What is an example of an SGLT2 inhibitor suitable for a patient with fasting plasma glucose of 115 mg/dL, serum creatinine of 1.92 mg/dL, and estimated glomerular filtration rate of approximately 30‑45 mL/min/1.73 m²?

SGLT2 Inhibitor Examples for Your Patient

For a patient with eGFR 30-45 mL/min/1.73 m² and type 2 diabetes, the appropriate SGLT2 inhibitors are canagliflozin (100 mg daily) or dapagliflozin (10 mg daily), with these being the agents that have documented kidney and cardiovascular benefits at this level of kidney function. 1

Specific SGLT2 Inhibitors and Dosing at eGFR 30-45

Based on the most recent consensus guidelines, here are your options:

Canagliflozin

• Dose: Maximum 100 mg daily at eGFR 30-44 mL/min/1.73 m²
• Initiation not recommended below eGFR 30, but may continue 100 mg daily if tolerated for kidney and cardiovascular benefit until dialysis 1

Dapagliflozin

• Dose: 10 mg daily at eGFR 30-44 mL/min/1.73 m²
• Initiation not recommended with eGFR <25 mL/min/1.73 m², but may continue if tolerated for kidney and cardiovascular benefit until dialysis 1

Empagliflozin

• Dose: 10 mg daily at eGFR 30-44 mL/min/1.73 m²
• However, use not recommended with eGFR <45 mL/min/1.73 m² per package insert 1

Ertugliflozin

• Not recommended with eGFR <45 mL/min/1.73 m² 1

Clinical Reasoning for Your Patient

Your patient with eGFR 30-45 mL/min/1.73 m² falls into CKD Stage 3b. The 2022 KDIGO/ADA consensus strongly recommends SGLT2 inhibitors with proven kidney or cardiovascular benefit for patients with T2D, CKD, and eGFR ≥20 mL/min/1.73 m² 1. The 2020 KDIGO guideline gave this a 1A recommendation for eGFR ≥30 mL/min/1.73 m² 2.

Prioritize canagliflozin or dapagliflozin because Practice Point 4.2.3 explicitly states: "The choice of an SGLT2i should prioritize agents with documented kidney or cardiovascular benefits and take eGFR into account" 2. Both agents have robust evidence for kidney protection in this eGFR range 1.

Key Clinical Considerations

Glucose-Lowering vs. Organ Protection

• Critical distinction: While glucose-lowering efficacy is reduced at eGFR <45 mL/min/1.73 m², kidney and cardiovascular benefits are preserved 1
• Continue SGLT2 inhibitors even if eGFR falls below 30 mL/min/1.73 m² once initiated, unless not tolerated or dialysis begins 2

Initial eGFR Dip

• Expect a reversible decrease in eGFR with initiation—this is generally not an indication to discontinue therapy 2
• Monitor kidney function every 3-6 months at this eGFR level 2

Volume Status Management

• With serum creatinine 1.92 mg/dL, assess volume status before initiation
• Consider decreasing thiazide or loop diuretic dosages if patient is on these medications
• Advise about symptoms of volume depletion and low blood pressure
• Follow up on volume status after drug initiation 2

Safety Monitoring

• Genital mycotic infections: Counsel on hygiene measures (6% vs 1% placebo) 1
• Euglycemic ketoacidosis: Withhold during prolonged fasting, surgery, or critical illness 2
• Hypoglycemia risk: If patient is on insulin or sulfonylureas, may need to reduce doses of these agents 2

Combination Therapy Approach

Most patients with T2D, CKD, and eGFR ≥30 mL/min/1.73 m² benefit from both metformin and an SGLT2 inhibitor 2. With your patient's eGFR 30-45:

• Metformin: Reduce dose to half of maximum (e.g., 1000 mg/day total) 2, 3
• SGLT2 inhibitor: Add canagliflozin 100 mg or dapagliflozin 10 mg daily
• If additional glucose control needed, add long-acting GLP-1 RA as preferred third agent 2, 3

The fasting glucose of 115 mg/dL suggests reasonable glycemic control, but SGLT2 inhibitors should still be initiated for their kidney and cardiovascular protective effects independent of glucose lowering 1.