Resource used: OpenAthens access to NHS Knowledge and Library Hub
The situation
I was contacted by a secondary care colleague with a query about a patient with type 2 diabetes who had an active foot ulcer and was prescribed an SGLT2 inhibitor. The concern related to the MHRA 2017 safety warning, which highlighted an increased risk of lower limb amputation associated with canagliflozin, and questioned use SGLT2 in this group of patients in primary care.
While the MHRA warning is well recognised, I explained that the situation is not clear cut, particularly for SGLT2 inhibitors other than canagliflozin. Evidence from large cardiovascular outcome trials has demonstrated significant cardiovascular and renal benefits with empagliflozin and dapagliflozin, and the risk of amputations has not been seen outside the CANVAS program.
However, recognising the uncertainty in this area, in addition to speaking to peers, I committed to reviewing the evidence in more detail to provide a balanced, evidence-based response.
Exploring the evidence using OpenAthens NHS Knowledge and Library HubRegulation 18: Staffing — Support, Training and Development
Using the NHS Knowledge and Library Hub, I ran a search for ‘SGLT2-inhibitors’ AND ‘diabetic foot ulcers.’ I filtered to peer review. At number 5, it highlighted a recently published Delphi consensus study that specifically addressed the use of SGLT2 inhibitors in people with diabetes-related foot disease. This resource was particularly valuable as it brought together expert opinion from multiple professional backgrounds, including diabetologists, GPs, nurses, and pharmacists.
This Delphi study aimed to generate consensus-based clinical recommendations where high-quality trial evidence is limited. Through two rounds of structured surveys, the panel reached agreement on several key statements relevant to the case in question.
Key findings that informed practice
The Delphi consensus highlighted that there was consensus on the following relevant areas.
Agreement that those with a previous healed ulcer or amputation should have consideration made to being prescribed an SGLT2 inhibitors
Disagreement that SGLT2 inhibitors per se increased amputation risk
Agreement that canagliflozin should be avoided in patients with diabetes-related foot disease.
Disagreement that patients already established on an SGLT2 inhibitor should automatically stop treatment if a foot ulcer develops, reflecting the balance of risk versus benefit.
This evidence helps put NICE guidance into context, which advises stopping treatment if foot complications develop, but also acknowledges the limited evidence base and ongoing uncertainty.
Impact on my work
Finding this resource through the NHS Knowledge and Library Hub allowed me to:
Respond confidently and accurately to secondary care colleagues
Give me confidence that prescribing decisions made by my team were evidence-informed rather than routine or unsafe
The resource also strengthened multidisciplinary discussion, helping to bridge differences in interpretation between primary and secondary care.
How to access Knowledge and Library Services
NHS Knowledge and Library Services gives you access to the most up to date and trusted evidence and information in healthcare today. It enables high quality decision making, professional development, research and innovation to achieve health improvement. To take full advantage of all the tools and resources, you first need to create an OpenAthens account.
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