Do you prefer to simultaneously start an ACEi/ARB and SGLT2i or initiate one prior to the other in a patient with proteinuria secondary to diabetic kidney disease?

I would start ACE/ARB first. If, after 4-5 months the proteinuria is not within goal, then would add SGLT-2. Also, this will ensure that blood pressure does not drop too much.

I would almost always start one, see how things go, then consider another if needed. If hypertensive would start with an ACEI/ARB. I would want to see creatinine, K, BP before adding an SGLT-2i. If BP well controlled and not a lot of proteinuria, could consider SGLTi first.

The use of SGLT2I's lessens blood flow going to the diabetic glomerulus (G) via the afferent arteriole of the G. This reduction causes a lowering of the pressure in the G.

ARBs and ACE-I's lower the pressure in the G by reducing the pressure of the efferent arteriole.

The additive effect of lowerin...

I typically start ARB or ACEi and then reassess the degree of Uacr; if, after a few months, renal function has tolerated it, and the Uacr remains above 30 mg/g, I will add the SGLT2i, given the significant cardiovascular benefits, which are greater than the renal benefits. In the elderly, I frequent...