When should Farxiga (dapagliflozin) be initiated in patients with type 2 diabetes?

When to Start Farxiga (Dapagliflozin)

Farxiga (dapagliflozin) should be initiated in patients with type 2 diabetes who have established atherosclerotic cardiovascular disease, heart failure with reduced ejection fraction, chronic kidney disease, or multiple cardiovascular risk factors to reduce cardiovascular events and CKD progression. 1

Patient Selection Algorithm

First-Line Indications (Start Immediately):

• Established cardiovascular disease 1
  • History of myocardial infarction, stroke, or peripheral arterial disease
  • At hospital discharge after admission for cardiovascular event
• Heart failure with reduced ejection fraction 1
• Chronic kidney disease with eGFR ≥20 mL/min/1.73 m² 1
  • Particularly beneficial with albuminuria or history of documented eGFR loss
• Multiple cardiovascular risk factors 1, 2

Second-Line Indications (Add to Existing Therapy):

• When glycemic control is not achieved with metformin monotherapy 1
• When weight loss is a priority 2
• As part of combination therapy when A1C ≥9% 1

Dosing and Renal Function Considerations

• Standard dose: 10 mg once daily 1, 3
• Renal function thresholds:
  • Can initiate with eGFR ≥25 mL/min/1.73 m² 1
  • May continue with eGFR as low as 20 mL/min/1.73 m² for cardiovascular and renal benefits 1
  • Not recommended for initiation with eGFR <25 mL/min/1.73 m² 1
  • May continue until dialysis if tolerated 1

Clinical Benefits by Patient Population

1. Patients with established cardiovascular disease:

   • Reduces major adverse cardiovascular events 1, 4
   • Reduces hospitalization for heart failure 1, 5

2. Patients with heart failure:

   • Reduces risk of worsening heart failure and cardiovascular death 1, 5
   • Benefits observed regardless of diabetes status 5

3. Patients with chronic kidney disease:

   • Reduces risk of sustained eGFR decline, end-stage kidney disease, and renal death 1, 6
   • Benefits observed with eGFR as low as 25 mL/min/1.73 m² 6
   • Effects independent of diabetes status 6

4. Patients with type 2 diabetes without established complications:

   • Provides effective glycemic control 7, 8
   • Offers additional benefits of weight reduction and blood pressure lowering 4

Important Monitoring and Precautions

• Before initiation:

  • Assess renal function (eGFR)
  • Evaluate volume status (avoid in hypovolemia)
  • Review concomitant medications (especially diuretics)

• After initiation:

  • Monitor for genital mycotic infections (most common adverse effect) 7, 4
  • Watch for signs of diabetic ketoacidosis (rare but serious) 4
  • Monitor renal function periodically, especially in elderly patients 3
  • Assess for hypotension, particularly in patients ≥65 years 3

Special Populations

• Elderly patients: No dosage adjustment needed based on age alone, but higher risk of hypotension 3
• Pregnancy/breastfeeding: Not recommended 2, 3
• Pediatric patients: Approved for type 2 diabetes in patients aged 10 years and older 3

Common Pitfalls to Avoid

1. Delaying initiation in high-risk patients with established cardiovascular or kidney disease
2. Discontinuing unnecessarily when eGFR declines (can continue for cardiorenal benefits even when glycemic effects diminish)
3. Failing to recognize that benefits extend beyond glycemic control
4. Not advising patients about increased risk of genital infections and symptoms of volume depletion
5. Overlooking the need to temporarily withhold during acute illness, surgery, or situations with risk of dehydration

By following this guidance, clinicians can appropriately initiate Farxiga in patients who will derive the greatest cardiovascular and renal benefits while minimizing potential adverse effects.