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 and showing clear signs of healing, as supported by the most recent guidelines and studies 1.
Key Considerations for Reintroduction
- Ensure the patient's kidney function is adequate through laboratory testing, as both cellulitis and antibiotics can impact renal function.
- Be aware of the potential risks associated with SGLT2 inhibitors, including genital mycotic infections, euglycemic diabetic ketoacidosis, and the rare but serious condition of necrotizing fasciitis (Fournier's gangrene).
- Monitor for signs of hypovolemia and consider proactive dose reduction of diuretics in patients at high risk, as SGLT2 inhibitors can contribute to volume depletion.
- Educate patients on the signs and symptoms of diabetic ketoacidosis and the importance of maintaining at least low-dose insulin during SGLT2 inhibitor therapy, especially during periods of acute illness or stress.
Benefits of Reintroduction
- Resuming SGLT2 inhibitors helps maintain long-term glycemic control.
- Provides cardiovascular benefits, including reducing the risk of major adverse cardiovascular events.
- Offers renal benefits, such as reducing the risk of kidney disease progression and hospitalization for heart failure, as demonstrated in recent studies 1.
Practical Approach
- Follow a sick day protocol for patients on SGLT2 inhibitors, which includes temporarily withholding the medication during illness, encouraging hydration, monitoring blood glucose and ketone levels, and seeking medical help early if necessary.
- Consider the patient's overall clinical status, including the presence of conditions that may predispose them to hypoperfusion and hypoxemia, when deciding to reintroduce SGLT2 inhibitors.
- Always prioritize the patient's safety and adjust the treatment plan as needed based on their individual response and risk factors, guided by the latest clinical evidence 1.
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.
- However, studies suggest that SGLT2 inhibitors should be temporarily discontinued during periods of acute illness, such as cellulitis, as they can increase the risk of diabetic ketoacidosis (DKA) 2.
- The risk of DKA is higher in patients with certain risk factors, including prior DKA, low baseline serum bicarbonate, and use of certain medications such as digoxin and dementia medications 3.
- SGLT2 inhibitors can be considered for reintroduction when the patient is stable and no longer at risk for DKA, but the exact timing is not specified in the available studies.
- It is recommended to avoid using SGLT2 inhibitors for the inpatient management of hyperglycemia due to the increased risk of DKA and other complications 4.
- The decision to reintroduce SGLT2 inhibitors should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 5, 6.