From the Guidelines
SGLT2 inhibitors should be discontinued in diabetic patients with critical limb ischemia due to the potential risk of exacerbating peripheral vascular disease and increasing the risk of amputations, as suggested by the 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes 1. The decision to discontinue SGLT2 inhibitors in patients with critical limb ischemia is based on the potential risks associated with these medications, including volume depletion, hemoconcentration, and an increased risk of diabetic ketoacidosis, which could further complicate management in a patient with critical illness 1. Some key points to consider when managing diabetes in patients with critical limb ischemia include:
- The importance of strict glycemic control to improve limb outcomes, as highlighted in the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD 1
- The need for revascularization to be attempted when possible, and amputation only considered when revascularization options fail, as suggested by the 2019 ESC guidelines 1
- The potential benefits of alternative diabetes management agents, such as insulin, metformin (if kidney function permits), or DPP-4 inhibitors, depending on the clinical situation and the patient's overall condition It is essential to weigh the potential benefits and risks of SGLT2 inhibitors in patients with critical limb ischemia and to consider alternative management strategies to minimize the risk of adverse outcomes. The 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes provides guidance on the use of SGLT2 inhibitors in patients with cardiovascular disease, including those with peripheral artery disease and critical limb ischemia 1. In patients with critical limb ischemia, the potential risks associated with SGLT2 inhibitors may outweigh the benefits, and alternative management strategies should be considered to minimize the risk of adverse outcomes.
From the Research
SGLT Inhibitor Use in Diabetic Patients with Critical Limb Ischemia
- The decision to stop SGLT inhibitors in diabetic patients with critical limb ischemia should be based on individual patient factors and the presence of other comorbidities 2.
- There is no direct evidence to suggest that SGLT inhibitors should be stopped in patients with critical limb ischemia, as the available studies focus on the management of critical limb ischemia and the use of revascularization techniques 3, 4, 5, 6.
- A meta-analysis of 51,713 individuals found that SGLT-2 inhibitors were not significantly associated with an increased risk of amputation, even in patients with established peripheral artery disease 2.
Management of Critical Limb Ischemia
- The management of critical limb ischemia in diabetic patients involves a multidisciplinary approach, including best medical therapy, rapid diagnosis, prompt revascularization, and expert wound management 3, 4.
- Revascularization techniques, including endovascular and open surgical approaches, can be effective in improving outcomes in patients with critical limb ischemia 3, 4, 5, 6.
- The choice of revascularization technique should be individualized based on patient factors, including the presence of comorbidities and the severity of the ischemia 4, 6.
Use of SGLT Inhibitors in High-Risk Patients
- SGLT-2 inhibitors have been found to be safe in terms of major adverse limb events, even in high-risk subgroups, including patients with established peripheral artery disease 2.
- The available evidence suggests that SGLT-2 inhibitors can be continued in patients with critical limb ischemia, as they do not appear to increase the risk of amputation 2.