Can I give dapagliflozin (SGLT2 inhibitor) to a patient with pneumonia?

Can Dapagliflozin Be Given to a Patient with Pneumonia?

Yes, dapagliflozin can generally be given to a patient with pneumonia, but it should be temporarily withheld during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent diabetic ketoacidosis and volume depletion. 1

Key Safety Considerations During Acute Illness

Sick Day Management Rules:

• Temporarily discontinue dapagliflozin during any acute illness, particularly when patients experience reduced food and fluid intake 1
• The Kidney International guidelines specifically recommend holding dapagliflozin during fever, vomiting, or diarrhea 1
• The Mayo Clinic Proceedings recommends discontinuing dapagliflozin during any intercurrent illness requiring hospitalization 1

Clinical Context from COVID-19 Pneumonia Data

Importantly, the DARE-19 trial provides reassuring safety data specifically in hospitalized pneumonia patients:

• Hospitalized COVID-19 pneumonia patients with high cardiometabolic risk who were randomized to in-hospital dapagliflozin were numerically less likely than placebo to have respiratory decompensation, cardiac decompensation, acute kidney injury, drug discontinuation, and death 2
• This supports the in-hospital safety profile of SGLT2 inhibitors among clinically tenuous patients 2

Critical Monitoring Requirements

Monitor for these specific complications:

• Diabetic ketoacidosis (DKA) even with normal blood glucose levels (euglycemic DKA), which is a serious risk during illness in patients taking SGLT2 inhibitors 1
• Check blood or urine ketones if patients develop malaise, nausea, or vomiting 1
• Assess volume status carefully, as the diuretic effect of dapagliflozin combined with illness-related fluid losses significantly increases risk of hypovolemia 1
• Genital mycotic infections and urinary tract infections, which occur more frequently with SGLT2 inhibitors 2, 3

Insulin Management During Illness

If the patient requires insulin:

• Maintain at least low-dose insulin in insulin-requiring individuals even when dapagliflozin is held, as complete insulin cessation increases DKA risk 1
• Do not reduce insulin doses excessively when holding dapagliflozin during illness, as this combination significantly elevates ketoacidosis risk 1

When to Resume Dapagliflozin

Resume dapagliflozin only after:

• Patient has recovered from acute illness 1
• Normal oral intake is re-established 1
• Volume status is stable 1

Common Pitfalls to Avoid

• Do not continue dapagliflozin if the patient has reduced oral intake or is NPO (nothing by mouth), as this significantly increases DKA and volume depletion risk 1
• Consider proactive dose reduction of concurrent diuretics in patients at high risk for volume depletion 1
• Patients already on diuretic therapy are at higher risk of volume depletion during acute illness 1

Practical Algorithm

For a patient with pneumonia:

1. If the patient is eating and drinking normally with stable vital signs: Continue dapagliflozin with close monitoring for volume status and ketoacidosis symptoms 2, 1
2. If the patient has reduced oral intake, fever, vomiting, or requires hospitalization: Hold dapagliflozin temporarily 1
3. If the patient is on insulin: Maintain at least low-dose insulin even when dapagliflozin is held 1
4. Resume dapagliflozin only after recovery and return to normal oral intake 1