SGLT2 inhibitors (gliflozins) — patient guide

This page covers all the medicines in the SGLT2 inhibitor family (sometimes called gliflozins). If your medicine’s name ends in -flozin, this is your page.

---

Read this first — when to stop the tablet

eDKA — ketoacidosis can happen at a normal blood glucose. If you feel unwell with nausea, vomiting, abdominal pain, heavy or rapid breathing, or unusual lethargy — stop the SGLT2 and go to an emergency department. Tell the triage nurse you are on an SGLT2 inhibitor and ask to be checked for ketones, even if the glucose reading is normal. This is the single most important safety point for this class.

Fournier gangrene — severe genital or perineal pain with redness, swelling, and fever = emergency department. Rare but serious; do not wait for a GP appointment.

Sick-day pause. Hold the medicine during any of:

• Vomiting or diarrhoea lasting more than a few hours
• Significant fever, infection, or heat illness
• Fasting more than 24 hours, or significantly reduced food intake
• Heavy alcohol or binge drinking
• Starting or restarting a ketogenic or very-low-carb eating pattern
• At least 3 days before any planned major surgery (4 days for canagliflozin)

Restart only when you are eating, drinking, and clinically well.

---

Find your medicine

Generic name	Common brand names	Strengths	How often
Empagliflozin	Jardiance, generics	10 / 25 mg	Once daily
Dapagliflozin	Forxiga, generics	5 / 10 mg	Once daily
Ertugliflozin	Steglatro	5 / 15 mg	Once daily
Canagliflozin	Invokana	100 / 300 mg	Once daily

Combination tablets — if your tablet is one of these, you are on an SGLT2 inhibitor plus a second drug:

Combination brand	What’s in it
Jardiamet / Synjardy	Empagliflozin + metformin
Xigduo XR	Dapagliflozin + metformin
Segluromet	Ertugliflozin + metformin
Glyxambi	Empagliflozin + linagliptin (DPP-4)
Steglujan	Ertugliflozin + sitagliptin (DPP-4)
Qtern	Dapagliflozin + saxagliptin (DPP-4)

Note on canagliflozin (Invokana). Following the lower-limb amputation signal in the CANVAS trial, canagliflozin was delisted from the PBS in Australia in 2017. It is rarely prescribed in routine AU practice now. If a script for Invokana is offered, ask your pharmacist about current AU availability and whether empagliflozin or dapagliflozin would suit your situation.

Closely related family — GLP-1 receptor agonists (semaglutide / Ozempic, dulaglutide / Trulicity, liraglutide / Victoza). Different mechanism, different injection route in most cases, sometimes combined with an SGLT2 for layered cardiometabolic benefit. Separate page when ready.

---

What it treats

SGLT2 inhibitors started life as a glucose-lowering medicine for type 2 diabetes. The trial story since 2015 has expanded the use considerably. Your reason for taking one may be one or more of:

• Type 2 diabetes — to lower blood glucose, usually on a background of metformin.
• Heart failure with reduced ejection fraction (HFrEF) — with or without diabetes.
• Heart failure with preserved ejection fraction (HFpEF) — with or without diabetes.
• Chronic kidney disease — to slow the rate at which kidney function declines and reduce protein leak into urine, with or without diabetes.
• Cardiovascular risk reduction in T2DM with established cardiovascular disease.

The mechanism is the same in all of these. The goal differs, and that matters: in heart failure and CKD, we keep the medicine going even if you don’t have diabetes and even if glucose is normal — because the protective effect on the heart and kidneys is independent of the glucose lowering. Your GP or specialist will tell you which group you sit in.

---

The basics

1. Take it at the same time every day. Once daily, usually in the morning so the diuretic effect doesn’t disturb sleep. Miss a dose? Take the next one — don’t double up.
2. Pause the tablet on a sick day (see the box at the top). This is the single most important safety habit for this medicine.
3. Drink to thirst. These medicines act as a mild diuretic — adequate water intake matters, especially in hot weather or on exercise days.
4. Daily perineal hygiene and foot inspection. Both reduce the most common complications of this class.

Everything else — side effects, the blood test you’ll need, the integrative angle — is below.

---

What to expect in the first month

Week 1

• Increased urination is expected and most noticeable in the first 1 to 2 weeks. It usually settles as the body adjusts.
• You may feel mild thirst — drink to thirst with water.
• Some people feel light-headed on standing in the first week, especially if also on a diuretic or an ACE inhibitor. Get up slowly.
• You probably won’t “feel” a glucose-lowering effect. These medicines don’t produce a noticeable hypo on their own.

Week 2

• Get the blood test that was ordered — kidney function, electrolytes, and HbA1c if relevant.
• Watch for any sign of genital itch, discomfort, or unusual discharge — treat early with a standard antifungal if needed.
• A small, transient eGFR drop on the blood test is expected (similar to what happens with an ACE inhibitor) and reflects how the drug works. It is not a reason to stop.

Weeks 3-4

• The diuretic and glucose effects steady. If you have a home BP cuff, expect a modest 3-5 mmHg systolic reduction.
• Weight may drop by 1-2 kg in the first month. Average loss across the class settles around 2-3 kg over 6 months.
• A review appointment is appropriate around this point — to look at the bloods, the BP, and how you’re feeling.

When will it start working?

For glucose lowering, the first effect is within hours but the steady-state HbA1c shift takes 3 months to show on the blood test. For heart failure symptoms — exertional breathlessness, leg swelling — patients often notice improvement within weeks. For kidney protection, the benefit is structural and shows over years, not weeks. The point of the medicine in CKD is to keep your kidneys working for longer, not to give you a felt-experience week-to-week.

---

Tap any section below to expand the detail.

How does it work?

SGLT2 stands for sodium-glucose cotransporter 2 — a protein in the kidney’s proximal tubule that pulls glucose back into the body from the urine before it can be excreted. Block that protein, and excess glucose is passed out in the urine instead. That single mechanism produces several downstream effects:

• Glucose drops by 0.5 to 1.0% on HbA1c, more in higher-baseline patients.
• Modest weight loss — averaging 2 to 3 kg — because the excreted glucose carries calories with it.
• Modest blood pressure reduction — around 3 to 5 mmHg systolic — through osmotic diuresis and sodium loss.
• Pressure inside the kidney’s filtering units (glomeruli) drops — which is why the medicine slows kidney damage even in patients without diabetes.
• Cardiac workload eases — the combination of natriuresis, modest preload reduction, and a metabolic shift toward ketone use by the heart appears to contribute to the heart failure benefit. The exact mechanism is still being worked out.

The cardiorenal benefit is not just a downstream of glucose lowering. It happens in patients without diabetes too — which is part of why these medicines are now used well beyond their original niche.

Side effects in detail

Common (usually mild and self-limiting)

• Increased urination, especially in the first 1 to 2 weeks. Usually settles. Take the tablet in the morning to reduce night-time disturbance.
• Genital fungal infection — vulvovaginal thrush in around 5 to 10% of women, balanitis in around 1 to 3% of men. Treatable with standard topical or oral antifungals. Most episodes happen in the first 3 to 6 months. Daily warm-water cleansing and breathable underwear reduce the risk.
• Mild dizziness or light-headedness on standing, especially in the first week and especially if also on a diuretic, an ACE inhibitor, or an ARB. Get up slowly. Drink to thirst.
• Small transient drop in eGFR on the kidney blood test on initiation. Expected, not a reason to stop. A sustained or larger drop needs review.
• Mild thirst — drink to thirst with water rather than sugary or sports drinks.

Uncommon

• Constipation or mild abdominal discomfort.
• Mild rash.
• Modest LDL cholesterol rise of around 0.1 to 0.2 mmol/L — clinical significance debated; the overall cardiovascular benefit is established despite this.

Rare but serious — go to ED

• Euglycaemic diabetic ketoacidosis (eDKA). Ketoacidosis at near-normal blood glucose. Symptoms: nausea, vomiting, abdominal pain, deep or rapid breathing, lethargy, fruity breath. Risk factors: low-carbohydrate intake, fasting, surgery, acute illness, alcohol excess, dehydration, prior DKA history. Stop the medicine and present to ED — even if the glucose meter reads normal. Per the TGA Medicines Safety Update, this is a class-wide signal, not specific to any one gliflozin.
• Fournier gangrene. Necrotising perineal infection. Severe pain, redness, swelling, fever in the genital or perineal area = ED, do not wait. TGA and FDA post-marketing safety signal.
• Severe dehydration with light-headedness, fainting, or markedly reduced urine output — particularly in hot weather, during gastro illness, or on a strong diuretic.
• Lower-limb amputation — a roughly 2x signal seen with canagliflozin in CANVAS, much less prominent (debated whether present at all) with empagliflozin or dapagliflozin. Foot inspection counsel applies to anyone on the class — particularly with peripheral arterial disease, prior ulcer, or neuropathy.
• Bone fracture — a modest signal specific to canagliflozin in CANVAS; not seen in the empagliflozin or dapagliflozin trials. Falls-prevention review is reasonable for older adults on canagliflozin specifically.

Drugs, food, and alcohol

Tell us or your pharmacist before combining with:

• Insulin or sulfonylureas (gliclazide / Diamicron, glimepiride / Amaryl). The SGLT2 alone rarely causes hypoglycaemia, but the combination does. Doses of the partner medicine are often reduced when starting an SGLT2.
• Loop and thiazide diuretics (frusemide / Lasix, indapamide / Natrilix, hydrochlorothiazide). Additive volume loss and risk of dizziness, especially in older patients or in hot weather. Sometimes the diuretic dose is adjusted on initiation.
• ACE inhibitors / ARBs / mineralocorticoid antagonists (spironolactone / Aldactone, eplerenone). Generally synergistic for cardiorenal protection — the combination is intentional in heart failure and CKD. The small transient eGFR drop on starting an SGLT2 is expected and not a reason to stop.
• Anti-inflammatories (ibuprofen / Nurofen, diclofenac / Voltaren, naproxen, celecoxib). Combined with an SGLT2 plus a diuretic plus an ACE inhibitor or ARB (the so-called “quadruple whammy”), regular NSAID use significantly stresses the kidneys. Occasional use is usually fine; regular use needs a planned conversation. Paracetamol is fine.
• Lithium. Limited data on the combination. Monitor levels more closely.

Food. No specific food restrictions, with one important exception: a strict low-carb or ketogenic eating pattern, prolonged fasting, or repeatedly skipped meals significantly raises the risk of euglycaemic ketoacidosis. If you want to try one of these eating approaches, plan it with the prescribing GP first — the right move may be to switch class before starting.

Alcohol. Light to moderate is generally okay. Heavy or binge drinking raises eDKA risk because it reduces carbohydrate intake and shifts the body toward ketogenesis. Counsel particularly applies around festive periods, weekend bingeing, and travel.

Generic substitution at the pharmacy. Generic versions are bioequivalent and work the same. Branded and generic empagliflozin or dapagliflozin are interchangeable at PBS pricing.

Monitoring — what blood tests and when

• Baseline before starting: eGFR, electrolytes (sodium, potassium, magnesium), HbA1c if relevant, and a urine ACR (albumin-to-creatinine ratio) if CKD or diabetes is part of the picture.
• Blood test at 2-4 weeks after starting or after a dose change. Checks kidney function and electrolytes. A small transient eGFR drop is expected and not a reason to stop.
• Blood test at 3 months to confirm steady state, plus HbA1c if treating diabetes.
• Then annually with your routine review, unless something changes.
• Foot check at every GP visit if you have diabetes, peripheral arterial disease, prior ulcer, or neuropathy.

Message us if you start a new medicine (including over-the-counter or supplements), get a gastro illness lasting more than a day, start a new eating pattern (especially low-carb or fasting), or notice persistent dizziness, unusual genital symptoms, or any wound on the feet that is slow to heal.

Stopping or pausing

Don’t stop without talking to us first.

• If side effects are the problem, we usually swap medicines or change class rather than stop. There are several alternatives — other SGLT2s, GLP-1 receptor agonists, DPP-4 inhibitors, or returning to the previous regimen.
• Sick day rules (top of page) — pausing during gastro, fever, fasting, heavy alcohol, or for at least 3 days before major surgery (4 for canagliflozin) is normal and expected use, not stopping.
• Before surgery — the anaesthetic and surgical team will usually confirm the perioperative hold. The standard AU guidance is 3 days for empagliflozin, dapagliflozin, and ertugliflozin, and 4 days for canagliflozin. Restart only when you are eating, drinking, and clinically well — not on the morning after surgery.
• If you are admitted to hospital acutely unwell, the inpatient team will usually hold the SGLT2 routinely. Make sure they know you are on one.
• Stopping cold turkey without a reason — if the medicine is doing more than treating glucose (heart, kidney), you lose the cardiorenal protection regardless of how the glucose looks.

Pregnancy and breastfeeding

SGLT2 inhibitors are not for use in pregnancy or breastfeeding. Safety data is limited and the standard pre-conception plan is to switch to insulin.

• Planning a pregnancy: tell us before trying. We swap to insulin pre-conception, which has the longest safety record across pregnancy and lactation.
• Already on one and just found out you’re pregnant: contact us as soon as possible. The medicine is held and we transition to insulin under endocrinology or shared antenatal care.
• Breastfeeding: not recommended. If glucose control needs medication during breastfeeding, insulin is the usual choice.

If you’re on a combination tablet

Several SGLT2 inhibitors come pre-combined with a second medicine. If your tablet is one of these, the SGLT2 part has the same rules described on this page — but the partner drug has its own profile too:

• Jardiamet / Synjardy — empagliflozin plus metformin. Both lower glucose. Metformin adds gastrointestinal side effects (nausea, loose stools) and its own sick-day rule.
• Xigduo XR — dapagliflozin plus metformin. Same combination logic.
• Segluromet — ertugliflozin plus metformin.
• Glyxambi — empagliflozin plus linagliptin (a DPP-4 inhibitor).
• Steglujan — ertugliflozin plus sitagliptin (a DPP-4 inhibitor).
• Qtern — dapagliflozin plus saxagliptin (a DPP-4 inhibitor).

The page for metformin and the page for DPP-4 inhibitors will be linked here as they go live.

Cost and PBS

SGLT2 inhibitors are on the PBS with Streamlined Authority for several indications, including type 2 diabetes (on background metformin), heart failure with reduced or preserved ejection fraction, and chronic kidney disease — with and without diabetes for the HF and CKD indications. The exact authority criteria vary by drug and indication and have expanded over recent years.

From 1 January 2026, the PBS co-payment is:

• General patient: up to $25.00 per script
• Concession card holder: up to $7.70 per script

Generic empagliflozin and dapagliflozin are available and at PBS pricing cost the same as the branded versions. Combination tablets (Jardiamet, Xigduo XR, etc.) are also PBS-listed under their own authority criteria.

Confirm with your pharmacist — they can tell you the exact price for your script under your specific authority and concession status.

---

The integrative view

Most of the patients I see want to do everything they reasonably can in addition to taking the medicine. This section is the longer version of that conversation.

Two principles. First: SGLT2 inhibitors are well-evidenced medicines for the indications they’re prescribed for. Lifestyle changes work too. Combined, they work better than either alone. Second: medicines aren’t always permanent. For type 2 diabetes, sustained changes in eating, movement, weight, and metabolic health can sometimes bring HbA1c down to a level where the dose comes down — but in heart failure and CKD, the medicine usually stays because the protection is structural, not glucose-driven.

Strong evidence — these reliably improve metabolic and cardiovascular health

These are interventions where the data is solid enough that I’d recommend them to any patient on an SGLT2 inhibitor — for type 2 diabetes, heart failure, or CKD.

• Mediterranean-pattern eating — vegetables, legumes, whole grains, fish, olive oil, nuts, modest dairy, less processed food. Improves glycaemic control, reduces cardiovascular events, and supports kidney health. Per PREDIMED (NEJM 2018), around 30% relative reduction in major cardiovascular events in higher-risk adults.
• Aerobic activity — 150 minutes per week of brisk walking, cycling, or swimming. Improves insulin sensitivity, lowers HbA1c by around 0.5-0.7%, and reduces cardiovascular events.
• Resistance training — 2 to 3 sessions per week. Independently improves glucose handling and protects against age-related muscle loss, which matters because muscle is the largest glucose sink in the body.
• Modest weight loss — even a 5-10% reduction improves HbA1c, blood pressure, and liver fat. For HFpEF specifically, weight loss is one of the few interventions outside medication with reproducible symptom benefit.
• Sleep — consistent 7 to 8 hours, treat sleep apnoea if present. Insulin resistance worsens markedly with poor sleep. Snoring plus daytime tiredness plus observed pauses in breathing warrants a sleep study.

Moderate evidence — likely helpful

• Adequate carbohydrate, distributed across the day — counter-intuitively, the standard nutrition advice for an SGLT2 patient is not to go very low carb. The medicine’s eDKA risk rises with low-carb intake. The right pattern is good-quality carbohydrates (vegetables, legumes, intact grains, fruit) distributed across meals rather than concentrated or skipped.
• Magnesium-rich foods (leafy greens, nuts, seeds, legumes). Supports insulin signalling. Food first; supplements only if there’s a specific reason or a low level on a blood test.
• Hydration to thirst with plain water — these medicines act as a mild diuretic, and adequate hydration reduces light-headedness and supports kidney perfusion. Avoid sugary or sports drinks unless physically working in heat for extended periods.
• Stress reduction practices — meditation, slow breathing (around 6 breaths per minute), yoga. Modest effect on glucose and BP over months of practice.
• Strength and balance work in older patients on canagliflozin — given the bone-fracture signal specific to that drug in CANVAS, falls-prevention is reasonable. Tai chi, structured strength work, or a physiotherapy-led falls-prevention program.

Limited or emerging evidence

• Berberine 500 mg twice or three times daily. Some randomised data shows HbA1c reduction in T2DM in a similar range to metformin. Not a substitute for prescribed medication; possible interactions with statins and several other drugs. Discuss before starting.
• Cinnamon, chromium, alpha-lipoic acid — mixed evidence for HbA1c. Not interventions I’d lean on as primary tools.
• Time-restricted eating with a 12-14 hour overnight window — generally tolerable on an SGLT2 if carbohydrate intake during the eating window is adequate. Anything more restrictive (16:8 with deliberately low carbs, 24-hour fasts) needs a planned discussion first because of eDKA risk.

Specific to being on an SGLT2 inhibitor

• Carbohydrate adequacy is the counter-intuitive headline. Most metabolic-health advice trends low-carb. On an SGLT2, that direction raises a metabolic-emergency risk. Plan eating patterns with this in mind.
• Perineal hygiene matters more than usual. Daily warm-water cleansing of the genital area, prompt drying, breathable underwear, avoidance of harsh perfumed soaps. The glycosuria means yeast has more food than it normally would.
• Daily foot inspection — between toes, under the arch, over pressure points. Catches early ulceration. Particularly important if you have any peripheral arterial disease, neuropathy, or prior foot wound.
• Hydration in hot weather and exercise — drink to thirst with water. Be more careful in summer, on long walks, during illness, and if you are also on a diuretic.
• Sick-day plan written down somewhere accessible — fridge magnet, phone note, wallet card. The list is broader than most BP medicines: vomiting, diarrhoea, fever, fasting more than 24 hours, heavy alcohol, starting a low-carb pattern, 3 days before major surgery.

Earning a lower dose

For type 2 diabetes, if you genuinely change your eating, movement, weight, and metabolic health, HbA1c may drop enough that the dose can be reduced — sometimes the medicine comes off entirely. This is a goal worth aiming for, with regular HbA1c monitoring and a plan made together.

For heart failure and CKD, the SGLT2 usually stays even if glucose normalises, even if BP normalises, even if you feel well. The structural protection is the reason it’s prescribed.

---

Track these between now and your next visit

• Home BP readings if you have a monitor — a couple of times a week, same time of day.
• Any genital itch, discomfort, or unusual discharge — note when it started and what you did.
• Any sick day — when you paused the medicine, why, and when you restarted.
• Anything new you’ve bought over the counter (painkillers, supplements, anti-fungals).
• Foot changes — any wound, redness, swelling, or pain on the feet.
• Weight — once weekly, same day, same conditions.

Bring the list to your review appointment.

---

This is general information, not personal medical advice. Every patient is different. Decisions about your medicines — which one, what dose, when to stop, what to combine with — are made with the doctor who prescribed them. If anything on this page appears to contradict advice from your treating doctor, follow your doctor; they have context about your situation that this page cannot.

Reading this page does not establish a doctor-patient relationship with Dr Hoebing Lo. If you are not a current patient, please discuss your medicines with your own GP, specialist, or pharmacist.

About the integrative content. The lifestyle, dietary, and complementary recommendations on this page summarise current published research. Effect sizes are approximations from clinical studies — your individual response will vary, and real-world results are commonly smaller than trial results because day-to-day life differs from study conditions. Supplements and herbal products are not interchangeable with prescribed medication and can interact with it. Talk to your doctor and pharmacist before starting any new supplement, herbal product, or significant change in diet.

Currency. This page reflects clinical practice as of the last-reviewed date. Medicine evolves; specific details may date between reviews. Pricing shown is indicative; confirm with your pharmacist.

No commercial relationships. Dr Hoebing Lo has no financial or commercial relationship with the manufacturer of any medicine, brand, or supplement mentioned on this page.

Emergencies. If you have nausea, vomiting, abdominal pain, heavy or rapid breathing, or unusual lethargy while on an SGLT2 inhibitor, stop the medicine and go to your nearest emergency department — even if your blood glucose meter reads normal. If you have severe pain, redness, or swelling in the genital or perineal area, especially with fever, call 000 or go directly to ED. Do not wait, and do not message us first.