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Diabetes Distilled: MHRA drug safety update on SGLT2 inhibitors

Kevin Fernando
The MHRA issued a drug safety update in March reminding healthcare professionals to stop sodium–glucose cotransporter 2 (SGLT2) inhibitor therapy, and to monitor ketones in those individuals who are hospitalised for major surgical procedures or acute serious medical illness. Whilst this update is more immediately relevant to our secondary care colleagues, it does serve as a useful reminder of the drug safety alert published in 2016 regarding the risk of euglycaemic diabetic ketoacidosis.

The MHRA issued a drug safety update in March reminding us to stop sodium–glucose cotransporter 2 (SGLT2) inhibitor therapy in those individuals who are hospitalised for major surgical procedures or acute serious medical illness. Additionally, ketone levels should be routinely monitored during hospitalisation (blood ketone testing is preferred to urine), and SGLT2 inhibitor treatment can be restarted once ketone values are normal and the individual is stable.

Whilst this update is more immediately relevant to our secondary care colleagues, it does serve as a useful reminder of the MHRA drug safety alert published in 2016, which is relevant to all in primary care. SGLT2 inhibitors can be associated with euglycaemic diabetic ketoacidosis (DKA; i.e. that occurring at normal or near-normal glucose levels). Individuals on SGLT2 inhibitors need to be counselled about the possible symptoms and signs of DKA (which I appreciate is very challenging as these are often very non-specific), and to contact primary care for advice if unwell.

If we suspect DKA, we need to check for ketones (again, blood ketone testing is preferred), even if blood glucose levels are normal or near normal. There is no need to issue ketone testing strips to those on SGLT2 inhibitors, but we should have access to them in our respective workplaces.

Along with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, we need to consider, on an individual basis, temporarily stopping SGLT2 inhibitors during any acute dehydrating illness to reduce the risk of developing DKA. SGLT2 inhibitors can be reintroduced once stable and eating and drinking normally.

To access the publication, click here

Other helpful resources
Diabetes UK: Coronavirus and diabetes. This regularly updated page is very helpful for those living with diabetes and their families and answers many commonly asked questions

JDRF: Coronavirus (COVID-19) – information for people living with type 1 diabetes. This regularly updated page contains useful links and information about coronavirus and what people living with type 1 diabetes need to know

NHS England & NHS Improvement London: Diabetes COVID-19 key information. Useful guidance to support the delivery of diabetes care during the pandemic. Guide for London Clinical Networks but there is plenty of helpful information for wherever we work

Primary Care Diabetes Society: COVID-19 and diabetes factsheet. This quick reference guide reviews a number of issues that healthcare professionals may need to consider when caring for people with diabetes

Diabetes & Primary Care: How to advise on sick day rules. A brief guide to managing diabetes during intercurrent illness

TREND-UK: Resources to help support nurses amid the coronavirus pandemic. Helpful patient information leaflets for those living with type 1 and type 2 diabetes and what to do when unwell

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PCDS consensus statement: A strategy for managing the supply shortage of the GLP-1 RAs Ozempic and Trulicity
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