Should Farxiga (Dapagliflozin) Be Held in Acute Kidney Injury?
Yes, Farxiga (dapagliflozin) should be temporarily discontinued during episodes of acute kidney injury until renal function has returned to baseline or stabilized. 1
Rationale for Holding SGLT2 Inhibitors in AKI
SGLT2 inhibitors like dapagliflozin have several mechanisms that can potentially worsen kidney function during acute illness:
- Diuretic and natriuretic effects - Can exacerbate volume depletion in AKI 1
- Initial eGFR dip - SGLT2 inhibitors typically cause a 3-5 mL/min/1.73m² reduction in eGFR within the first 4 weeks of therapy 1, 2
- Potential for worsening kidney injury - When combined with other risk factors such as volume depletion, concurrent RAAS inhibitors, or nephrotoxic medications 3
Management Algorithm for Farxiga in AKI
Immediately discontinue Farxiga when AKI is diagnosed
- The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend implementing "sick day protocols" which include holding SGLT2 inhibitors during acute illness, particularly when accompanied by volume depletion 1
Address underlying causes of AKI
Monitor renal function closely
- Track serum creatinine until stabilization or return to baseline
Restart considerations after AKI resolution
- Wait until renal function has returned to baseline or stabilized
- Ensure adequate volume status before restarting
- Consider starting at a lower dose than previously used
- Monitor renal function within 2-4 weeks after restarting 1
Special Considerations
High-Risk Scenarios
Be particularly vigilant about holding Farxiga in these situations:
- Concurrent use of RAAS inhibitors (ACEi/ARBs) 3
- Use of other nephrotoxic agents (NSAIDs, contrast media) 3, 4
- Acute illness with volume depletion (diarrhea, vomiting, sepsis) 3
- Pre-existing reduced GFR 3
Evidence of Safety in Specific Contexts
Despite the general recommendation to hold Farxiga in AKI, some research suggests potential safety in specific controlled settings:
In the DAPA-CKD trial, patients who experienced an acute reduction in eGFR >10% after starting dapagliflozin actually had a slower long-term eGFR decline (-1.58 vs -2.44 ml/min/1.73m² per year) compared to those with less pronounced reductions 2
A randomized study of dapagliflozin in acute decompensated heart failure found no increased frequency of AKI episodes compared to control (13% vs 9.4%, p=0.45), despite an initial GFR reduction at 48 hours 5
However, these studies were conducted in controlled settings with careful monitoring, and the general recommendation for clinical practice remains to hold Farxiga during AKI episodes.
Resuming Farxiga After AKI Resolution
When restarting Farxiga after an AKI episode:
- Ensure renal function has returned to baseline or stabilized
- Consider starting at a lower dose
- Monitor renal function and electrolytes within 2-4 weeks
- Be aware that a small, expected eGFR dip (3-5 mL/min/1.73m²) may occur 1, 2
In conclusion, while Farxiga provides significant long-term benefits for patients with type 2 diabetes, it should be temporarily discontinued during episodes of AKI to prevent potential worsening of kidney function.