I’m pleased that you found it useful. Practical examples are always easier to follow and remember. I’ll be doing more of these- stay tuned! 👍

Thanks for your comment. I am pleased that you found it useful. The next one is nearly ready, likely out this weekend 👍

Thank you for your comment. It is a very valid question. The thresholds vary for each different SGLT2 inhibitor. Because of their mode of action through glycosuria, SGLT2 inhibitors work better when the renal function is good. But they can still be used at lower eGFR thresholds, we just have to be aware that the antidiabetic effect may be less noticeable. The most flexible one is dapagliflozin, which you can initiate as long as the eGFR is >15. SGLT2 inhibitors are mostly metabolised in the liver and very little is excreted in the urine. So, as I understand it, it is really not so much a question of toxicity but of lack of efficacy on glycaemia. NICE give some detailed information on this website cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/sglt-2-inhibitors/#:~:text=In%20people%20with%20an%20eGFR%20between%2030%2D45%20mL%2Fmin,canagliflozin%20should%20not%20be%20initiated. It is true that it starts by saying that “in general avoid initiation if estimated glomerular filtration rate (eGFR) is less than 60 mL/min/1.73 m2; avoid continuation if eGFR is less than 45 mL/min/1.73 m2.” But then it moves on to give details of specific SGLT2 inhibitors: (below is cut and pasted from their website) * “Note: dapagliflozin is licensed for use in chronic kidney disease, but should not be initiated in people with eGFR less than 15mL/min/1.73 m2. The glucose-lowering efficacy of dapagliflozin is reduced when eGFR is less than 45 mL/min/1.73m2. For more information, see the section on Diabetic kidney disease. * Specifically relating to canagliflozin * In people with an eGFR 60 mL/min/1.73 m2 or higher canagliflozin should be initiated at 100 mg. In patients tolerating 100 mg and requiring additional glycaemic control, the dose can be increased to 300 mg. * In people with an eGFR between 30-60 mL/min/1.73 m2 canagliflozin should be initiated at 100 mg and maintained at this dose. * In people with an eGFR less than 30 mL/min/1.73 m2 canagliflozin should not be initiated. However, for those people already taking canagliflozin they can be maintained on 100mg. * Monitor renal function at least twice yearly in the presence of moderate renal impairment. More regular monitoring or modification of therapy may be required if there is a trend in reduction of eGFR, the addition of other medication which may reduce renal function, or evidence of volume depletion (for example, postural dizziness or hypotension.) * Specifically relating to empagliflozin * In people who have an eGFR below 60 ml/min/1.73 m2 or creatinine clearance (CrCl) below 60 ml/min the daily dose of empagliflozin is limited to 10 mg. * In people with type 2 diabetes and established cardiovascular disease empagliflozin can be initiated and continued at 10mg once daily, down to a threshold of eGFR 30 ml/min/1.73 m2 or CrCl 30 ml/min. * Empagliflozin is not recommended when eGFR is below 30 ml/min/1.73 m2 or CrCl below 30 ml/min. * In people who have heart failure, empagliflozin is not recommended if the eGFR less than 20 ml/min/1.73 m2. * Empagliflozin should not be used in patients with end-stage renal disease or in patients on haemodialysis. * Renal function should be monitored prior to empagliflozin initiation and periodically during treatment, this is, at least yearly and prior to initiation of any concomitant medicinal product that may have a negative impact on renal function.” My favourite is dapagliflozin. It give you the most flexibility in terms of eGFR thresholds for initiation and continuation and, in addition to the diabetes and heart failure indications, it is also recommended as treatment of CKD (see: www.nice.org.uk/guidance/ta775/chapter/1-Recommendations). It will end up depending on your clinical judgement. A diabetic patient with heart failure and CKD has potentially a lot to gain from an SGLT2 inhibitor in general and dapagliflozin in particular, so I would err on the side of giving it.

@@practicalgp Many thanks Sir, it is really helpful 👍

👏😃👍