Guideline-Directed Medical Therapies for Diabetic Kidney Disease Among Thai People With Type 2 Diabetes

Background. The “pillar approach” was recently proposed to holistically address diabetic kidney disease (DKD). Theptarin Diabetes Staging (TDS) is a staging system for type 2 diabetes (T2D) designed to prevent or delay the progression to advanced stages. Objective. To evaluate the rate of guideline-directed medical therapies (GDMT) among individuals with DKD from 2021 to 2025 according to the TDS system. Methodology. A retrospective review of medical records of T2D patients with TDS stage 4Ka (moderately increased persistent albuminuria), Stage 4Kb (severely increased persistent albuminuria), and stage 5Ka (eGFR <45 mL/min/1.73 m²) was conducted. The rates of RASi, SGLT2i, GLP-1 RA, and finerenone use, along with achievement of metabolic targets, were evaluated prospectively from 2021 to 2025. Results. A total of 206 medical records were reviewed (mean age 64.1 ± 10.3 years, A1C 7.3 ± 1.2%, mean eGFR 71.6 ± 24.5 mL/min/1.73 m²). In 2021, the use of RASi was 78.2%, 51.5% for SGLT2i and 13.6% for GLP-1 RA among all patients. Four years later, rates of GDMT improved as follows: RASi 79.7%, SGLT2i 59.3%, GLP-1 RA 19.8% and finerenone 2.8%. However, only 1.1% of all patients in 2025 received all 4 GDMT items. More stable or improved TDS were observed in patients who received GDMT ≥3 classes across all 4 medication classes, compared with those who received GDMT <3 classes (96.2% vs. 78.8%, P-value = 0.036). Conclusion. The real-world implementation of GDMT among DKD patients remains inadequate, and more efforts are required to improve GDMT adoption. Regular reviews and feedback are warranted to improve attainment of treatment targets and better clinical outcomes.