SGLT2 Inhibitor Selection for Patient with CKD and Proteinuria
Dapagliflozin (Farxiga) should be initiated for this patient with eGFR 54 mL/min/1.73m² and 1.3g proteinuria who is already on maximum ARB therapy.
Rationale for SGLT2 Inhibitor Selection
The 2024 KDIGO guidelines strongly recommend SGLT2 inhibitors for patients with CKD and proteinuria. Based on the patient's clinical parameters:
- eGFR of 54 mL/min/1.73m² (falls within G3a CKD category)
- Significant proteinuria (1.3g, which is >200mg/g)
- Already on maximum ARB therapy
Both dapagliflozin (Farxiga) and empagliflozin (Jardiance) are SGLT2 inhibitors, but there are important differences to consider:
Why Dapagliflozin (Farxiga) is Preferred:
- Dapagliflozin has stronger evidence for use in non-diabetic proteinuric CKD 1
- KDIGO 2024 guidelines recommend SGLT2i for patients with eGFR ≥20 mL/min/1.73m² with urine ACR ≥200 mg/g (≥20 mg/mmol) 1
- Dapagliflozin has been specifically studied in patients with proteinuria without diabetes 2
Why Not Empagliflozin (Jardiance):
- FDA label for empagliflozin states it "should not be initiated in patients with an eGFR less than 45 mL/min/1.73 m²" 3
- While the patient's current eGFR is 54, there is risk of further decline that could limit empagliflozin's use
Implementation Strategy
- Initiate dapagliflozin at 10mg once daily
- Monitoring protocol:
- Check renal function and electrolytes within 2-4 weeks of initiation
- Expect a small, transient decline in eGFR (5-10%) initially, which is not a reason to discontinue 4
- Continue monitoring eGFR every 3 months
Expected Benefits
- Reduction in proteinuria: Studies show dapagliflozin can reduce proteinuria by 30-40% in patients with baseline proteinuria >0.5g/g 5, 4
- Slowing of eGFR decline: After initial dip, dapagliflozin provides long-term kidney protection 1
- Cardiovascular protection: Additional benefit beyond renoprotection
Important Precautions
- Initial eGFR decline: Expect a 5-10% decline in eGFR within first month, which is associated with better long-term renoprotection 4
- Volume status: Monitor for signs of volume depletion, especially since patient is already on maximum ARB
- Sick day protocol: Advise patient to temporarily hold dapagliflozin during acute illness, surgery, or prolonged fasting 1
- Continue ARB therapy: Maintain maximum tolerated ARB dose as combination therapy provides additive benefit 1
Clinical Pearls
- The initial decline in eGFR with dapagliflozin is actually associated with better long-term outcomes and greater proteinuria reduction 4
- SGLT2 inhibitors can be continued even if eGFR falls below the initiation threshold (as long as it remains above 20 mL/min/1.73m²) 1
- Unlike empagliflozin, dapagliflozin has been specifically studied in non-diabetic proteinuric kidney disease 2
- Consider adding a non-steroidal MRA (like finerenone) in the future if proteinuria persists despite SGLT2i and maximum ARB therapy 1