SGLT2i inhibitors (eg empagliflozin, dapagliflozin, canagliflozin) have a phenomenal evidence base and have been shown to be beneficial in diabetes, heart disease (particularly heart failure) and kidney disease.

Achieving a good start is important. A bad early experience could turn you off a really beneficial class of medication.

1. Hold the medication on days you are ill enough that you might get dehydrated

This is a great medication, but best not to take it when you’re dehydrated.

2. Hold the medication in advance of surgery

One of the feared side effects of this class of medication is diabetic ketoacidosis. It is more common after the stress of surgery.

3. If already on a diuretic, talk to your doctor about whether you need to stop or reduce the dose of the diuretic when starting an SGLT2 inhibitor.

This medicine has diuretic-like properties and in some cases, it may be a good idea to reduce the dose of a diuretic or stop it altogether when starting this new medication.

4. For patients with type 2 diabetes, consider cutting back on insulin or sulfonylureas (eg glyburide, gliclazide, etc) when starting an SGLT2i

For people with preserved kidney function and type 2 diabetes, this medication can improve blood sugar control. While this class doesn’t cause low blood sugars on its own, it can lower blood sugar enough to allow insulin or a sulfonylurea to cause dangerous hypoglycemia.

5. Avoid in type 1 diabetes

Given the risk of diabetic ketoacidosis, this class of medication is generally avoided in those with type 1 diabetes. 

6. Engage in careful genital hygiene

This class of medication runs the risk of genital yeast infections (it makes you urinate sugar, and yeast loves sugar). That means wiping/cleaning the genitals with water if urine dribbles. Keep the area dry and avoid constrictive/non-breathable underwear.

7. For people with preserved kidney function (GFR > 45), start at a low dose

When kidney function is preserved, the blood sugar lowering and diuretic effect can be more pronounced at higher doses. Best to start at a lower dose.