What Farxiga Treats
Farxiga (dapagliflozin) is FDA-approved to treat four distinct conditions: type 2 diabetes mellitus for glycemic control, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and chronic kidney disease (CKD) to reduce progression of kidney disease and cardiovascular death. 1
Approved Indications
Type 2 Diabetes Mellitus
Farxiga lowers blood glucose by blocking sodium-glucose cotransporter-2 (SGLT2) in the kidneys, causing glucose excretion in urine. It is used as monotherapy when metformin is not tolerated, or as add-on therapy with other glucose-lowering medications including insulin 2, 1. The typical starting dose is 5 mg once daily, which can be increased to 10 mg if additional glycemic control is needed 2.
Important dosing caveat: For glucose lowering specifically, do not initiate Farxiga if eGFR is below 45 mL/min/1.73 m² 2. However, this restriction does NOT apply when using it for heart failure or CKD indications.
Heart Failure with Reduced Ejection Fraction (HFrEF)
Farxiga reduces cardiovascular death and hospitalization for heart failure in patients with symptomatic HFrEF (NYHA class II-IV), regardless of whether they have diabetes 3. The DAPA-HF trial demonstrated a 26% reduction in the composite outcome of worsening heart failure or cardiovascular death (HR 0.74), with benefits seen in both diabetic and non-diabetic patients 4.
The dose for HFrEF is 10 mg once daily, and it can be initiated even if eGFR is as low as 25 mL/min/1.73 m² 2, 3. This represents a critical distinction from the diabetes indication—you can start Farxiga for heart failure at much lower kidney function levels.
Heart Failure with Preserved Ejection Fraction (HFpEF)
The DELIVER trial established that Farxiga reduces hospitalization for heart failure and cardiovascular death in patients with HFpEF (ejection fraction >40%), with an 18% risk reduction in the primary composite outcome 4. Again, benefits were consistent regardless of diabetes status 4.
Chronic Kidney Disease
Farxiga is indicated to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with CKD 2, 3. The DAPA-CKD trial showed a 39% reduction in the composite renal outcome (HR 0.61) in patients with eGFR 25-75 mL/min/1.73 m² and albuminuria (UACR 22.6-565.6 mg/mmol) 3.
For CKD indication, use 10 mg once daily if eGFR is 25 to <45 mL/min/1.73 m². Do not initiate if eGFR is below 25, though you may continue in patients already on therapy 2.
Key Clinical Considerations
Dosing Algorithm by Indication
- Type 2 diabetes (glycemic control): Start 5 mg daily, increase to 10 mg if needed. Do not initiate if eGFR <45 2
- Heart failure (HFrEF or HFpEF): Use 10 mg daily. Can initiate down to eGFR 25 2, 3
- Chronic kidney disease: Use 10 mg daily if eGFR 25-45. Do not initiate if eGFR <25 2
Common Pitfalls to Avoid
Do not withhold Farxiga from heart failure or CKD patients simply because their eGFR is below 45—this is a common error stemming from confusion with the diabetes indication 2, 3. The cardiovascular and renal benefits persist at lower eGFR levels.
Do not stop Farxiga if eGFR temporarily drops 10-15% after initiation—this initial dip is expected due to hemodynamic effects and typically resolves within 1-3 months 3. The long-term effect is actually slower eGFR decline compared to placebo 3.
Safety Profile
The most common adverse effects are genital mycotic infections (occurring in 10-15% of women, less in men) and urinary tract infections 3, 1. These typically do not require discontinuation and can be managed with antifungal or antibiotic therapy 3.
Rare but serious risks include diabetic ketoacidosis (primarily in type 1 diabetes, which is contraindicated), Fournier's gangrene, and volume depletion 1. Monitor for signs of volume depletion, especially in elderly patients or those on diuretics, and consider reducing diuretic doses if needed 3.
Contraindications include: dialysis, type 1 diabetes, and severe hypersensitivity to dapagliflozin 1.