Which SGLT2 inhibitor is recommended for a patient with an eGFR of 34, starting losartan 25mg for blood pressure management?

SGLT2 Inhibitor Selection for Patient with eGFR 34 and Starting Losartan

For a patient with an eGFR of 34 mL/min/1.73m², dapagliflozin 10 mg daily is the recommended SGLT2 inhibitor as it is specifically approved for use with eGFR 25-45 mL/min/1.73m² and can be safely combined with losartan for blood pressure management. 1

SGLT2 Inhibitor Options with eGFR 34

When selecting an SGLT2 inhibitor for a patient with reduced kidney function (eGFR 34 mL/min/1.73m²), the following considerations apply:

• Dapagliflozin: Approved at 10 mg daily for eGFR 25-45 mL/min/1.73m² (Stage 3b CKD) 1
• Canagliflozin: Maximum 100 mg daily in this eGFR range 1
• Empagliflozin: 10 mg daily in this eGFR range, but not recommended for initiation when eGFR <45 mL/min/1.73m² 1
• Ertugliflozin: Not recommended with eGFR <45 mL/min/1.73m² 1

Rationale for Dapagliflozin Selection

1. Specific approval for eGFR range: Dapagliflozin is explicitly approved for use at 10 mg daily with an eGFR of 25 to <45 mL/min/1.73m² 1

2. Cardiovascular and kidney benefits: SGLT2 inhibitors provide cardiovascular and kidney benefits even when glucose-lowering efficacy is reduced at lower eGFR levels 1

3. Compatibility with losartan: Dapagliflozin can be safely used with losartan, which is an appropriate choice for blood pressure management in CKD 1

4. Continued benefit at lower eGFR: Once initiated, dapagliflozin can be continued for kidney and cardiovascular benefit until dialysis even if eGFR declines further 1

Losartan Considerations

Starting losartan 25 mg is appropriate for this patient:

• RAS blockers recommended in CKD: RAS blockers like losartan are more effective at reducing albuminuria than other antihypertensive agents in CKD patients 1

• Appropriate starting dose: Losartan 25-50 mg once daily is the recommended initial dose, with target doses of 50-150 mg once daily 1

• Blood pressure targets: For patients with CKD and eGFR >30 mL/min/1.73m², target systolic BP should be 120-129 mmHg if tolerated 1

• No dose adjustment needed: Losartan does not require dose adjustment for this level of kidney function 2, 3

Monitoring Recommendations

When initiating this combination therapy:

• Volume status: Monitor for hypovolemia, especially during initial weeks of SGLT2i therapy 1

• Glycemic control: Follow up to reassess glycemia as hypoglycemia risk may increase with combination therapy 1

• Renal function: Monitor eGFR periodically to ensure continued appropriateness of therapy 1

• Blood pressure response: Assess BP response to losartan, noting that full antihypertensive effect of SGLT2 inhibitors may take ≥6 months to be fully realized 4

Potential Side Effects and Precautions

• Genital mycotic infections: Occur in approximately 6% of patients on SGLT2 inhibitors; more common in women 1

• Euglycemic ketoacidosis: Risk is low but present; maintain at least low-dose insulin if patient is on insulin therapy 1

• First-dose hypotension: Uncommon with losartan but monitor BP after initiation 2, 5

• Electrolyte imbalances: Monitor potassium levels as both medications can affect potassium balance 1

By selecting dapagliflozin and initiating losartan 25 mg, you're providing evidence-based therapy that addresses both glycemic control and blood pressure management while offering cardiovascular and renal protection for this patient with reduced kidney function.