Re-examining the widespread policy of stopping SGLT2 inhibitors during acute illness: a perspective based on the updated evidence

Sodium Glucose Co-Transporter-2 (SGLT2) inhibitors are now seen as an integral part of therapy in type 2 diabetes to not only control blood glucose but to improve cardiovascular and kidney outcomes. Diabetic Ketoacidosis (DKA) is an uncommon but a serious complication of type 2 diabetes which has a high case fatality rate. The absolute risk of DKA in large, prospective randomized clinical trials (RCTs) in people with type 2 diabetes using SGLT2 inhibitors has been very low, although the relative risk is higher in those assigned to SGLT2i compared with placebo. In those without diabetes prescribed SGLT2 inhibitors for heart failure or chronic kidney disease, the risk of DKA is similar to placebo. Over the course of the COVID-19 pandemic, cases of DKA have also been reported in cases of COVID-19 hospitalizations. Consensus guidelines have recommended that SGLT2 inhibitors should be avoided in cases of serious illness and suggest they are not recommended for routine in-hospital use. However, recent data suggest potential beneficial effects of SGLT2 inhibitors in the setting of acute illness with COVID-19 with no increase in adverse events and low rates of DKA which were non-severe. Given the low rates of DKA in cardiovascular outcome trials and in hospitalised type 2 diabetes patients, the potential for SGLT2 inhibitors not being re-initiated following discharge and their cardiovascular and kidney benefits, we believe the practice of routine “sick day” guidance should be re-examined based on current evidence with a call for further research in this area. Further high quality trials of initiation of SGLT2 inhibitors in people admitted to hospital with cardiovascular disease or kidney disease and trials of continuation of SGLT2 inhibitors in people with careful monitoring of DKA should be conducted. These should be further supplemented with large observational studies