What monitoring parameters are recommended for a patient with diabetes and albuminuria on Farxiga (dapagliflozin) and Losartan (losartan potassium)?

Monitoring Parameters for Diabetic Albuminuria Management with Farxiga and Losartan

For patients with diabetes and albuminuria on Farxiga (dapagliflozin) and Losartan (losartan potassium), monitoring should include urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) every 6 months, along with serum potassium and creatinine levels every 3-6 months. 1

Core Monitoring Parameters

Renal Function Monitoring

• Urinary albumin-to-creatinine ratio (UACR):

  • Baseline and every 6 months if UACR is 30-299 mg/g (moderately increased albuminuria)
  • Every 3 months if UACR is ≥300 mg/g (severely increased albuminuria) 1
  • Preferably using morning spot urine samples 1
  • Goal: Reduction of ≥30% from baseline UACR 1

• Estimated glomerular filtration rate (eGFR):

  • Baseline and every 6 months
  • More frequently (every 3 months) if eGFR <60 mL/min/1.73 m² 1
  • Use race-neutral eGFR equation (2021 CKD-EPI creatinine equation) 1

• Serum creatinine and potassium:

  • Baseline and 1-2 weeks after initiation or dose adjustment of losartan
  • Every 3-6 months during stable therapy 1
  • More frequent monitoring if eGFR <60 mL/min/1.73 m² 1

Blood Pressure Monitoring

• At each clinical visit (minimum every 3 months)
• Target: <130/80 mmHg for most patients with diabetes and albuminuria 1, 2
• Monitor for orthostatic hypotension, especially with combined therapy

Glycemic Control Monitoring

• HbA1c every 3 months
• Target: <7% for most patients (individualize based on hypoglycemia risk) 1, 2
• Monitor for euglycemic diabetic ketoacidosis with Farxiga (rare but serious)

Frequency of Monitoring Based on CKD Stage

The frequency of monitoring should be adjusted based on the CKD stage as defined by both eGFR and albuminuria levels 1:

• Normal to mildly increased risk (eGFR ≥60 mL/min/1.73 m² and UACR <30 mg/g):

  • Annual monitoring of eGFR and UACR

• Moderately increased risk (eGFR ≥60 mL/min/1.73 m² and UACR 30-299 mg/g):

  • Monitor eGFR and UACR every 6 months
  • Serum potassium and creatinine every 6 months

• High risk (eGFR 30-59 mL/min/1.73 m² or UACR ≥300 mg/g):

  • Monitor eGFR and UACR every 3-4 months
  • Serum potassium and creatinine every 3 months

• Very high risk (eGFR <30 mL/min/1.73 m² or UACR ≥300 mg/g with eGFR <60 mL/min/1.73 m²):

  • Monitor eGFR and UACR every 3 months
  • Consider nephrology referral 1

Medication-Specific Monitoring

Losartan (ARB) Specific Monitoring

• Serum potassium: Monitor for hyperkalemia, especially in patients with reduced eGFR 1, 3
• Serum creatinine: Watch for acute increases (>30%) which may indicate renal artery stenosis 1
• Blood pressure: Monitor for hypotension, especially at initiation 3
• Efficacy: Assess for reduction in albuminuria (goal: ≥30% reduction from baseline) 4

Farxiga (SGLT2 inhibitor) Specific Monitoring

• Genital mycotic infections: Assess at each visit, especially in females
• Urinary tract infections: Monitor for symptoms
• Volume status: Watch for signs of dehydration or hypotension
• Diabetic ketoacidosis: Monitor for symptoms even with normal glucose levels
• Efficacy: Assess for reduction in albuminuria (shown to reduce UACR across all baseline categories) 5

Important Considerations and Pitfalls

1. Confounding factors for albuminuria assessment:

   • Avoid measuring UACR within 24 hours of vigorous exercise
   • False elevations can occur with urinary tract infections, fever, heart failure, marked hyperglycemia, or marked hypertension 1, 2
   • Confirm persistent albuminuria with 2-3 specimens over 3-6 months 1, 2

2. Medication interactions:

   • Avoid concurrent use of NSAIDs which can reduce efficacy and increase renal risk
   • Caution with potassium supplements or potassium-sparing diuretics due to hyperkalemia risk with losartan 3
   • Monitor for hypoglycemia if patient is on insulin or sulfonylureas with Farxiga 6

3. When to consider nephrology referral:

   • Rapid decline in eGFR (>3 mL/min/1.73 m² per year)
   • eGFR <30 mL/min/1.73 m²
   • Persistent severe albuminuria (>300 mg/g) despite optimal therapy
   • Uncertain etiology of kidney disease 1

By following these monitoring parameters, clinicians can optimize the renoprotective benefits of combination therapy with Farxiga and losartan while minimizing potential adverse effects in patients with diabetic kidney disease.