Managing type 2 diabetes mellitus (T2DM) is complex and challenging, especially in light of the range of medications available for treatment. The role of metformin as first-line oral therapy continues to dominate treatment guidelines, but additional pharmacotherapy is also available, including but not limited to sodium-glucose cotransporter-2 inhibitor (SGLT2i) agents.

Due to recent scrutiny and potential misconceptions concerning the efficacy, safety, and appropriate inclusion of different therapies within the T2DM treatment plan, the Improving Diabetes Steering Committee—comprised of a panel of expert advisers from across primary and secondary care practices—has worked collaboratively to develop a risk/benefit tool that focuses on specific considerations for appropriate prescribing of SGLT2i agents.

The tool provides clinicians with a systematic approach to consider the incorporation of SGLT2is and provides a checklist as a good reminder for routine best practice:
• Check electrolyte and renal function regularly for all individuals prescribed an SGLT2i. This is particularly important for individuals with comorbidities and those on concomitant medications, especially people on diuretic therapies.
• Check electrolyte and renal function regularly, as appropriate.
• Consider reducing or discontinuing diuretic medicines for treatment of edema or hypertension, especially if blood pressure is well controlled.
• Review medicines regularly and de-escalate therapy where possible.
The tool also has practical advice to guide patients through periods of illness. During periods of sickness, people with T2DM should:
• Stay well hydrated, eat little and often, and record blood glucose frequently.
• Stop taking SGLT2i, metformin, and GLP-1 RA medicines if unable to eat or drink, and contact their diabetes team for further directions.
• If unable to eat or appetite is reduced, meals may be replaced with high-carbohydrate snacks or drinks (e.g., fruit juice, glucose tablets).
• If vomiting, drowsy, unable to keep fluids down, or suffering with persistent diarrhea, seek medical help immediately.

Co-author Dr. Kevin Fernando (FRCGP, FRCP Edin. FAcadMEd MSc), affiliated with the North Berwick Health Centre, near Edinburgh, Scotland, commented, “Managing patients with type 2 diabetes is complex and can be challenging, particularly for clinicians working in Primary Care who are faced with many competing clinical priorities. We felt it was important to help provide everyday, usable tools that will help healthcare professionals ensure their patients receive optimal care for their type 2 diabetes.”

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