Can Farxiga (dapagliflozin) be used in adults with chronic kidney disease when eGFR is ≥ 25 mL/min/1.73 m², and what are the contraindications?

Can Farxiga Be Used for Kidney Disease?

Yes, Farxiga (dapagliflozin) is strongly recommended for adults with chronic kidney disease when eGFR is ≥25 mL/min/1.73 m², particularly in those with significant albuminuria or heart failure, and should be continued even if eGFR drops below 25 mL/min/1.73 m² once initiated.

Indications and eGFR Thresholds

The 2024 KDIGO guidelines provide clear, evidence-based recommendations for SGLT2 inhibitor use in CKD 1:

• Strong recommendation (1A): Use dapagliflozin in adults with CKD when eGFR ≥20 mL/min/1.73 m² AND either:

  • Urine albumin-to-creatinine ratio (ACR) ≥200 mg/g (≥20 mg/mmol), OR
  • Heart failure (regardless of albuminuria level)

• Conditional recommendation (2B): Consider dapagliflozin in adults with eGFR 20-45 mL/min/1.73 m² with ACR <200 mg/g (<20 mg/mmol)

The FDA label confirms that Farxiga was evaluated in 4,304 patients with CKD and eGFR 25-75 mL/min/1.73 m² in the DAPA-CKD trial, demonstrating consistent safety across all eGFR subgroups 2.

Key Clinical Considerations

Initiation Threshold

• Do not newly initiate Farxiga when eGFR <25 mL/min/1.73 m² (FDA label) or <20 mL/min/1.73 m² (KDIGO guidelines) 1, 2
• The 2024 BMJ guideline specifies: "SGLT2 inhibitors should generally not be newly initiated with GFR <20 mL/min per 1.73 m²" 3

Continuation Below Threshold

Critical practice point: Once initiated, continue dapagliflozin even if eGFR falls below the initiation threshold 1. The FDA label explicitly states: "Once enrolled in the DAPA-CKD and DELIVER trials, adult patients were not required to discontinue therapy if eGFR fell below 25 mL/min/1.73 m² or if dialysis was initiated" 2. Research confirms benefit-to-risk favors continuation when eGFR deteriorates to <25 mL/min/1.73 m² 4.

Monitoring Requirements

• No need to increase monitoring frequency after SGLT2i initiation 1
• The reversible initial eGFR decrease is not an indication to discontinue therapy 1
• Monitor for volume depletion, hypotension, and acute kidney injury, especially in patients with diabetes and renal impairment 2

Contraindications and Precautions

Absolute Contraindications

• Patients on dialysis (efficacy and safety not established) 2
• Active bladder cancer 5

Relative Contraindications/Special Populations

The 2024 BMJ guideline notes recommendations may not apply to 3:

• Polycystic kidney disease
• Rare kidney diseases
• Kidney transplant recipients
• eGFR <20 mL/min/1.73 m² not on kidney replacement therapy

Temporary Withholding

Withhold dapagliflozin during 1:

• Prolonged fasting
• Surgery
• Critical medical illness (increased ketosis risk)

Clinical Outcomes Evidence

The landmark DAPA-CKD trial (2020) demonstrated that dapagliflozin significantly reduced 6:

• Primary composite outcome (≥50% eGFR decline, ESKD, or renal/CV death): HR 0.61 (95% CI 0.51-0.72; P<0.001)
• All-cause mortality: HR 0.69 (95% CI 0.53-0.88; P=0.004)
• Number needed to treat: 19 patients to prevent one primary outcome event

These benefits were consistent regardless of type 2 diabetes status 6.

Recent 2025 data show dapagliflozin also improves health-related quality of life, slowing decline in physical health and reducing kidney disease symptoms 7.

Common Pitfalls to Avoid

1. Don't stop dapagliflozin when eGFR drops below initiation threshold - this is the most critical error. Continue until dialysis initiation 1, 2.

2. Don't discontinue for initial eGFR dip - the early reversible decrease in eGFR is expected and not harmful 1.

3. Don't restrict use to diabetic patients only - benefits extend to all CKD patients meeting criteria, regardless of diabetes status 1, 6.

4. Don't use for glycemic control alone when eGFR <45 mL/min/1.73 m² in patients without established CV disease or CV risk factors 2.

Practical Algorithm

For patients with CKD:

1. Check eGFR and urine ACR
2. If eGFR ≥25 mL/min/1.73 m² AND (ACR ≥200 mg/g OR heart failure present) → Start dapagliflozin 10 mg daily
3. If eGFR 25-45 mL/min/1.73 m² with ACR <200 mg/g → Consider dapagliflozin based on individual risk
4. Once started, continue even if eGFR falls below 25 mL/min/1.73 m²
5. Stop only at dialysis initiation or if intolerable side effects occur

The evidence strongly supports dapagliflozin use in CKD to reduce mortality, slow kidney disease progression, and improve quality of life 1, 6, 7.