When to Continue, Pause, or Stop SGLT-2 Inhibitors in Heart Failure: A Complication-based Clinical Guide.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have become an essential part of guideline-directed medical therapy for heart failure due to their proven ability to reduce hospitalizations and improve survival, independent of diabetes status. Despite these benefits, their use can be complicated by genitourinary side effects such as genital mycotic infections, urinary tract infections, and, rarely, serious complications including urosepsis, Fournier's gangrene, and euglycemic diabetic ketoacidosis. These events often leave clinicians uncertain about whether therapy should be continued, paused, or permanently discontinued. Current guidance remains limited and inconsistent, with most recommendations derived from case reports, expert opinion, or post-marketing surveillance. In this review, we summarize the mechanisms and benefits of SGLT2 inhibitors, outline common and serious adverse events, and propose a practical, case-based approach to guide decisions about continuing, pausing, or discontinuing therapy. Evidence suggests that most mild genitourinary infections can be managed with standard treatment while maintaining therapy, whereas severe, recurrent, or life-threatening events may warrant temporary or permanent discontinuation. A structured, individualized approach that balances risks and benefits allows clinicians to preserve the cardiovascular benefits of SGLT2 inhibitors while minimizing preventable harm.