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When to Continue, Pause, or Stop SGLT-2 Inhibitors in Heart Failure: A Complication-based Clinical Guide
Nicole A Tesoro1, Jasvin K Manha2, Sumanth K Bandaru3
1Department of Medicine, NYC Health + Hospitals/South Brooklyn Health, New York, USA.
Insights
Sodium-glucose cotransporter 2 (SGLT2) inhibitors benefit heart failure patients. This review guides clinicians on managing SGLT2 inhibitor genitourinary side effects to balance benefits and harm.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors are vital for heart failure management, improving survival and reducing hospitalizations.
- Their use is associated with genitourinary side effects, ranging from mild infections to rare severe complications like urosepsis and euglycemic diabetic ketoacidosis.
Purpose of the Study:
- To review the benefits and mechanisms of SGLT2 inhibitors.
- To outline common and serious adverse events associated with SGLT2 inhibitors.
- To propose a practical, case-based approach for managing SGLT2 inhibitor therapy concerning adverse events.
Main Methods:
- Literature review summarizing SGLT2 inhibitor mechanisms, benefits, and adverse events.
- Analysis of current guidance and case reports regarding genitourinary side effects.
- Development of a structured, individualized approach for clinical decision-making.
Main Results:
- SGLT2 inhibitors offer significant cardiovascular benefits independent of diabetes status.
- Genitourinary infections are common, but mild cases can often be managed with standard treatment while continuing SGLT2 inhibitor therapy.
- Severe, recurrent, or life-threatening events may necessitate temporary or permanent discontinuation of SGLT2 inhibitors.
Conclusions:
- A structured, individualized approach is crucial for managing SGLT2 inhibitor-related adverse events.
- Clinicians can preserve the cardiovascular benefits of SGLT2 inhibitors by carefully balancing risks and benefits.
- This approach aims to minimize harm while maximizing therapeutic outcomes in heart failure patients.
Abstract:
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have become an essential part of guideline-directed medical therapy for heart failure due to their proven ability to reduce hospitalizations and improve survival, independent of diabetes status. Despite these benefits, their use can be complicated by genitourinary side effects such as genital mycotic infections, urinary tract infections, and, rarely, serious complications including urosepsis, Fournier's gangrene, and euglycemic diabetic ketoacidosis. These events often leave clinicians uncertain about whether therapy should be continued, paused, or permanently discontinued. Current guidance remains limited and inconsistent, with most recommendations derived from case reports, expert opinion, or post-marketing surveillance. In this review, we summarize the mechanisms and benefits of SGLT2 inhibitors, outline common and serious adverse events, and propose a practical, case-based approach to guide decisions about continuing, pausing, or discontinuing therapy. Evidence suggests that most mild genitourinary infections can be managed with standard treatment while maintaining therapy, whereas severe, recurrent, or life-threatening events may warrant temporary or permanent discontinuation. A structured, individualized approach that balances risks and benefits allows clinicians to preserve the cardiovascular benefits of SGLT2 inhibitors while minimizing preventable harm.
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