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UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease 2023 UPDATE

UK Kidney Association (UKKA) · 2023 · United Kingdom

Source and licence

Authors
Alistair J. Roddick, Alexa Wonnacott, David Webb et al.
Title
UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease 2023 UPDATE
Journal
BMC Nephrology, 2023
DOI
10.1186/s12882-023-03339-3
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10598949

Licence statement of the original publication

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendations for use of SGLT-2 inhibitors in people with type 2 diabetes

  • Due to the benefits of SGLT-2 inhibitors on kidney outcomes (CKD and acute kidney injury (AKI)) and cardiovascular risk: • We recommend initiating SGLT-2 inhibition in people with chronic kidney disease and type 2 diabetes, irrespective of primary kidney disease,* for any of the following 4 clinical scenarios (Grade 1A): eGFR of 20–45 mL/min/1.73 m2 eGFR of > 45 mL/min/1.73m2 and a urinary albumin-to-creatinine ratio (uACR) of ≥ 25 mg/mmol† Symptomatic heart failure, irrespective of ejection fraction Established coronary disease

Rationale

  • We suggest initiating SGLT-2 inhibition to modify cardiovascular risk and slow rate of kidney function decline in people with an eGFR > 45–60 mL/min/1.73m2 and a uACR of < 25 mg/mmol, recognising effects on glycaemic control will be limitedGrade 2B
  • We suggest clinicians consider initiating SGLT-2 inhibition in people with an eGFR below 20 mL/min/1.73m2 to slow progression of kidney diseaseGrade 2B

Recommendations for use of SGLT-2 inhibitors in people without diabetes

  • We recommend initiating SGLT-2 inhibition in people with chronic kidney disease, irrespective of primary kidney disease,* for any of the following clinical scenarios (Grade 1A): eGFR of ≥ 20 mL/min/1.73m2 and a urinary albumin-to-creatinine ratio (uACR) of ≥ 25 mg/mmol† Symptomatic heart failure, irrespective of ejection fraction
  • Symptomatic heart failure, irrespective of ejection fraction

Rationale

  • We recommend initiating SGLT-2 inhibition to slow rate of kidney function decline in people with an eGFR of 20–45 mL/min/1.73 m2 and a uACR of < 25 mg/mmol*Grade 1B

Recommendations for implementation in people with or without type 2 diabetes

  • We recommend using SGLT-2 inhibitors with demonstrated efficacy for their given indicationsGrade 1A

Rationale

  • We recommend using clinically appropriate single agent renin-angiotensin system (RAS) blockade in combination with SGLT-2 inhibition, wherever RAS blockade is indicated and toleratedGrade 1A
  • We suggest following NICE guidelines on use of uACR for screening of albuminuria (NICE NG203). We recognise that more pragmatic approaches to identifying risk of kidney disease progression may be necessary whilst local access to uACR measurement is improvedGrade 2C
  • We recommend that SGLT-2 inhibition can be continued until the need for dialysis or kidney transplantation arisesGrade 1A
  • We suggest that co-prescription of SGLT-2 inhibition with MRA can be considered, where each are individually indicatedGrade 2B
  • We suggest the beneficial effects of SGLT-2 inhibition on kidney disease progression or risk of heart failure hospitalisation are likely to be a class effectGrade 2B

Recommendations for implementation: Diabetic Ketoacidosis (DKA)

  • We recommend that people with type 1 DM should only have SGLT-2 inhibitors initiated under the strict direction of the diabetes team (see section 7a of the supplementary appendix)Grade 1C
  • We recommend that people with type 2 DM at greater risk of DKA (defined in Table 5a.1 of the supplementary appendix) should have SGLT-2 inhibitors initiated with caution after discussion with the diabetes teamGrade 1C
  • We recommend SGLT-2 inhibitors are discontinued when an individual develops DKAGrade 1A
  • We suggest that after an episode of DKA and where a clear contributing factor has been identified, there should be discussion with the person and clinical team to establish whether the benefits of re- introducing an SGLT-2 inhibitor outweigh the risksGrade 2D
  • When initiating SGLT-2 inhibitors, we suggest that individuals should be advised on the signs and symptoms of DKA and be instructed to temporarily withhold SGLT-2 inhibitors and to seek immediate medical advice if symptoms developGrade 1C
  • We recommend always offering advice on sick day guidance when initiating SGLT-2 inhibitors and reminding them of this at every medication reviewGrade 1C
  • We suggest that individuals taking SGLT-2 inhibitors should be advised against following a ketogenic dietGrade 2C
  • We suggest that for people who choose to intermittently fast (e.g. for Ramadan), and particularly for those who are elderly, on diuretics or have CKD, consider withholding SGLT-2 inhibitors for the duration of the fasting period and for those people with diabetes ketone testing should be undertaken if unwellGrade 2D

Recommendations for implementation: hypoglycaemia

  • We recommend considering reducing the dose of insulin/SUs/meglitinides when initiating SGLT-2 inhibitors to reduce the risk of hypoglycaemiaGrade 1C
  • We recommend that when initiating SGLT-2 inhibitors in people taking SUs (e.g. gliclazide) or meglitinides (e.g. repaglinide) when the HbA1c < 58 mmol/mol AND eGFR > 45 mL/min/1.73m2, consider reducing dose of SU or meglitinide by 50% to reduce risk of hypoglycaemiaGrade 1C
  • We recommend that when starting SGLT-2 inhibitors in people taking insulin when the HbA1c < 58 mmol/mol AND eGFR > 45 mL/min/1.73m2, consider reducing the insulin dose by 20% to avoid hypoglycaemiaGrade 1C
  • We recommend that when starting SGLT-2 inhibitors in people taking only metformin ± pioglitazone ± DPP-4i/gliptins or GLP-1RA therapy, no dosage adjustment is necessaryGrade 1C

Recommendations for implementation: acute kidney injury (AKI), hypovolaemia and potassium

  • We recommend that individuals initiated on an SGLT-2 inhibitor do not routinely require an early assessment of kidney function or potassium following initiation of treatmentGrade 1C
  • We suggest that if an individual has a kidney function assessment within the first few weeks post initiation of an SGLT-2 inhibitor, a decline in eGFR needs to be interpreted with caution and in the context of an expected drug effect to avoid unwarranted discontinuation of treatmentGrade 2B
  • We suggest that individuals on diuretics are counselled on the symptoms of hypovolaemia and advised to seek medical attention if they develop any such symptoms after starting SGLT-2 inhibitionGrade 2B
  • We suggest that clinicians consider an early clinical review and if appropriate a diuretic or antihypertensive dose reduction in individuals they consider at high risk of hypovolaemiaGrade 2C
  • We recommend that SGLT-2 inhibitors are temporarily withheld during acute illnessGrade 1C

Recommendations for implementation: peripheral vascular disease (PVD) and amputation risk

  • We suggest avoiding initiation of SGLT-2 inhibitors in the presence of active foot disease (infection, ulceration and ischaemia) and withholding treatment in those who develop foot complications whilst taking an SGLT-2 inhibitorGrade 2B
  • We suggest a shared decision-making approach, with appropriate counselling on risks and benefits of treatment and the importance of routine preventative foot care measures for: Individuals at high risk of amputation (previous amputations, existing PVD, peripheral neuropathy) Re-initiation of SGLT-2 inhibitors after treatment and satisfactory resolution of a foot complication that occurred whist taking SGLT-2 inhibitorsGrade 2B
  • Individuals at high risk of amputation (previous amputations, existing PVD, peripheral neuropathy)
  • Re-initiation of SGLT-2 inhibitors after treatment and satisfactory resolution of a foot complication that occurred whist taking SGLT-2 inhibitorsGrade 2B

Recommendations for implementation: fracture risk

  • In people with CKD treated with SGLT-2 inhibitors, we suggest monitoring of bone parameters including calcium, phosphate and parathyroid hormone should be performed as appropriate for CKD stage (NICE NG203)Grade 2D

Recommendations for implementation: multimorbidity and frailty

  • We suggest an approach to care that takes account of frailty and multimorbidity where these apply. This can include: Establishing the person’s goals, values and priorities Consideration of the balance of disease and treatment burden (for example, prognostic benefits in people with limited life expectancy or frailty) Agreeing an individualised management planGrade 2D
  • Establishing the person’s goals, values and priorities
  • Consideration of the balance of disease and treatment burden (for example, prognostic benefits in people with limited life expectancy or frailty)
  • Agreeing an individualised management planGrade 2D

Recommendations for implementation: mycotic genital infections and fournier’s gangrene

  • We recommend that all people are counselled on the risks of mycotic genital infections prior to initiation of SGLT-2 inhibitorsGrade 1D
  • We recommend that all people are counselled on self-care to maintain good genital hygieneGrade 1C
  • We recommend that all people are counselled on the symptoms of mycotic genital infections and how to seek help including self-managementGrade 1D
  • We suggest that for those individuals with a history of recurrent mycotic genital infections on SGLT-2 inhibition, consideration is given to offering prophylactic anti-fungal treatment, which should be reviewed after 6 months of therapy or earlier if clinically indicatedGrade 2D
  • We suggest that SGLT-2 inhibitor therapy can be continued during the treatment of mycotic genital infectionsGrade 2D
  • We highlight the specific MHRA warning and suggest that all people are counselled on the symptoms of Fournier’s gangrene and advised to stop SGLT-2 inhibitors and to seek urgent help if they develop such symptomsGrade 2D

Recommendations for implementation: urinary tract infection

  • We recommend temporary discontinuation of SGLT-2 inhibitors when treating acute pyelonephritis or urosepsisGrade 1C

Recommendations for implementation: children, pregnancy and breastfeeding

  • We suggest that all women of child-bearing potential are counselled, prior to conception, on the risks of SGLT-2 inhibitors during pregnancyGrade 2D
  • We suggest SGLT-2 inhibitor therapy is discontinued upon planning, suspicion or confirmation of pregnancyGrade 2D
  • We suggest SGLT-2 inhibitors are not used in women who are breastfeedingGrade 2D

Recommendations for implementation in specific populations: people with type 1 diabetes

  • We recommend that SGLT-2 inhibitors be initiated in people with type 1 DM, only under the strict direction of the diabetes teamGrade 1C
  • We suggest considering referring people with type 1 DM to the specialist diabetes team, for consideration of an SGLT-2 inhibitor, if they have an eGFR ≥ 20 mL/min/1.73m2, and a uACR ≥ 25 mg/mmol despite being on maximum tolerated ACEi/ARBGrade 2C
  • We recommend all people with type 1 DM started on SGLT-2 inhibitors be provided with ketone monitoring, be advised on the signs and symptoms of DKA and to seek immediate medical advice if any of these symptoms develop or ketone levels are > 0.6 mmol/LGrade 1B

Recommendations for implementation in specific populations: kidney transplant recipients

  • There is currently insufficient evidence on safety and efficacy to provide Recommendations for use of SGLT-2 inhibition in people with a functioning kidney transplant.
  • Any use of SGLT-2 inhibition to treat diabetes mellitus in a kidney transplant recipient should be evaluated by multi-disciplinary discussionGrade 2D

Recommendations for implementation in specific populations: acute decompensated heart failure

  • We suggest initiating SGLT-2 inhibition in people with CKD (eGFR ≥ 20 mL/min/1.73m2) with acute decompensated heart failure.2B

Abstract

Large placebo-controlled trials have demonstrated kidney and cardiovascular clinical benefits of SGLT-2 inhibitors. Data from the EMPA-KIDNEY and DELIVER trials and associated meta-analyses triggered an update to the UK Kidney Association Clinical Practice Guideline on Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease. We provide a summary of the full guideline and highlight the rationale for recent updates. The use of SGLT-2 inhibitors in people with specific medical conditions, including type 1 diabetes, kidney transplants, and people admitted to hospital with heart failure is also considered, along with Recommendations for future research and Recommendations for implementation. A full “lay” summary of the guidelines is provided as an appendix to ensure that these guidelines are accessible and understandable to people who are not medical professionals.

Supplementary Information: The online version contains supplementary material available at 10.1186/s12882-023-03339-3.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Guideline structure
  • Recommendations for use of SGLT-2 inhibitors in people with type 2 diabetes
  • Recommendations for use of SGLT-2 inhibitors in people without diabetes
  • Recommendations for implementation in people with or without type 2 diabetes
  • Recommendations for implementation: Diabetic Ketoacidosis (DKA)
  • Recommendations for implementation: hypoglycaemia
  • Recommendations for implementation: acute kidney injury (AKI), hypovolaemia and potassium
  • Recommendations for implementation: peripheral vascular disease (PVD) and amputation risk
  • Recommendations for implementation: fracture risk
  • Recommendations for implementation: multimorbidity and frailty
  • Recommendations for implementation: mycotic genital infections and fournier’s gangrene
  • Recommendations for implementation: urinary tract infection
  • Recommendations for implementation: children, pregnancy and breastfeeding
  • Recommendations for implementation in specific populations: people with type 1 diabetes
  • Recommendations for implementation in specific populations: kidney transplant recipients
  • Recommendations for implementation in specific populations: acute decompensated heart failure
  • Clinical research and audit recommendations in people with or without type 2 diabetes

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