Table 5.

Cautions associated with the use of SGLT2 inhibitors

Caution	Comment
Genito-urinary mycotic infections	Caution if history of frequent or severe prior infection Usually dealt with by hygiene advice and clotrimazole cream
Initial nocturia and orthostatic hypotension	Advice on care when getting up, especially at night
Hypovolaemia and dehydration	Advice to take in sufficient fluid especially in hot climates Awareness of relevant symptoms and ‘sick day’ rules
‘Atypical’ euglycaemic ketoacidosis	Mostly indicates under insulinisation because the glucosuria has lowered the plasma glucose, but there is insufficient insulin to prevent excess lipolysis. The resulting release of excess fatty acids gives rise to excess ketones. Avoid over-ambitious reductions of insulin dose. Consider if misdiagnosis of type 1 as type 2 diabetes
Urinary tract infections (UTI) and acute kidney injury (AKI)	Contrary to initial concerns, risk of UTI and AKI have been less common with use of an SGLT2 inhibitor
Risk of bone fracture	Unconfirmed with extensive routine use
Risk of lower limb amputation	Unconfirmed with extensive routine use, but vigilance suggested in patients with severe peripheral artery disease
Fournier’s gangrene	Very rare, association with SGLT2 inhibitors unclear
Interaction with antihypertensive medications	Dose adjustments to existing medication with a loop and/or thiazide diuretic or RAAS blocker may be required when starting an SGLT2 inhibitor to prevent volume depletion and orthostatic hypotension

RAAS renin–angiotensin–aldosterone system