What is the recommended use and dosage of Dapagliflozin (Forxiga) for patients with type 2 diabetes?

Dapagliflozin (Forxiga) for Type 2 Diabetes: Recommended Use and Dosage

For patients with type 2 diabetes, dapagliflozin is recommended at a starting dose of 5 mg orally once daily, which can be increased to 10 mg once daily for additional glycemic control. 1

Indications

• Dapagliflozin is indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus 1
• It is also indicated to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus who have established cardiovascular disease or multiple cardiovascular risk factors 1, 2
• Additional indications include reducing the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression 1
• Dapagliflozin can reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in adults with heart failure, regardless of diabetes status 2, 1

Dosing Guidelines

• For glycemic control in type 2 diabetes:
  • Starting dose: 5 mg orally once daily 1
  • Dose can be increased to 10 mg once daily for additional glycemic control 1
• For cardiovascular and renal indications:
  • Fixed dose of 10 mg orally once daily 1, 2
• Administration can be with or without food 3

Renal Function Considerations

• For glycemic control:
  • eGFR ≥45 mL/min/1.73 m²: No dose adjustment needed 1
  • eGFR <45 mL/min/1.73 m²: Not recommended for glycemic control (likely ineffective) 1
• For cardiovascular and renal indications:
  • eGFR ≥25 mL/min/1.73 m²: No dose adjustment needed 1
  • eGFR <25 mL/min/1.73 m²: Not recommended to initiate therapy 1
  • If eGFR falls below 25 mL/min/1.73 m² during treatment, patients may continue with 10 mg once daily 1

Clinical Benefits

• Glycemic control: Dapagliflozin produces sustained, dose-dependent reductions in HbA1c ranging from 0.54-0.89% over 12-24 weeks 4
• Weight reduction: Approximately 2-3 kg weight loss 4, 5
• Blood pressure reduction: Systolic 2-5 mmHg, diastolic 1.5-3 mmHg 4, 5
• Cardiovascular benefits: Reduces hospitalization for heart failure and cardiovascular death 2, 6
• Renal benefits: May reduce progression of renal disease 3
• Long-term efficacy: Maintains reductions in HbA1c, systolic blood pressure, and body weight over 2 years 5

Safety Considerations and Monitoring

• Prior to initiation:
  • Assess renal function 1
  • Evaluate volume status and correct any volume depletion 1
• Temporary interruption:
  • Withhold dapagliflozin for at least 3 days before major surgery or procedures with prolonged fasting 1, 2
  • Resume when patient is clinically stable and has resumed oral intake 1
• Common adverse effects:
  • Genital fungal infections (more common with dapagliflozin 7.4-14.3% vs. placebo 3.0%) 7, 2
  • Urinary tract infections (8.4-13.8% vs. placebo 5.6%) 7, 2
  • Low risk of hypoglycemia when used as monotherapy 3, 4
• Serious adverse effects to monitor:
  • Diabetic ketoacidosis (rare but serious) 2, 1
  • Volume depletion, especially in elderly patients or those on diuretics 1, 8

Contraindications

• History of serious hypersensitivity reaction to dapagliflozin or any of its excipients 1
• Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus 1

Special Populations

• Elderly patients (≥65 years): Effective with similar benefits as seen in younger patients 8
• Patients with cardiovascular disease: Particularly beneficial due to cardiovascular risk reduction 2, 5
• Patients on insulin: Consider reducing insulin dose by approximately 20% when starting dapagliflozin to prevent hypoglycemia 6