What they are
SGLT2 inhibitors are a class of medication that block a protein in the kidney called Sodium-Glucose Cotransporter 2 (SGLT2), which normally reabsorbs glucose back into the bloodstream. Blocking SGLT2 causes the kidneys to excrete extra glucose into the urine, lowering blood sugar.
Common SGLT2 inhibitors include:
- Dapagliflozin (Farxiga)
- Empagliflozin (Jardiance)
- Canagliflozin (Invokana)
- Ertugliflozin (Steglatro)
They were originally approved for type 2 diabetes, but extensive research over the past decade has revealed substantial benefits beyond glucose control.
Why nephrologists use them
SGLT2 inhibitors slow the progression of chronic kidney disease in patients both with and without diabetes. In landmark clinical trials (DAPA-CKD, EMPA-KIDNEY, CREDENCE), they reduced the combined risk of kidney failure, heart failure hospitalization, and cardiovascular death by 25–40%. The benefit appears across a wide range of patients, including those with CKD from causes other than diabetes.
Key effects:
- Reduce protein loss in the urine
- Lower the pressure inside the kidney's filtering units
- Reduce blood pressure modestly
- Promote modest weight loss
- Reduce hospitalization for heart failure
These medications are now considered foundational therapy for most patients with CKD and proteinuria, alongside ACE inhibitors or ARBs.
Who benefits
SGLT2 inhibitors are particularly recommended for:
- CKD with proteinuria (with or without diabetes)
- Type 2 diabetes with kidney or cardiovascular disease
- Heart failure (with or without diabetes)
Side effects to know about
Most side effects are manageable, but a few warrant attention:
- Genital yeast infections (women) and balanitis (men): the most common side effect, related to glucose in the urine. Usually treatable with topical antifungal medication. Good genital hygiene reduces risk.
- Mild dehydration and lightheadedness: especially when first starting or in hot weather. Adequate fluid intake helps.
- Urinary tract infections: slightly increased risk in some patients.
- Euglycemic diabetic ketoacidosis (rare but serious): high ketones in the blood despite near-normal blood sugar. Symptoms include nausea, vomiting, abdominal pain, and rapid breathing. Stop the medication and seek emergency care if these symptoms develop. Especially important to hold around surgery, severe illness, or prolonged fasting.
- Initial creatinine bump: a small early rise in serum creatinine is expected and not a reason to stop. Larger or sustained rises warrant evaluation.
Monitoring
After starting, your nephrologist will typically recheck kidney function and electrolytes within 4–6 weeks, then every 3–6 months. The medication is usually safe to continue until eGFR drops below approximately 20–25, depending on the specific agent.