Canagliflozin (CKD)

How it works

It blocks SGLT2 in the proximal renal tubule, increasing urinary glucose and sodium excretion; the resulting tubuloglomerular feedback reduces intraglomerular pressure and slows nephropathy progression.

Prescribing in practice

• Counsel on diabetic ketoacidosis, which can occur with near-normal blood glucose; withhold during acute illness, dehydration or before surgery (sick-day rules), and stop if ketoacidosis is suspected.
• Canagliflozin specifically has been associated with an increased risk of lower-limb amputation and of fracture; assess foot health and review in patients at risk.
• Volume depletion and genital mycotic and urinary infections are common; glucose-lowering efficacy falls at low eGFR though renal benefit persists down to defined thresholds in the SPC.

Monitoring

Monitor renal function, volume status and ketone awareness, and review foot health and fracture risk during treatment.

Counselling the patient

• Stop the tablet and seek urgent advice if you feel very unwell with nausea, vomiting, deep breathing or abdominal pain.
• Maintain good foot care and report any new foot ulcers, sores or infection.
• Drink adequate fluids and watch for genital itching or thrush, which is treatable.

Evidence & guidelines

The CREDENCE trial showed canagliflozin reduced progression of kidney disease and cardiovascular events in patients with type 2 diabetes and diabetic nephropathy.