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

Prescribing Notes

• Prescribe as per NICE NG28 recommendations.  See also NICE visual summary for blood glucose lowering therapy in adults with type 2 diabetes. Differences in licensed indications between the SGLT-2 inhibitors should be considered when selecting an appropriate drug.
• For information on using SGLT-2 inhibitors for people with type 2 diabetes and CKD refer to NICE NG28.
• Counsel patients on the signs and symptoms of DKA and advise them to seek immediate medical advice if they develop any of these.
• Counsel patients on ‘sick day rules’ with SGLT-2 inhibitors.
• See the Patient Area for a downloadable SGLT2i PIL.

Non-diabetes indications

• Heart Failure: Empagliflozin and dapagliflozin are licensed for heart failure, see NICE:NG106 for further information.
• CKD: Dapagliflozin and empagliflozin are accepted for use as an option for treating CKD in adults, only if used as an add- on to optimised standard care as specified in NICE TA1075 and NICE TA942.

Cautions

• 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 and frail/elderly patients.
• Serious cases of DKA have been reported in patients taking a SGLT-2 inhibitor. A number of factors may predispose patients to DKA e.g. a history of pancreatitis, alcohol abuse, conditions leading to restricted food intake or severe dehydration see MHRA for full details. Address modifiable risks for DKA before starting an SGLT-2 inhibitor. For example, people who are following a very low carbohydrate or ketogenic diet may need to delay treatment until they have changed their diet.
• SGLT-2 inhibitors should be interrupted in patients who are hospitalised for major surgical procedures or acute serious medical illnesses and ketone levels measured – refer to MHRA.
• SGLT-2 inhibitors should be permanently discontinued post DKA unless another clear precipitating factor is identified and resolved (specialist decision).
• SGLT-2 inhibitors should not be prescribed in type 1 diabetes.
• 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 SGLT-2 inhibitors. If Fournier’s gangrene is suspected, stop the SGLT-2 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.