When admitting a patient for acute decompensated heart failure (ADHF), when would you hold Farxiga (dapagliflozin)?

When to Hold Farxiga (Dapagliflozin) During ADHF Admission

Farxiga (dapagliflozin) should be held in patients admitted for acute decompensated heart failure (ADHF) only when there is hemodynamic instability, eGFR <20-25 mL/min/1.73m², or in cases of diabetic ketoacidosis. 1, 2

Indications for Holding Farxiga During ADHF Admission

• Hemodynamic instability: Hold Farxiga in patients with significant hypotension (systolic BP <100 mmHg) or requiring intravenous vasopressors/inotropes 1
• Severe renal impairment: Hold if eGFR falls below 20-25 mL/min/1.73m² (though recent evidence suggests potential benefit even with eGFR <25 mL/min/1.73m²) 2, 3
• Diabetic ketoacidosis (DKA): Hold immediately if euglycemic DKA is suspected or confirmed 4
• Acute illness with reduced oral intake: Hold temporarily during periods when the patient is NPO or has significantly reduced oral intake 4
• Perioperative period: Hold if the patient requires urgent surgical intervention during the ADHF admission 4

When to Continue or Initiate Farxiga During ADHF Admission

• Hemodynamically stable patients: Continue or initiate Farxiga in patients with stable blood pressure (SBP >100 mmHg) who are not requiring IV vasodilators or increasing doses of IV diuretics 1
• Adequate renal function: Continue or initiate if eGFR ≥20-25 mL/min/1.73m² 2, 3
• Early clinical stabilization: Consider initiating Farxiga once the patient is stabilized (typically day 2-5 of hospitalization) 1
• Pre-discharge initiation: If not started earlier during hospitalization, initiate before discharge to reduce risk of readmission and mortality 1

Benefits of Continuing/Initiating Farxiga During ADHF

• Enhanced diuresis: Dapagliflozin can provide complementary diuretic effects when added to loop diuretics, potentially allowing for lower doses of furosemide 5, 6
• Reduced readmissions: Early initiation of SGLT2 inhibitors during hospitalization reduces the risk of heart failure readmissions 1
• Mortality benefit: Continuation or early initiation provides mortality benefits that accrue rapidly within days to weeks 1
• Renal protection: Despite initial mild decrease in GFR, dapagliflozin provides long-term renal protection 6

Monitoring Recommendations When Continuing Farxiga

• Renal function: Monitor serum creatinine and eGFR daily during the acute phase of ADHF 6
• Volume status: Carefully assess fluid status and adjust diuretic therapy accordingly 5, 6
• Blood pressure: Monitor for symptomatic hypotension, though SGLT2 inhibitors have minimal to no effect on blood pressure in most patients 1
• Glycemic control: In diabetic patients, monitor blood glucose levels and adjust other antidiabetic medications as needed 7, 8
• Electrolytes: Monitor serum electrolytes, particularly in patients receiving multiple diuretics 5

Common Pitfalls to Avoid

• Inappropriate discontinuation: Unnecessarily holding Farxiga during hospitalization may lead to missed therapeutic benefits and increased risk that patients will never receive this therapy 1
• Overreaction to initial GFR decline: A small initial decrease in GFR (5-10%) is expected and not a reason to discontinue therapy 6
• Failure to adjust concomitant medications: Insulin doses may need adjustment to prevent hypoglycemia when continuing Farxiga 4
• Overlooking sick day management: Failure to provide clear instructions about when to temporarily hold Farxiga during acute illness 4
• Neglecting to restart after temporary hold: If Farxiga is temporarily held during acute hemodynamic instability, remember to restart once the patient is stabilized 1

By following these guidelines, clinicians can appropriately manage Farxiga therapy during ADHF admissions to maximize benefits while minimizing risks.