What dose of Farxiga (dapagliflozin) should be added to a patient on metformin and another oral hypoglycemic agent with an A1c of 10.4?

Farxiga (Dapagliflozin) Dosing for Patient with A1c of 10.4% on Metformin and Another Oral Agent

For a patient with an A1c of 10.4% on metformin and another oral agent, you should add Farxiga (dapagliflozin) at a dose of 10 mg once daily. 1

Rationale for Dosing Decision

The FDA label for dapagliflozin clearly indicates that for patients with type 2 diabetes:

• The recommended starting dose is 5 mg once daily
• For additional glycemic control, the dose can be increased to 10 mg once daily 1

Given the significantly elevated A1c of 10.4%, which indicates poor glycemic control despite dual therapy with metformin and another agent (likely a sulfonylurea based on the mention of "mantis" which may refer to glimepiride/Amaryl), starting with the maximum dose of 10 mg daily is appropriate to achieve more robust glycemic control.

Expected Benefits of Adding Dapagliflozin 10 mg

1. Glycemic Improvement:

   • Dapagliflozin 10 mg added to metformin provides an additional A1c reduction of approximately 0.5-0.8% 1, 2
   • In triple therapy with metformin and another agent, dapagliflozin can provide A1c reductions of up to 0.74% 3

2. Additional Benefits:

   • Weight reduction of approximately 2-3 kg 4
   • Modest systolic blood pressure reduction of 3-5 mmHg 4
   • Low risk of hypoglycemia 1, 2

Renal Considerations

Before initiating dapagliflozin, assess renal function:

• For glycemic control, dapagliflozin is recommended for patients with eGFR ≥45 mL/min/1.73 m² 1
• Dapagliflozin is not recommended for glycemic control in patients with eGFR <45 mL/min/1.73 m² 5, 1

Safety Considerations and Monitoring

1. Volume Status:

   • Assess volume status before initiating therapy 1
   • Correct volume depletion before starting dapagliflozin 1

2. Potential Side Effects:

   • Genital mycotic infections (6-14.6% incidence) 5, 2
   • Urinary tract infections (8-13.3% incidence) 5, 2
   • Risk of euglycemic diabetic ketoacidosis, especially in insulin-dependent patients 5, 1

3. Follow-up Monitoring:

   • Monitor A1c after approximately 3 months of therapy 6
   • Reassess renal function periodically 1
   • Educate patient about symptoms of ketoacidosis, genital infections, and hypoglycemia 6

Important Cautions

• Temporarily interrupt dapagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting 1
• Resume when the patient is clinically stable and has resumed oral intake 1
• Patients should be educated about maintaining adequate hydration 5

Algorithm for Treatment Adjustment

1. If A1c goal not achieved after 3 months:

   • Consider adding or switching to injectable therapy (GLP-1 RA or insulin) 5
   • For patients with very high A1c (>10%), consider insulin therapy if not responding adequately 5

2. If side effects occur:

   • For genital mycotic infections: treat with appropriate antifungal therapy; most cases do not require discontinuation 5
   • For volume depletion: consider temporary interruption and fluid repletion 1
   • For euglycemic ketoacidosis: discontinue dapagliflozin and seek immediate medical attention 5

By adding dapagliflozin 10 mg once daily to the current regimen of metformin and another oral agent, you can expect significant improvement in glycemic control with the added benefits of weight loss and blood pressure reduction in this patient with poorly controlled type 2 diabetes.