Utilities of Sodium-Glucose Cotransporter-2 Inhibitor in the Intensive Care Units

Background Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have become foundational therapies for heart failure and chronic kidney disease and are increasingly used in critically ill patients. Their established benefits for kidney and heart health, along with emerging evidence from acute-care settings, indicate growing interest in their potential role in intensive care medicine. However, whether these benefits can be translated to critically ill populations remains uncertain, and concerns regarding safety continue to influence clinical practice. Summary Clinical evidence supporting the use of SGLT2 inhibitors (SGLT2i) during acute illness is expanding. Benefits have been most consistently observed in acute heart failure, perioperative care, and renal outcomes, where randomized and observational studies suggest improved decongestion, reduced acute kidney injury, and favorable cardiorenal outcomes. These observations are supported by several biological effects of SGLT2i that extend beyond glucose lowering, including modulation of fluid balance, renal hemodynamics, metabolic adaptation, inflammation, and endothelial function-pathways that are central to the development of organ dysfunction during critical illness. However, important uncertainties remain regarding which critically ill patients are most likely to benefit, whether chronic therapy should be continued during acute illness, and how potential benefits should be balanced against safety concerns in the ICU. This review integrates current mechanistic and clinical evidence, examines the balance between potential benefits and risks, discusses practical management considerations, and highlights key research priorities to better define the role of SGLT2i in critical care medicine.   Key Messages - SGLT2 inhibitors show promise in critical care but are not established therapies. - Cardiorenal benefits must be balanced against metabolic and hemodynamic risks. - Future research should define the right patient, the right timing, and the right treatment strategy.