What is the starting dose of dapagliflozin (Farxiga) for patients with type 2 diabetes or heart failure?

Dapagliflozin Starting Dose for Type 2 Diabetes and Heart Failure

The recommended starting dose of dapagliflozin is 10 mg once daily for heart failure indications and 5 mg once daily for type 2 diabetes, which can be titrated to 10 mg daily if needed for additional glycemic control. 1

Dosing Recommendations by Indication

Type 2 Diabetes

• Starting dose: 5 mg once daily 1
• Can be titrated to 10 mg once daily for additional glycemic control 1
• Renal considerations:
  • For eGFR ≥45 mL/min/1.73 m²: No dose adjustment required 1
  • For eGFR <45 mL/min/1.73 m²: Not recommended for glycemic control 1, 2

Heart Failure

• Starting dose: 10 mg once daily 1, 3
• No titration needed - maintain at 10 mg once daily
• Renal considerations:
  • For eGFR ≥25 mL/min/1.73 m²: 10 mg once daily 1, 2
  • For eGFR <25 mL/min/1.73 m²: Initiation not recommended, but may continue at 10 mg daily in patients already receiving treatment 2, 1

Chronic Kidney Disease

• Starting dose: 10 mg once daily 1
• Renal considerations:
  • For eGFR ≥25 mL/min/1.73 m²: 10 mg once daily 1
  • For eGFR <25 mL/min/1.73 m²: Initiation not recommended 1

Clinical Evidence Supporting Dosing

The 10 mg daily dose of dapagliflozin has demonstrated significant benefits in heart failure trials:

• In the DAPA-HF trial, dapagliflozin 10 mg daily reduced the composite outcome of worsening heart failure or cardiovascular death by 26% (HR 0.74; 95% CI 0.65-0.85) 4
• Benefits were observed regardless of diabetes status, with similar efficacy in patients with and without diabetes (HR 0.75 and 0.73, respectively) 5
• In patients with heart failure with preserved ejection fraction (DELIVER trial), dapagliflozin 10 mg daily reduced the primary composite outcome by 18% (HR 0.82; 95% CI 0.73-0.92) 6, 3

Important Monitoring and Precautions

• Prior to initiation:

  • Assess renal function 1
  • Evaluate volume status and correct any volume depletion before starting 1

• Temporary interruption:

  • Withhold dapagliflozin for at least 3 days before major surgery or procedures requiring prolonged fasting 1, 3
  • Resume when the patient is clinically stable and has resumed oral intake 1

• Contraindications:

  • History of serious hypersensitivity to dapagliflozin 1, 2
  • Patients on dialysis 2, 3

• Common adverse effects to monitor:

  • Genital mycotic infections 2, 3
  • Urinary tract infections 2, 3
  • Volume depletion/hypotension, particularly in patients with renal impairment, low systolic blood pressure, or those on diuretics 2, 3
  • Euglycemic diabetic ketoacidosis (rare but serious) 2, 3

Clinical Pearls

• Dapagliflozin can be used in patients with heart failure regardless of diabetes status 5
• When used for heart failure, the 10 mg dose is initiated directly without titration 1
• For patients with type 2 diabetes, starting at 5 mg and titrating to 10 mg may help minimize side effects while achieving glycemic control 1
• The medication can be continued at 10 mg daily in patients with heart failure even if eGFR falls below 25 mL/min/1.73 m² after initiation 1, 2
• Dapagliflozin is the only SGLT2 inhibitor option for patients with eGFR 20-30 mL/min/1.73m² 3

Remember that dapagliflozin provides benefits beyond glycemic control, including cardiovascular and renal protection, which makes the appropriate dosing crucial for optimizing patient outcomes.