Pertinent Questions for Medication Therapy Management (MTM) for Farxiga (Dapagliflozin)
The most important questions for MTM of Farxiga should focus on renal function, cardiovascular status, and monitoring for specific adverse effects like genital mycotic infections and volume depletion.
Renal Function Assessment
- What is the patient's current eGFR? (Farxiga is not recommended for glycemic control when eGFR <45 mL/min/1.73 m², but can be used for heart failure and CKD benefits down to 20-30 mL/min/1.73 m²) 1, 2
- Has the patient experienced any initial "eGFR dip" (3-5 mL/min/1.73 m²) after starting Farxiga? This is expected and usually stabilizes 2
- Is the patient on dialysis? (Farxiga is not recommended for patients on dialysis) 2, 1
Cardiovascular Status
- Does the patient have established cardiovascular disease or heart failure? (Farxiga has specific benefits for reducing cardiovascular death and heart failure hospitalization) 2
- Is the patient experiencing any symptoms of volume depletion (dizziness, orthostatic hypotension, dehydration)? 1, 2
- Is the patient taking diuretics? (Consider dose adjustment of diuretics when initiating Farxiga) 2
Hypoglycemia Risk
- Is the patient taking insulin or insulin secretagogues (sulfonylureas)? (Consider dose reduction of these medications to prevent hypoglycemia) 1, 2
- Has the patient experienced any hypoglycemic episodes since starting Farxiga? 3
- Does the patient know how to recognize and manage hypoglycemia? 2
Infection Risk
- Has the patient experienced any symptoms of genital mycotic infections (itching, discharge, discomfort)? 1, 4
- Has the patient had any urinary tract infections since starting Farxiga? 4, 1
- Is the patient practicing good genital hygiene to prevent infections? 2
Diabetic Ketoacidosis (DKA) Risk
- Does the patient know the "sick day" protocol for Farxiga? (Hold during acute illness with vomiting, diarrhea, or reduced food intake) 2, 1
- Is the patient aware of the symptoms of DKA, which can occur with normal blood glucose levels (euglycemic DKA)? 1, 2
- Is the patient scheduled for any surgical procedures? (Farxiga should be held at least 3 days before surgery) 1
Medication Adherence
- Is the patient taking Farxiga as prescribed (once daily)? 1
- Has the patient missed any doses? What barriers exist to adherence?
- Can the patient afford the medication? (Cost can be a barrier to SGLT2 inhibitor use) 2
Lifestyle Factors
- Is the patient maintaining adequate hydration? (Important due to the diuretic effect of Farxiga) 2
- Has the patient experienced weight loss since starting Farxiga? (Expected beneficial effect) 3
- Is the patient following dietary and exercise recommendations for diabetes management? 2
Monitoring Parameters
- When was the patient's last HbA1c measurement? Has it improved since starting Farxiga? 5
- Is the patient monitoring blood glucose at home? What are the patterns? 2
- When was the patient's last kidney function test? 1, 2
Special Considerations
- For female patients: Is the patient pregnant or planning pregnancy? (Farxiga is not recommended during pregnancy) 1
- For elderly patients: Is the patient experiencing any symptoms of postural hypotension? (Higher risk in elderly) 1
- For patients with heart failure: Has the patient noticed any improvement in heart failure symptoms since starting Farxiga? 2, 6
Common Pitfalls to Avoid
- Not recognizing the initial eGFR dip as an expected effect that typically stabilizes 2
- Failing to adjust doses of insulin or sulfonylureas when adding Farxiga, increasing hypoglycemia risk 1, 7
- Not educating patients about genital hygiene to prevent mycotic infections 2, 4
- Continuing Farxiga during acute illness or before surgical procedures 1, 2
- Not recognizing that euglycemic DKA can occur (ketoacidosis without significantly elevated blood glucose) 1
By addressing these key areas during MTM for Farxiga, pharmacists can help optimize therapy outcomes while minimizing adverse effects, ultimately improving morbidity, mortality, and quality of life for patients.