What is the recommended use and dosage of Dapagliflozin (SGLT2 inhibitor) for patients with type 2 diabetes mellitus?

Dapagliflozin for Type 2 Diabetes Mellitus

For patients with type 2 diabetes mellitus, dapagliflozin should be initiated at 5 mg orally once daily and can be increased to 10 mg daily for additional glycemic control, with renal function assessment required before starting therapy. 1, 2

Dosage Recommendations

• Starting dose: 5 mg orally once daily for glycemic control 1
• Maintenance dose: Can be increased to 10 mg orally once daily for additional glycemic control 1
• Cardiovascular/renal benefits: 10 mg orally once daily is the recommended dose 2, 1

Renal Considerations

• For patients with eGFR ≥45 mL/min/1.73 m², use standard dosing 1
• Not recommended for glycemic control in patients with eGFR <45 mL/min/1.73 m² as it will likely be ineffective 1
• For cardiovascular and renal indications (not glycemic control), can be used in patients with eGFR ≥25 mL/min/1.73 m² 1

Indications

Dapagliflozin is FDA-approved for:

1. Glycemic control in T2DM (as adjunct to diet and exercise) 1
2. Reducing risk of hospitalization for heart failure in T2DM patients with established cardiovascular disease or multiple risk factors 2, 1
3. Reducing risk of cardiovascular death, heart failure hospitalization, and urgent heart failure visits in adults with heart failure 1
4. Reducing risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and heart failure hospitalization in adults with chronic kidney disease 1

Pre-Treatment Assessment

Before initiating dapagliflozin:

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

Monitoring and Precautions

• Hypoglycemia risk: Consider reducing insulin or insulin secretagogue doses by approximately 20% when starting dapagliflozin 2
• Volume depletion: Monitor for signs of hypotension, especially in elderly patients or those on diuretics 2
• Infections: Be vigilant for genital fungal infections and urinary tract infections, which are more common with dapagliflozin 2
• Surgery: Withhold dapagliflozin for at least 3 days before major surgery or procedures requiring prolonged fasting 1

Contraindications

• History of serious hypersensitivity reactions to dapagliflozin 1
• Pregnancy or breastfeeding 2

Clinical Benefits Beyond Glycemic Control

Dapagliflozin has demonstrated significant cardiovascular benefits:

• 26% reduction in worsening heart failure or CV death in the DAPA-HF study 2
• Cardioprotective effects appear to be independent of glucose-lowering effects 2, 3

Common Pitfalls to Avoid

1. Failing to assess renal function: Always check eGFR before initiating therapy
2. Not adjusting concomitant medications: Reduce insulin/secretagogue doses to prevent hypoglycemia
3. Missing pre-surgical discontinuation: Remember to hold dapagliflozin before major surgeries
4. Overlooking volume status: Ensure patients are euvolemic before starting therapy
5. Ignoring infection risk: Educate patients about symptoms of genital and urinary tract infections

Dapagliflozin provides both glycemic control and cardiovascular/renal benefits for patients with type 2 diabetes, with a generally favorable safety profile when used appropriately with proper patient selection and monitoring.