17/05/2026
Avoid These 10 Mistakes When Prescribing SGLT2 Inhibitors & GLP-1 RAs
1️⃣ Do not treat SGLT2 inhibitors and GLP-1 RAs as “only sugar drugs.”
Their value is now beyond HbA1c. SGLT2 inhibitors are organ-protective drugs for CKD and heart failure, even when HbA1c is not high. GLP-1 RAs also provide cardiovascular, renal, metabolic, and weight-related benefits.
2️⃣ Do not stop SGLT2 inhibitors for the expected early eGFR dip.
A fall in eGFR of around 10–15% after initiation is common and usually reflects beneficial intraglomerular hemodynamic change, not renal toxicity. Up to 30% decline in the first 3 months may be acceptable, but >30% or progressive decline needs evaluation for dehydration, hypotension, excess diuretics, NSAID use, or another renal insult.
3️⃣ Do not overreact to ge***al fungal infections.
Ge***al candidiasis is the commonest adverse effect of SGLT2 inhibitors, especially in obesity, prior fungal infection, and poor hygiene. Most cases can be treated with topical or oral antifungals without stopping the drug. Routine antibiotic or antifungal prophylaxis is not advised.
4️⃣ Never miss euglycemic ketoacidosis.
SGLT2 inhibitor–associated ketoacidosis may occur with glucose not very high. Suspect it in diabetes patients with nausea, vomiting, abdominal pain, breathlessness, fasting, infection, surgery, alcohol excess, ketogenic diet, or insulin omission. Check ketones and acid–base status early.
5️⃣ Teach “sick day rules” clearly.
During acute illness, dehydration, poor oral intake, fasting, or surgery, SGLT2 inhibitors should be temporarily withheld. Patients should maintain fluids, take carbohydrates if possible, continue necessary insulin, and check ketones when unwell.
6️⃣ Stop SGLT2 inhibitors before surgery.
SGLT2 inhibitors should generally be stopped 3 days before surgery and restarted only when the patient is eating normally, hydrated, and clinically stable. This is especially important in patients on insulin, low-carbohydrate diets, or prolonged fasting.
7️⃣ Do not routinely stop GLP-1 RAs before every procedure.
Unlike SGLT2 inhibitors, GLP-1 RAs do not require blanket discontinuation before surgery or endoscopy. Assess risk individually. Hold or modify only in patients with severe nausea, vomiting, known gastroparesis, recent dose escalation, or high aspiration risk. A 24-hour clear liquid diet may be useful in selected cases.
8️⃣ Watch the retina when HbA1c falls rapidly with semaglutide.
Rapid glycemic improvement may transiently worsen diabetic retinopathy in high-risk patients, especially those with pre-proliferative or proliferative retinopathy and very high baseline HbA1c. Retinal screening before initiation and close ophthalmology follow-up are essential.
9️⃣ Do not combine GLP-1 RAs with DPP-4 inhibitors.
This combination adds cost without meaningful extra benefit. When starting a GLP-1 RA, stop sitagliptin, linagliptin, vildagliptin, or other DPP-4 inhibitors.
🔟 Reduce insulin or sulfonylurea when starting GLP-1 RA.
GLP-1 RAs alone have low hypoglycemia risk, but hypoglycemia increases when combined with sulfonylureas, glinides, or insulin. Consider reducing sulfonylurea or basal insulin dose, especially if HbA1c is near target or glucose readings are low.
Practical Bedside Message
SGLT2 inhibitors protect kidney and heart. GLP-1 RAs protect weight, heart, kidney, and metabolism. But both require prescription intelligence.
The commonest preventable errors are: stopping SGLT2 inhibitors for a harmless eGFR dip, missing euglycemic ketoacidosis, poor perioperative planning, ignoring ge***al hygiene counselling, combining GLP-1 RA with DPP-4 inhibitor, and failing to reduce insulin or sulfonylurea.
Take Home
Prescribe SGLT2 inhibitors and GLP-1 RAs for organ protection, not just HbA1c—but prevent harm by anticipating eGFR dip, ge***al infections, euglycemic DKA, perioperative risks, retinopathy worsening, and hypoglycemia with insulin or sulfonylureas.
