How to dose Farxigar in a patient with moderate impaired renal function (GFR 40)?

Dosing Farxiga in a Patient with Moderate Renal Impairment (GFR 40)

For a patient with moderate renal impairment (GFR 40 mL/min/1.73 m²), Farxiga (dapagliflozin) can be safely administered at the standard dose of 10 mg once daily for heart failure or chronic kidney disease indications, but it is not recommended for glycemic control at this level of renal function.

Dosing Recommendations Based on Indication

For Glycemic Control in Type 2 Diabetes:

• Not recommended when eGFR is less than 45 mL/min/1.73 m² 1
• Farxiga is likely to be ineffective for glycemic control in this setting due to its mechanism of action

For Other Indications (Heart Failure, CKD, Cardiovascular Risk Reduction):

• Standard dose of 10 mg once daily is appropriate for patients with eGFR ≥ 25 mL/min/1.73 m² 1
• A patient with GFR 40 falls within this range and can receive the full dose

Important Clinical Considerations

Monitoring Requirements:

• Assess renal function prior to initiation of therapy
• Continue monitoring renal function periodically during treatment
• Assess volume status before starting and correct any volume depletion

Safety Precautions:

• Be vigilant for potential adverse effects:
  • Volume depletion (particularly in elderly patients)
  • Genital mycotic infections
  • Urinary tract infections
  • Hypotension

Temporary Interruption:

• Withhold Farxiga for at least 3 days prior to major surgery or procedures associated with prolonged fasting
• Resume when the patient is clinically stable and has resumed oral intake 1

Renal Function Trajectory

• If eGFR declines below 25 mL/min/1.73 m² while on treatment:
  • For heart failure or CKD indications: May continue Farxiga 10 mg once daily
  • For glycemic control: Should have already been discontinued when eGFR fell below 45 mL/min/1.73 m²

Practical Application

1. Confirm the indication for Farxiga use in this patient
2. If for glycemic control only: Do not use Farxiga (select alternative diabetes medication)
3. If for heart failure, CKD, or cardiovascular risk reduction: Use standard dose of 10 mg once daily
4. Schedule regular monitoring of renal function
5. Educate patient about potential side effects and when to seek medical attention

This approach ensures optimal use of Farxiga based on the patient's level of renal function while maximizing potential benefits for cardiovascular and renal outcomes when appropriate.