SGLT2i for treating CKD

This information is to provide guidance to clinicians across South West London (SWL) on sodium glucose co-transporter 2 inhibitors (SGLT2i) for treating chronic kidney disease (CKD) in adults.

Dapagliflozin and empagliflozin are currently sodium-glucose co-transporter 2 inhibitor (SGLT-2i) licensed for the treatment of CKD. Adding dapagliflozin or empagliflozin to current standard care has been shown to significantly reduce the risk of having declining kidney function, end-stage kidney disease and all cause of mortality in the DAPA-CKD trial and EMPA-Kidney trial.

SGLT-2i work by blocking the SGLT-2 protein in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose and sodium excretion. Blocking this protein alleviates kidney damage by reducing pressure and inflammation in the kidneys independent of the glucose lowering effects.

SWL Formulary status

NHS SWL recommends prescribing dapagliflozin as the preferred SGLT-2i for the treatment of CKD, when prescribed in line with NICE Technology appraisal guidance [TA1075] and approved product licence. Empagliflozin is also available as an alternate option for treatment of CKD, in line with NICE Technology appraisal guidance [TA942].

Refer to the SWL Joint Formulary for local recommendations on the use of SGLT-2i.

Initiation criteria

NICE recommends prescribing Dapagliflozin (NICE TA1075) OR Empagliflozin (NICE TA942) only if:

• it is an add-on to optimised standard care including the highest tolerated licensed dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), unless these are contraindicated, and
• people have an estimated glomerular filtration rate (eGFR) of:
  • 20 ml/min/1.73 m² to less than 45 ml/min/1.73m² or
  • 45 ml/min/1.73 m² to 90 ml/min/1.73 m² and either
    • a urine albumin-to-creatinine ratio of 22.6 mg/mmol or more, or
    • type 2 diabetes.

Prescribing Guidance

Refer to BNF or SPC for the following:

• Dose
• Contraindications
• Cautions
• Interactions
• Side-effects
• Use in hepatic impairment
• Use in renal impairment
• Monitoring and safety information

Do not prescribe NICE approved SGLT-2i in the following patients

• Type 1 diabetes: Refer to MHRA guidance.
• History of diabetic ketoacidosis (DKA): Refer to MHRA guidance.
• Hypersensitivity to active substance or excipients (tablets contain lactose).
• Pregnancy and breastfeeding.
• Avoid empagliflozin in severe hepatic impairment (Child-Pugh C).
• Empagliflozin is not recommended if eGFR is less than 20 mL/min/1.73 m².
• Dapagliflozin should not be initiated if eGFR is less than 15mL/min/1.73 m².
• Active foot disease (such as skin ulceration, osteomyelitis, or gangrene).
• Already taking another SGLT-2i (consider switch to dapagliflozin as the preferred SGLT-2i in SWL).

Important safety information

• Severe hepatic impairment – consider starting dapagliflozin at a lower 5 mg once daily dose; increase to 10 mg once daily if tolerated.
• Diabetic ketoacidosis (MHRA guidance)
  • Not yet been reported in patients without diabetes. Inform patients of the signs and symptoms of DKA, as patients with undiagnosed T2DM may be at risk.
• Patients undergoing surgical procedures or acute serious medical illness – risk of DKA in the peri-operative period. Temporarily withhold and monitor blood ketone levels. See MHRA guidance for further information and sick day rules.
• Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum). This is a rare but serious and potentially life-threatening infection predominantly in men. If suspected, therapy should be stopped immediately, and emergency treatment organised. Advise patients to seek urgent medical attention if they experience severe pain, tenderness, erythema, or swelling in the genital or perineal area, accompanied by fever or malaise (MHRA guidance).
• Renal excretion of lithium may be increased with concurrent prescribing of SGLT-2i which may lead to decreased blood lithium levels. Serum lithium concentration should be monitored more frequently after SGLT-2i initiation and dose changes.

Good practice prescribing:

Ensure SGLT-2i is linked to the indication and a prescription direction is added e.g. “for Chronic Kidney Disease”, as well as the dispensing label in pharmacy. This is to avoid ambiguity and ensure it is not inadvertently stopped as part of a routine diabetes review.

Monitoring requirements

On Initiation

On initiation, measure and assess baseline:

Blood Pressure:

Caution if systolic blood pressure (SBP) less than 95mmHg or if symptomatic hypotension, particularly in patient who are:

• elderly (older than 65 years old) or frail

• on anti-hypertensive therapy with a history of hypotension
• prescribed diuretics at risk of hypotension or dehydration

Renal function:

If eGFR fall below NICE recommendations, it is not recommended to initiate however, if patient stabilised on treatment refer to the summary of product characteristics for dapagliflozin and empagliflozin.

If eGFR falls below 15ml/min/1.73m²– consider renal advice and reviewing co-prescribed medications/co-morbidities that may affect eGFR.

Hepatic function:

Severe hepatic impairment with dapagliflozin reported- manufacturer advises caution with dapagliflozin- see prescribing guidance for dose recommendation.

HbA1c and glucose levels

It is good practice to check HbA1c prior to starting therapy to exclude undiagnosed type 2 diabetes.

If HbA1c is above 48mmol/mol -manage according to NICE guidance for type 2 diabetes and SWL SGLT2i in type 2 diabetes guideline and/or seek specialist diabetic advice on how best to adjust existing diabetic medication and management prior to initiation/ during treatment.

Ongoing Monitoring and review

CKD review

Annually, unless clinical condition or medication changes in which case more frequent monitoring may be required.

Blood pressure

Within the first 3 months and then annually, unless clinical condition or medication changes in which case more frequent monitoring may be required.

Renal function

Check as clinically indicated and at least annually thereafter.

HBA1c and glucose levels

If clinically indicated.

Liver function tests

If clinically indicated.

Side effects and adherence review

Within the first 3 months, as indicated and at least annually thereafter.

Other

If patient presents with intercurrent conditions that may lead to volume depletion (e.g. gastrointestinal illness) monitor volume status (this includes physical examination, BP measurements) and laboratory tests including haematocrit and electrolytes, urea.

Patient information:

• Patients should be counselled on the adverse side effect associated with dapagliflozin -refer to BNF or SPC
• Sick day rules should be discussed on initiation and reiterated at every opportunity
• A UKKA patient information sheet for patients with diabetes or UKKA patient information sheet for patients without diabetes is available to support patients. Patients should also be advised to read the Patient Information Leaflet (PIL)

V2: Approved by SWL integrated medicines optimisation committee June 2026