reading a dipstick.

The cautions that still apply

Dapagliflozin for CKD is a single 10 mg daily dose with no titration, which makes it operationally simple. The cautions are largely the familiar SGLT2 ones, and they carry across whether or not the patient has diabetes:

• Genitourinary infection — genital thrush and, less often, UTI, particularly in the first months. Hygiene advice at initiation is worthwhile; recurrent or severe infection is a reason to reconsider.
• Volume depletion — relevant in older patients and those on diuretics. Review concurrent diuretic doses at initiation.
• Sick-day rules — pause during acute illness with vomiting, diarrhoea, fever or sepsis, and around major surgery. Restart once the person is eating and drinking normally and any volume depletion has been corrected; after a hospital admission, once ketones are normal and the condition has stabilised. Ketoacidosis on an SGLT2 inhibitor can be euglycaemic, with near-normal glucose, so test for ketones in anyone with symptoms of it, even if glucose is not raised. The risk is much lower in patients without diabetes, but the pause-during-acute-illness principle still holds.
• Foot care — continued vigilance, especially for patients with prior ulcer, neuropathy, or amputation.

Our SGLT2 inhibitors in UK primary care guide covers these cautions in more operational detail, including the euglycaemic DKA picture in the diabetes population.

Finding the patients who qualify

The yield here is in the register, not the new diagnosis. A targeted search of the CKD register — patients with reduced eGFR, those with albuminuria already recorded, and those with no uACR on file — surfaces the eligible-but-untreated cohort quickly.

A practical sequence:

1. Search the CKD register for patients in the TA1075 eGFR bands.
2. Flag those with no recent uACR and arrange the test — this is the step that unlocks the higher eGFR band.
3. Check RAAS blockade is optimised to the highest tolerated dose.
4. Initiate the formulary-preferred SGLT2 inhibitor and set the eGFR-dip expectation. An early recheck is not routinely needed; if one is done, read a modest fall as expected.
5. Document the sick-day rules conversation.

None of this requires a new clinic. It is register work, and it is the highest-return use of the time.

A note on what this post is — and is not

This is a guideline and policy summary for awareness. It is not a substitute for NICE TA1075, NICE TA942, the NICE CKD guideline, the BNF, or local prescribing policy. Renal cut-offs, monitoring intervals, and licensing change intermittently and should be confirmed before initiation. Clinical and prescribing decisions remain the responsibility of the prescribing clinician.

The Monday Clinical Brief publishes weekly summaries of every new paper from five hand-picked journals in each of 31 UK medical specialties. We surface them, summarise them, and link to them, so practice-changing material does not get missed in a busy clinical week.

Related reading

• SGLT2 inhibitors in UK primary care 2026: the practical prescribing guide — the diabetes side of the same drug class, with the full cautions detail.
• NICE NG28 February 2026: SGLT2 inhibitors first-line for type 2 diabetes — the guideline update that moved this class to first-line in diabetes.
• Statins and CVD prevention in UK primary care 2026 (NICE NG238) — cardiovascular-risk management in the same high-risk CKD population.

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