For a patient with HbA1c 11.6% and estimated glomerular filtration rate of 39 mL/min/1.73 m², should I prescribe Farxiga (dapagliflozin) or Jardiance (empagliflozin)?

Prescribe Farxiga (Dapagliflozin) for This Patient

With an eGFR of 39 mL/min/1.73 m² and HbA1c of 11.6%, you should prescribe Farxiga (dapagliflozin) 10 mg daily, as Jardiance (empagliflozin) is not recommended for initiation at this level of kidney function.

Why Dapagliflozin Over Empagliflozin

The critical difference lies in the eGFR threshold for initiation:

• Dapagliflozin: Can be initiated down to eGFR ≥25 mL/min/1.73 m² 1, 2
• Empagliflozin: Initiation is not recommended with eGFR <45 mL/min/1.73 m² 1

Your patient's eGFR of 39 mL/min/1.73 m² falls in the Stage 3b CKD range (30-44 mL/min/1.73 m²), which is below empagliflozin's initiation threshold but well within dapagliflozin's approved range.

Dosing and Expectations

Dose: Dapagliflozin 10 mg once daily 2

At this eGFR level, understand that:

• Glucose-lowering efficacy will be reduced due to the mechanism of action (less glucose filtered through kidneys) 1
• Cardiovascular and kidney protective benefits are preserved regardless of glucose-lowering effect 1
• The primary benefit is slowing CKD progression and reducing cardiovascular events, not just glycemic control 3

Managing the High HbA1c (11.6%)

This patient needs aggressive glycemic management. The SGLT2 inhibitor alone won't adequately address this level of hyperglycemia at eGFR 39:

1. Add a GLP-1 receptor agonist (liraglutide, dulaglutide, or semaglutide) - these require no dose adjustment at this eGFR and provide additional cardiovascular benefit 1

2. Consider basal insulin if not already on it, titrated conservatively to avoid hypoglycemia 1

3. Metformin: If currently taking, reduce dose to maximum 1000 mg/day at this eGFR 1

Critical Safety Monitoring

Before starting dapagliflozin 1, 2:

• Assess volume status: Correct any volume depletion first
• Review diuretics: Consider reducing dose if on high-dose diuretics
• Educate on sick day protocol: Hold medication during acute illness, excessive exercise, or fasting
• Counsel on genital hygiene: To reduce mycotic infection risk (6% incidence) 1

Monitor for:

• Diabetic ketoacidosis: Educate on symptoms; maintain at least low-dose insulin if insulin-requiring 1
• Acute eGFR decline: Expect a reversible 2-3 mL/min/1.73 m² drop in first 2 weeks - this is hemodynamic and not a reason to stop 1, 4, 3
• Hypoglycemia: Reduce sulfonylurea or insulin doses proactively 1

Long-term Kidney Protection

The evidence strongly supports continuing dapagliflozin even as eGFR declines further:

• Can continue until eGFR falls below 25 mL/min/1.73 m² (or even 20 mL/min/1.73 m² per updated guidance) 1, 4
• Once initiated, continue for kidney and cardiovascular benefit until dialysis 1, 4
• Dapagliflozin slows chronic eGFR decline by approximately 1-2 mL/min/1.73 m² per year 3, 5

Common Pitfall to Avoid

Do not withhold SGLT2 inhibitors because of "poor glycemic efficacy" at low eGFR. The 2022 ADA/KDIGO consensus explicitly states that kidney and cardiovascular benefits persist even when glucose-lowering is minimal 1. This represents a paradigm shift - these are now kidney-protective drugs that also lower glucose, not just glucose-lowering drugs.