184.108.40.206 Sodium-glucose co-transporter 2 (SGLT-2) inhibitors
|Choice||Drug||Dosage (type 2 diabetes)|
|Formulary choices||Canagliflozin 100mg, 300mg tablets|
Dose: 10mg once daily
|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
- Glycaemic lowering 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.
- Dapagliflozin is accepted for use as an option for treating symptomatic chronic heart failure with reduced ejection fraction in adults, only if it is used as an add-on to optimised standard care. Treatment should only be started on the advice of a heart failure specialist. For further information see NICE TA679.
- 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.