Table 2.
Practical considerations in prescribing sodium-glucose cotransporter 2 inhibitors
| An acute and transient decline in eGFR is common in the first several weeks of therapy a |
| A decline of <30% does not warrant discontinuation |
| A decline of >30% should prompt the following |
| Assess volume status and consider a decreased dose of diuretics |
| Discontinue prescribed or over-the-counter nonsteroidal anti-inflammatory drugs |
| A reversible tubular toxicity due to osmotic injury (osmotic nephrosis) can rarely occur (31) |
| Hold SGLT2i in the setting of acute illness causing depletion of extracellular fluid volume (decreased intake, vomiting, and/or diarrhea) |
| Symptomatic drop in BP |
| Consider a decrease in dose of diuretics |
| Avoid down titration of renin-angiotensin-aldosterone blockers |
| Hypoglycemia |
| More likely to occur with eGFR >60 ml/min |
| Consider a 10%–20% decrease in insulin dose or decrease in the dose of sulfonylurea in collaboration with the endocrinologist |
| Risk attenuates as eGFR declines and is nonexistent at eGFR <30 ml/min |
| Given the long-term benefits, every effort should be made to maintain patients on SGLT2i therapy |
SGLT2i, sodium-glucose cotransporter 2 inhibitor.
a
The approach is similar to changes in eGFR following initiation of renin-angiotensin blockers (32).