Discontinuation of SGLT2 Inhibitors in Severe Renal Impairment

Classification of Renal Function and SGLT2 Inhibitor Efficacy

• A creatinine clearance of 15 mL/min corresponds to CKD stage 5 (kidney failure), which is defined as GFR <15 mL/min/1.73 m², typically requiring consideration of renal replacement therapy (dialysis or kidney transplantation) 1
• SGLT2 inhibitors like empagliflozin are not expected to be effective for glycemic control in advanced CKD, as their mechanism of action depends on adequate renal filtration, which is severely compromised at this level of kidney function 2, 3

Safety Considerations and Alternative Medications

• At very low creatinine clearance levels, there is increased risk of adverse effects including reduced drug clearance potentially leading to drug accumulation, and electrolyte abnormalities 2
• For patients with severe renal impairment requiring antidiabetic therapy, consider insulin (with dose adjustment), DPP-4 inhibitors with appropriate dose adjustments, or GLP-1 receptor agonists like liraglutide or dulaglutide which require no dose adjustment in severe renal impairment 2, 3

Common Pitfalls to Avoid

• Continuing SGLT2 inhibitors in severe renal impairment based on potential renoprotective effects without considering the safety risks, and not recognizing that the glycemic efficacy of SGLT2 inhibitors is significantly reduced at low GFR levels, potentially leading to inadequate diabetes control 2, 3