When to discontinue Sodium-Glucose Linked Transporter (SGLT) inhibitors?

From the Guidelines

SGLT-2 inhibitors should be stopped permanently if a patient develops diabetic ketoacidosis (DKA), severe or recurrent genital mycotic infections, severe urinary tract infections, or if estimated glomerular filtration rate (eGFR) falls below 30 ml/min/1.73m². When considering stopping SGLT-2 inhibitors, several factors should be taken into account to prioritize patient safety and minimize risks.

• The medications should be temporarily stopped during acute illness, especially when patients experience vomiting, diarrhea, or reduced oral intake that could lead to dehydration, as indicated in the study by 1.
• They should also be discontinued 3-4 days before major surgical procedures and can be resumed when the patient is eating normally and kidney function is stable, as suggested by 1.
• The decision to stop SGLT-2 inhibitors should consider the patient's individual risk factors, such as history of amputation, peripheral arterial disease, neuropathy, or diabetic foot ulcers, as mentioned in the study by 1.
• Additionally, the medications may increase the risk of volume depletion and hypotension, particularly in patients with tenuous volume status or those taking concurrent diuretics, as noted in the study by 1.
• The study by 1 provides guidance on dose modifications, contraindications, and cautions for SGLT-2 inhibitors, which should be considered when deciding whether to stop the medication.
• The most recent study by 1 provides a practical approach to initiating and managing SGLT-2 inhibitors in patients with type 2 diabetes and chronic kidney disease, including a sick day protocol and periprocedural care guidelines.
• It is essential to weigh the benefits of SGLT-2 inhibitors, including their cardiovascular and renal benefits, against the potential risks and to monitor patients closely for adverse effects, as recommended by 1 and 1.

From the FDA Drug Label

If ketoacidosis is suspected, discontinue INVOKANA, promptly evaluate, and treat ketoacidosis, if confirmed. Withhold INVOKANA, if possible, in temporary clinical situations that could predispose patients to ketoacidosis. Resume INVOKANA when the patient is clinically stable and has resumed oral intake [see Dosage and Administration (2. 5)]. Consider ketone monitoring in patients at risk for ketoacidosis if indicated by the clinical situation Assess for ketoacidosis regardless of presenting blood glucose levels in patients who present with signs and symptoms consistent with severe metabolic acidosis.

When to stop SGLT2 inhibitors:

• If ketoacidosis is suspected, discontinue the medication.
• In temporary clinical situations that could predispose patients to ketoacidosis, withhold the medication.
• If signs and symptoms of ketoacidosis occur, discontinue the medication and seek medical attention immediately.
• If lower limb infections, gangrene, or diabetic foot ulcers occur, discontinue the medication.
• If acute kidney injury or volume depletion occurs, discontinue the medication. 2 3 2

From the Research

Stopping SGLT2 Inhibitors

There is limited information available on when to stop SGLT2 inhibitors. However, the following points can be considered:

• The decision to stop SGLT2 inhibitors should be based on individual patient factors, such as adverse events, lack of efficacy, or changes in medical condition 4, 5.
• Common adverse events associated with SGLT2 inhibitors include genitourinary infections, volume depletion, diabetic ketoacidosis, and hypoglycemia 4, 5.
• In patients with acute heart failure, SGLT2 inhibitors have been shown to reduce the risk of heart failure events and readmissions 6.
• The efficacy and safety of SGLT2 inhibitors in preventing complications post-acute heart failure have been assessed, and the odds of all-cause mortality, cardiovascular mortality, heart failure events, and re-admissions rates were substantially reduced within the first 1−9 months of hospitalization 6.
• In patients with type 2 diabetes, SGLT2 inhibitors have been shown to improve glycaemic control, promote weight loss, and lower blood pressure, with added benefits of renal-protecting effects and reductions in major adverse cardiovascular outcomes 7, 8.

Key Considerations

• The benefits and risks of SGLT2 inhibitors should be carefully weighed in individual patients, taking into account their medical history, current condition, and potential for adverse events 4, 5.
• Physicians should be aware of the potential risks associated with SGLT2 inhibitors and take steps to mitigate them, such as monitoring for adverse events and adjusting treatment plans as needed 4, 5.
• The use of SGLT2 inhibitors in patients with type 2 diabetes and other conditions, such as heart failure and renal disease, should be guided by clinical guidelines and individual patient needs 6, 7, 8.