6.1.2.5 Sodium-glucose co-transporter 2 (SGLT-2) inhibitors

Choice	Drug	Dosage
Formulary choices	Canagliflozin ▼100mg, 300mg tablets	Dose: 100mg once daily; increased if tolerated to 300mg once daily if required.Dose to be taken preferably before breakfast. Renal impairment – see BNF Care should be taken when increasing the dose in adults 75 years and over
		Or
		Dapagliflozin10mg tablets	Dose: 10mg once daily Renal impairment - avoid if eGFR<60mL/min (ineffective) Adults 75 years and over: initiation not recommended
		Or
		Empagliflozin▼ 10mg, 25mg tablets	Dose: 10mg once daily, increased to 25mg once daily if necessary and tolerated. Renal impairment – see BNF Adults 85 years and over: initiation not recommended

Empagliflozin is recommended as first choice SGLT-2 inhibitor in patients with established cardiovascular disease.
Efficacy of SGLT-2 inhibitors is dependent on renal function and is reduced in patients who have moderate renal impairment and likely absent in patients with severe renal impairment.
Prescribe as per NICE Guideline NG28 recommendations. See also NICE Algorithm for blood glucose lowering therapy in adults with type 2 diabetes.
SGLT-2 inhibitors as monotherapies should be prescribed in line with NICE TA 390.
Counsel patients on ‘sick day guidance’ with SGLT-2 inhibitors – click here for further information.

Glycosuria, osmotic symptoms and a slightly higher rate of problems due to volume depletion effects (dehydration, hypovolaemia and hypotension) are seen with SGLT-2 inhibitors. Use with caution in those on loop diuretics, antimuscarinics for urinary symptoms and frail elderly patients.
Serious cases of diabetic ketoacidosis have been reported in patients taking an SGLT-2 inhibitor. See MHRA Drug Safety Update April 2016 for advice.
Canagliflozin may increase the risk of lower-limb amputation (mainly toes) in patients with type 2 diabetes. Evidence does not show an increased risk for dapagliflozin and empagliflozin, but the risk may be a class effect. Preventive foot care is important for all patients with diabetes. See MHRA advice for healthcare professionals.
There have been reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum) with SGLT2 inhibitors. If Fournier’s gangrene is suspected, stop the SGLT2 inhibitor and start treatment urgently (including antibiotics and surgical debridement). Fournier’s gangrene is a rare but potentially life-threatening infection that requires urgent medical attention. See MHRA for further details.