--- title: "Differential uptake of SGLT2 inhibitors in England after 2023 heart failure guideline expansion" id: "bmj-open-22-differential-uptake-of-sglt2-inhibitors-in-england-following-heart-failure" canonical_url: "https://medichelpline.com/clinical-feed/bmj-open-22-differential-uptake-of-sglt2-inhibitors-in-england-following-heart-failure" content_type: "clinical_feed_article" specialty: "Cardiology" source_name: "BMJ Open" source_url: "http://bmjopen.bmj.com/cgi/content/short/16/9/e122364?rss=1" published_at: "2026-09-22T17:11:09.000Z" evidence_level: "Journal Feed" license: "CC-BY-NC-4.0 / Informational Use" --- # Differential uptake of SGLT2 inhibitors in England after 2023 heart failure guideline expansion ## Provenance & Clinical Metadata - **Canonical URL:** https://medichelpline.com/clinical-feed/bmj-open-22-differential-uptake-of-sglt2-inhibitors-in-england-following-heart-failure - **Specialty:** [Cardiology](https://medichelpline.com/clinical-feed/cardiology.md) - **Primary Source:** BMJ Open - **Source URL:** [Original Journal Publication](http://bmjopen.bmj.com/cgi/content/short/16/9/e122364?rss=1) - **Published At:** 2026-09-22T17:11:09.000Z - **Evidence Rating:** Journal Feed ## Executive GIST (TL;DR) - This controlled interrupted time series study examined national primary care prescribing in England from January 2019 to December 2025 to assess changes in uptake of three monotherapy **SGLT2 inhibitors**—**dapagliflozin**, **empagliflozin**, and **canagliflozin**—after July 2023 guideline expansion for heart failure. - The analysis used segmented regression with Newey-West standard errors and month fixed effects to account for seasonality; aggregate drug-level data were analysed, with monthly utilisation in defined daily doses (DDDs) as the primary outcome. - Secondary outcomes included monthly prescription items, market share of total SGLT2 inhibitor DDDs, and net ingredient cost (NIC). - Overall utilisation rose for all three drugs, but trajectories diverged after July 2023: **dapagliflozin** market share increased from 33.2% to 55.9%, **empagliflozin** declined to 41.0%, and **canagliflozin** to 3.1% of total SGLT2 DDDs. - Controlled ITS found no immediate step change at the guideline expansion month; however, **dapagliflozin** showed a significant differential postintervention slope increase relative to **canagliflozin** (β=0.042, 95% CI 0.035 to 0.049). The reported p-value was not provided in the source. - A large concurrent fall in **dapagliflozin** NIC (from £1.38 to £0.35 per DDD) is an important competing explanation; exploratory adjustment for NIC reduced the dapagliflozin effect estimate by about one-third, but NIC may be endogenous and the attenuation cannot be interpreted causally. - The smaller price change for **empagliflozin** accompanied a more modest differential effect, an observation described as hypothesis-generating and requiring confirmation with methods able to separate guideline and price influences. - Key limitations: aggregate, ecological design without patient-level indications (so changes cannot be attributed specifically to heart failure), potential endogeneity of NIC, and inability to definitively ascribe causality to guideline changes. - The authors conclude guideline expansions affecting an entire drug class do not guarantee uniform uptake across individual drugs, highlighting the need for drug-specific monitoring that accounts for clinical, economic, and policy drivers. ## Clinical Analysis & Structured Key Points Objectives To assess differential changes in prescribing uptake of dapagliflozin and empagliflozin relative to canagliflozin in England following the July 2023 expansion of heart failure guideline recommendations. Design Controlled interrupted time series (ITS) analysis using segmented regression with Newey-West SEs and month fixed effects to account for seasonality. Setting and participants National monthly primary care prescribing data in England (January 2019 - December 2025). Aggregate prescribing data were analysed at the drug level. Primary and secondary outcome measures Primary outcome: monthly utilisation measured in defined daily doses (DDDs). Secondary outcomes: monthly prescription items, market share of total SGLT2 inhibitor DDDs and net ingredient cost (NIC). Results Overall utilisation increased for all three monotherapy SGLT2 inhibitors, but prescribing trajectories diverged markedly following the intervention. Dapagliflozin's market share rose from 33.2% to 55.9%, while empagliflozin declined to 41.0% and canagliflozin to 3.1%. The controlled ITS model showed no immediate step change at July 2023. However, dapagliflozin demonstrated a significant differential postintervention slope increase relative to canagliflozin (β=0.042, 95% CI 0.035 to 0.049; p Conclusions SGLT2 inhibitor uptake in English primary care has been highly heterogeneous. The marked acceleration in dapagliflozin prescribing from July 2023, against stable background trends for canagliflozin, is temporally consistent with expanded heart failure guideline recommendations. However, several important limitations preclude definitive causal attribution. First, because this study analysed aggregate prescribing data without patient-level indications, we cannot directly attribute observed changes to heart failure rather than to diabetes, chronic kidney disease or other factors. Second, the substantial concurrent reduction in dapagliflozin's NIC (from £1.38 to £0.35 per DDD) represents a competing explanation; exploratory adjustment for NIC attenuated the dapagliflozin estimate by approximately one-third, though this magnitude cannot be interpreted as a causal attribution because NIC may be endogenous. The observation that empagliflozin, which experienced a more modest price change, showed a smaller differential effect is hypothesis-generating and requires confirmation with methods that can separate guideline from price effects. Third, the ecological design inherently limits causal inference. These findings highlight that class-wide guideline updates do not translate into uniform prescribing and underscore the importance of monitoring drug-specific adoption patterns while considering the complex interplay of clinical, economic and policy factors. ## Related Clinical Research - [SGLT2 inhibitors and urinary tract infection risk: trial-level meta-analysis across T2D, HF, and C](https://medichelpline.com/clinical-feed/pubmed-42566081.md) (DOI: 10.1007/s40199-026-00637-7) - [SGLT2 inhibitors vs GLP-1 RAs and osteoarthritis risk in type 2 diabetes: a multi-institutional co](https://medichelpline.com/clinical-feed/plos-one-16-comparative-effects-of-sglt2-inhibitors-and-glp-1-receptor-agonists-on.md) - [SGLT2 inhibitors and secondary polycythemia: hematologic effects in type 2 diabetes](https://medichelpline.com/clinical-feed/pubmed-42587114.md) (DOI: 10.1007/s00228-026-04160-1) - [Machine learning and deep learning prediction of hypertension and key risk factors in Bangladesh](https://medichelpline.com/clinical-feed/plos-one-12-machine-learning-and-deep-learning-based-prediction-of-hypertension-and.md) - [Long-term cardiovascular risk after assisted reproductive technology and infertility: nationwide c](https://medichelpline.com/clinical-feed/plos-medicine-0-long-term-risk-of-cardiovascular-disease-after-assisted-reproductive-technology.md) ## Navigation - [← Back to Cardiology Feed](https://medichelpline.com/clinical-feed/cardiology.md) - [← All Clinical Specialties](https://medichelpline.com/clinical-feed.md) ## Medical & Regulatory Disclaimer > [!CAUTION] > MedicHelpline content is structured for research, educational, and professional discovery purposes. 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