SGLT2 Inhibitor Selection in T2DM with CKD

Guideline-Based Recommendations

The American Diabetes Association and Kidney Disease: Improving Global Outcomes (KDIGO) recommend SGLT2 inhibitors, including empagliflozin and dapagliflozin, with Class I, Level A evidence to reduce CKD progression and cardiovascular events in patients with T2DM and CKD 3, 4
The European Society of Cardiology recommends both agents to reduce cardiovascular death, myocardial infarction, stroke, and heart failure hospitalization in patients with T2DM at very high or high cardiovascular risk 4, 5
The American College of Cardiology recommends empagliflozin specifically to reduce the risk of death in patients with T2DM and cardiovascular disease, with a Class I recommendation 5, 6

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend initiating empagliflozin at eGFR ≥20 mL/min/1.73 m² based on EMPEROR trial data and updated 2022 KDIGO/ADA guidelines 1, 2
The FDA approves empagliflozin for use with eGFR >30 mL/min/1.73 m², though pivotal trials demonstrated benefit in subgroups with eGFR <30 mL/min/1.73 m² 3
The European Renal Association recommends initiating dapagliflozin at eGFR ≥25 mL/min/1.73 m² based on DAPA-CKD trial evidence showing clear efficacy and safety in patients with ACR ≥200 mg/g 1, 2

Choose empagliflozin when eGFR is 20-24 mL/min/1.73 m², or when the patient has established cardiovascular disease requiring mortality benefit, with a specific Class I recommendation for death reduction 1, 2, 5, 6
Choose dapagliflozin when eGFR is ≥25 mL/min/1.73 m² with significant albuminuria (ACR ≥200 mg/g), as this matches DAPA-CKD trial enrollment criteria 1, 2

Continue SGLT2 inhibitor even if eGFR falls below initiation threshold during treatment, unless the patient is not tolerating therapy or requires kidney replacement therapy, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1, 2
Monitor eGFR at least annually when ≥60 mL/min/1.73 m², increasing to every 3-6 months when <60 mL/min/1.73 m², as recommended by the American Diabetes Association 7

Monitor for hypovolemia and consider proactive diuretic dose reduction in high-risk patients, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1, 2
Hold SGLT2 inhibitor during acute illness to prevent volume depletion, and discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis, as recommended by the American College of Cardiology and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1, 2, 6
Reduce total daily insulin dose by approximately 20% if HbA1c is well-controlled at baseline, and consider weaning or stopping sulfonylureas or glinides to prevent hypoglycemia, as recommended by the American Diabetes Association 6
Educate patients on signs/symptoms for early recognition of diabetic ketoacidosis, and maintain at least low-dose insulin in insulin-requiring individuals, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1, 2