The Prescribing Tool is a quick reference guide to support clinicians with treatment decisions concerning SGLT2i therapies. The Tool aims to provide clarity regarding common areas of confusion in clinical practice, such as early and late use of SGLT2i treatments within the T2DM pathway, the risk of diabetic acidosis and lower limb amputations or bone fractures. The traffic light system highlights the types of people or situations you may encounter and appropriate approaches to prescribing in these cases:
• Green: Evidence supports SGLT2i prescribing in these situations
• Amber: Prescribe SGLT2i with caution • Red: Do not prescribe SGLT2i
An evidence level has been assigned to each category, based on randomised controlled trial (RCT) and observational data as well as NICE/SIGN guidelines and the licensed indication for each therapy within the SGLT2i class of medicines. The level of evidence has been scored according to the ADA Evidence-Grading System (summarised below). 1 ADA evidence-grading system for "Standards of Medical Care in Diabetes" 1
A Clear evidence from well-conducted, generalisable RCTs that are adequately powered, including:
• Evidence from a well-conducted multicentre trial or meta-analysis that incorporated quality ratings in the analysis The SGLT2i Prescribing Tool has been prepared by the Improving Diabetes Steering Committee. Napp Pharmaceuticals has fully funded the creation of this non-promotional document and has reviewed and certified it for medical accuracy and compliance with the ABPI Code of Practice. Fournier's gangrene risk E ¶ SGLT2i therapies should be prescribed with caution in people requiring a rapid reduction in insulin dose, due to insulinopenia, which may increase DKA risk. 2-5 *Decisions should be based upon recent eGFR measurement, rather than historical tests. ‡ Empagliflozin, dapagliflozin and ertugliflozin therapies may be initiated only in people with eGFR 60 mL/min/1.73m 2 and may continue to be prescribed in those requiring tighter glycaemic control until eGFR reaches 45 mL/min/1.73m 2 . 3-5 ¥ People with T2DM patients with albuminuria (urinary albumin: creatinine ratio >30 mg/mmol) and an eGFR ≥30 mL/min/1.73m 2 can now be initiated on canagliflozin 100mg and also maintained on treatment until dialysis or renal transplantation. 2 **The CREDENCE study and some sub-populations enrolled in published SGLT2i CV outcome trials included people receiving loop diuretics. [9] [10] [11] [12] However, canagliflozin is not currently licensed for use alongside loop diuretics and other SGLT2is recommend ongoing monitoring for signs of volume depletion. 2-5  Monitor HbA1c levels regularly and cease SGLT2is if elevated levels continue. • Dapagliflozin (5 mg) is the only SGLT2i licensed for in Type 1 diabetes (adjunct to insulin; initiated and supervised by a specialist). † SGLT2i treatment should be suspended in individuals with acute illness until fully recovered. [2] [3] [4] [5] 13, 14 Urinary symptoms, due to glucosuria, can be an issue for people prescribed SGLT2i medicines. [2] [3] [4] [5] However, UTIs are relatively rare and these medicines may be prescribed for people with a history of UTIs.
The SGLT2i Prescribing Tool has been prepared by the Improving Diabetes Steering Committee. Napp Pharmaceuticals has fully funded the creation of this non-promotional document and has reviewed and certified it for medical accuracy and compliance with the ABPI Code of Practice.