From the Guidelines
For a 57-year-old male with CHF and improving but still impaired renal function after AKI, restart furosemide at a lower dose, such as 20-40 mg daily, and dapagliflozin at 10 mg once daily, but only after the eGFR is consistently above 25 mL/min/1.73m², with close monitoring of renal function, electrolytes, and symptoms of volume depletion, as recommended by recent studies 1.
Key Considerations
- The patient's eGFR has improved to 32, which is above the threshold for restarting dapagliflozin, but close monitoring is still necessary due to the risk of recurrent kidney injury.
- Furosemide should be restarted at a lower dose than previously prescribed, with titration based on response and renal function, to minimize the risk of excessive diuresis and electrolyte abnormalities.
- Dapagliflozin has been shown to reduce the risk of major adverse cardiovascular events and cardiovascular death in patients with type 2 diabetes and cardiovascular disease, but its use requires careful consideration of the patient's renal function and potential risks 1.
Monitoring and Titration
- Monitor renal function, electrolytes, and symptoms of volume depletion within 3-7 days of restarting furosemide and dapagliflozin.
- Titrate the dose of furosemide based on the patient's response and renal function, with the goal of achieving optimal diuresis and minimizing adverse effects.
- Check renal function and electrolytes within one week of restarting dapagliflozin to ensure that the patient is tolerating the medication and to adjust the dose as needed.
Patient Education
- Ensure the patient maintains adequate hydration and understands symptoms of volume depletion to report, such as dizziness, lightheadedness, and fatigue.
- Educate the patient on the importance of monitoring renal function and electrolytes, and the potential risks and benefits of restarting furosemide and dapagliflozin.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION • Assess renal function prior to initiation and then as clinically indicated. Serum electrolytes (particularly potassium), CO2, creatinine and BUN should be determined frequently during the first few months of Furosemide tablets therapy and periodically thereafter.
The FDA drug label does not answer the question.
From the Research
Restarting Furosemide and Dapagliflozin in CHF Patient with Improved Renal Function
- The patient, a 57-year-old male with congestive heart failure (CHF), was admitted for acute kidney injury (AKI) with an initial eGFR of 6, which has improved to 32 after IV fluids.
- Furosemide (Lasix) 40mg/day and dapagliflozin (Forxiga) 10mg/day can be considered for restart in this patient, given the improvement in renal function.
Considerations for Restarting Dapagliflozin
- According to the DAPA-HF trial 2, dapagliflozin has been shown to be effective in patients with heart failure and reduced ejection fraction (HFrEF), with or without type 2 diabetes, and an estimated glomerular filtration rate (eGFR) ≥30 mL·min-1·1.73 m-2.
- The study found that the effect of dapagliflozin on the primary outcome (cardiovascular death or worsening heart failure) did not differ by eGFR category or examining eGFR as a continuous measurement.
- Another study 3 found that dapagliflozin reduced the risk of kidney failure and cardiovascular death/heart failure hospitalization and prolonged survival in chronic kidney disease (CKD) patients with or without type 2 diabetes, independently of history of heart failure.
Considerations for Restarting Furosemide
- The use of loop diuretics, such as furosemide, is common in patients with CHF and AKI, but requires careful monitoring of renal function and electrolyte balance 4.
- A pilot study 5 found that the use of dapagliflozin was associated with less need to increase diuretic therapy, including furosemide, without significant deterioration of renal function.
Monitoring and Precautions
- Close monitoring of serum potassium and renal function is recommended during the management of an episode of acute decompensated HF 4.
- The patient's renal function and electrolyte balance should be closely monitored after restarting furosemide and dapagliflozin, with adjustments made as necessary to avoid adverse effects.