What is the appropriate dosing for Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors?

From the Guidelines

SGLT2 inhibitors should be initiated at the lowest dose tested in CV and renal outcomes trials, which are 10 mg once daily for Empagliflozin, 10 mg once daily for Dapagliflozin, and 100 mg once daily for Canagliflozin, as stated in the 2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes 1. The dosing recommendations for SGLT2 inhibitors are as follows:

• Empagliflozin (Jardiance): 10 mg once daily, with no further dose titration needed for CV or renal risk reduction, but may be increased for further glucose reduction benefits if indicated.
• Dapagliflozin (Farxiga): 10 mg once daily, with no further dose titration needed for CV or renal risk reduction, but may be increased for further glucose reduction benefits if indicated.
• Canagliflozin (Invokana): 100 mg once daily, with no further dose titration needed for CV or renal risk reduction, but may be increased for further glucose reduction benefits if indicated. It is essential to consider the patient's renal function when prescribing SGLT2 inhibitors, as the dose may need to be adjusted or the medication avoided in patients with moderate to severe renal impairment, as recommended in the diabetes management in chronic kidney disease consensus report 1 and the diabetic kidney disease back in focus management field guide 1. The SGLT2 inhibitors work by blocking glucose reabsorption in the kidneys, leading to increased urinary glucose excretion, which reduces blood glucose levels and provides cardiovascular and renal benefits, as described in the 9. pharmacologic approaches to glycemic treatment standards of medical care in diabetes-2022 1. In patients with chronic kidney disease, SGLT2 inhibitors can be initiated for most patients with type 2 diabetes and eGFR ≥20 ml/min/1.73 m2, with careful monitoring and risk mitigation strategies, as recommended in the diabetes management in chronic kidney disease consensus report 1 and the diabetic kidney disease back in focus management field guide 1.

From the FDA Drug Label

No dose adjustments are recommended for dapagliflozin.

The appropriate dosing for Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors, such as dapagliflozin, is 10 mg once daily.

• Key points:
  • No dose adjustments are recommended for dapagliflozin.
  • Dapagliflozin can be administered in the morning or evening.
  • The clinical dose of dapagliflozin is 10 mg per day 2 2.

From the Research

Dosing Considerations for SGLT2 Inhibitors

• The appropriate dosing for Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors is not explicitly stated in the provided studies 3, 4, 5, 6, 7.
• However, it is mentioned that initiating the lowest dosage used in clinical trials is a practical consideration for prescription of SGLT2 inhibitors 6.
• The studies focus on the benefits, indications, and side effects of SGLT2 inhibitors, but do not provide specific dosing recommendations.

Key Points to Consider

• SGLT2 inhibitors have been associated with cardiovascular and renal benefits, as well as improved glycemic control 4, 5, 6, 7.
• The use of SGLT2 inhibitors has been expanded to include patients with heart failure, chronic kidney disease, and type 2 diabetes mellitus 4, 5, 6.
• Adverse events, such as genital mycotic infections and euglycemic diabetic ketoacidosis, should be monitored and mitigated 4, 5, 6, 7.

Practical Considerations

• Routine monitoring of renal function is advised at initiation of therapy, particularly for patients on loop diuretics 7.
• Mild initial reductions in eGFR are expected, usually stabilizing over time 7.
• Combination therapy with other agents, such as glucagon-like peptide-1 receptor agonists, may be considered to reduce residual albuminuria and cardiovascular risk 6.