SGLT2 inhibitors are a relatively new class of drug initially licensed for their glucose lowering effects in T2D. Emerging evidence suggests they provide benefits beyond HbA1C reduction, eg, reducing risk of hospitalisation for heart failure, cardiovascular death, and progression of diabetic nephropathy.

It is unclear at present whether these benefits are a class effect and some agents have licences for specific indications. The following flowchart demonstrates some of the factors to consider when initiating an SGLT2 inhibitor.

Further details regarding prescribing in renal/hepatic impairment can be found in the Achieving control in T2DM guidance.  Consideration should also be given to reducing sulfonylurea or insulin dose if adding in an SGLT2 inhibitor to reduce risk of hypoglycaemia.

Glucose lowering effects are dependent on adequate renal function, therefore SGLT2 inhibitors should not be started for glucose lowering if eGFR is less than 60mL/min.
They can be commenced with an eGFR between 30 to 60mL/min for renoprotection in individuals with proteinuria or in the management of heart failure with reduced ejection fraction, along with ACE inhibitor/ARB, etc. If used for these specific indications then they should be continued if eGFR drops below 45mL/min, unless in the context of acute kidney injury, and can be continued if eGFR drops below 30mL/min.

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