From the Guidelines
SGLT-2 inhibitors should be initiated at the lowest dose tested in CV and renal outcomes trials, with Canagliflozin at 100 mg PO daily, Dapagliflozin at 10 mg PO daily, and Empagliflozin at 10 mg PO daily, with no further dose titration needed for CV or renal risk reduction, but dose increases may provide further glucose reduction benefits if indicated, as per the 2020 expert consensus decision pathway 1.
Key Points to Consider
- The recommended doses for SGLT-2 inhibitors are as follows:
- Canagliflozin: 100 mg PO daily
- Dapagliflozin: 10 mg PO daily
- Empagliflozin: 10 mg PO daily
- Dose modifications are based on kidney function, with specific recommendations for patients with eGFR between 30-59 ml/min/1.73 m2, and contraindications for patients with eGFR below 30 ml/min/1.73 m2 or end-stage renal disease (ESRD) 1.
- Common side effects of SGLT-2 inhibitors include genital fungal infections, urinary tract infections, and euglycemic diabetic ketoacidosis, which should be monitored and managed accordingly 1.
- The 2022 KDIGO clinical practice guideline for diabetes management in chronic kidney disease provides a practical approach to initiating SGLT2 inhibitors in patients with type 2 diabetes and CKD, including patient selection, potential contraindications, and education on hypoglycemia and volume depletion risks 1.
Important Considerations for Patient Care
- Patients should be educated on the risks and benefits of SGLT-2 inhibitors, including the potential for genital mycotic infections, urinary tract infections, and volume depletion, and should be advised to stay hydrated and monitor their blood glucose and ketone levels regularly.
- A sick day protocol should be established for patients taking SGLT-2 inhibitors, which includes temporarily withholding the medication, keeping hydrated, and monitoring blood glucose and ketone levels more frequently 1.
- Periprocedural and perioperative care should include informing patients about the risk of diabetic ketoacidosis, withholding SGLT-2 inhibitors as needed, and measuring blood glucose and ketone levels on hospital admission 1.
From the FDA Drug Label
2.1 Recommended Dosage 2.2 Patients with Renal Impairment 3 DOSAGE FORMS AND STRENGTHS
The following SGLT2 inhibitors are listed with their dose and dose adjustment:
- Empagliflozin:
- Recommended dose: Not specified in the provided text
- Dose adjustment: Not specified in the provided text for patients with renal impairment, but it is mentioned that there is a section for it. Other SGLT2 inhibitors are not mentioned in the provided text. 2
From the Research
SGLT2 Inhibitors Medications
- Canagliflozin: 100mg or 300mg orally once daily, dose adjustment for patients with moderate renal impairment (eGFR 45 to less than 60 mL/min/1.73m^2) to 100mg orally once daily 3, 4
- Dapagliflozin: 5mg or 10mg orally once daily, dose adjustment for patients with moderate renal impairment (eGFR 30 to less than 60 mL/min/1.73m^2) to 5mg orally once daily 3, 4
- Empagliflozin: 10mg or 25mg orally once daily, dose adjustment for patients with moderate renal impairment (eGFR 30 to less than 60 mL/min/1.73m^2) to 10mg orally once daily 3, 4
Dose Adjustment
- Patients with severe renal impairment (eGFR less than 30 mL/min/1.73m^2) should not use SGLT2 inhibitors 5, 6
- Patients with hepatic impairment should use SGLT2 inhibitors with caution, as there is limited data available 6, 7
- Patients with a history of genital mycotic infections, urinary tract infections, or other adverse effects should be monitored closely while taking SGLT2 inhibitors 3, 4, 5, 6, 7
Important Considerations
- SGLT2 inhibitors should be used as an adjunct to diet and exercise, and in combination with other antihyperglycemic agents as needed 3, 4, 5, 6, 7
- Patients should be monitored for signs and symptoms of hypoglycemia, genital mycotic infections, urinary tract infections, and other adverse effects while taking SGLT2 inhibitors 3, 4, 5, 6, 7