From the Guidelines
SGLT2 inhibitors for diabetes can be safely reintroduced once the cellulitis has resolved, the patient is clinically stable, and has transitioned from IV to oral antibiotics, typically after being afebrile for at least 24-48 hours, with reduced erythema and swelling, and improving inflammatory markers, as recommended by recent guidelines 1. When considering the reintroduction of SGLT2 inhibitors, it is crucial to ensure the patient is well-hydrated, has stable renal function, and is eating normally. The decision to restart should be individualized based on the patient's overall condition, with close monitoring of renal function, hydration status, and blood glucose levels after reintroduction. Key considerations for restarting SGLT2 inhibitors include:
- Monitoring for signs of dehydration and acute kidney injury
- Assessing the patient's volume status and adjusting diuretic doses as needed
- Educating the patient on the risk of diabetic ketoacidosis and the importance of monitoring blood or urine ketones
- Counseling on genital hygiene to reduce the risk of genital mycotic infections
- Adjusting background glucose-lowering agents as necessary to minimize the risk of hypoglycemia It is also important to note that SGLT2 inhibitors can be initiated in patients with type 2 diabetes and chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) ≥20 ml/min/1.73 m2, as supported by recent studies 1. However, the benefits and risks of SGLT2 inhibitors should be carefully weighed in patients with CKD, and regular monitoring of renal function and electrolytes is recommended. In terms of specific monitoring and risk mitigation strategies, the following are recommended:
- Monitor eGFR with increasing frequency as eGFR falls to <60 ml/min/1.73 m2
- Adjust metformin dose as appropriate per eGFR
- Consider dose reduction in the presence of conditions that predispose patients to hypoperfusion and hypoxemia for eGFR 45–59 ml/min/1.73 m2
- Discontinue SGLT2 inhibitors for eGFR <30 ml/min/1.73 m2 or if the patient is not tolerating treatment or kidney replacement therapy is initiated
- Institute a sick day protocol to temporarily withhold SGLT2 inhibitors during illness or excessive exercise or alcohol intake.
From the Research
Reintroduction of SGLT2 Inhibitors after IV Antibiotic Treatment for Cellulitis
- There is no direct evidence on when SGLT2 inhibitors can be safely reintroduced after initial IV antibiotic treatment for cellulitis 2, 3, 4, 5, 6.
- However, it is recommended to temporarily discontinue SGLT2 inhibitors during periods of acute illness, such as cellulitis, as they can increase the risk of ketoacidosis 4.
- SGLT2 inhibitors should be avoided for the inpatient management of hyperglycemia due to the risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections 5.
- The decision to reintroduce SGLT2 inhibitors should be made on a case-by-case basis, considering the individual patient's risk factors and medical history 2, 3, 4, 5, 6.
- It is essential to monitor patients closely for signs of ketoacidosis and other adverse events when restarting SGLT2 inhibitors after a period of discontinuation 2, 3, 4, 5, 6.