SGLT2 Inhibitor Dosing for CKD Stages 1/2
For patients with CKD stages 1/2 (eGFR ≥60 mL/min/1.73 m²), standard SGLT2 inhibitor dosing is recommended without adjustment: dapagliflozin 10 mg daily, empagliflozin 10 mg daily, or canagliflozin 100-300 mg daily. 1, 2, 3
Specific SGLT2 Inhibitor Dosing Recommendations
Dapagliflozin
- Standard dose: 10 mg orally once daily 1, 2
- No dose adjustment required for CKD stages 1/2 (eGFR ≥60 mL/min/1.73 m²) 1, 2
- Provides both glycemic control and cardiorenal protection at this dose 2
Empagliflozin
- Standard dose: 10 mg orally once daily 3, 4
- No dose adjustment required for CKD stages 1/2 (eGFR ≥60 mL/min/1.73 m²) 1, 3
- May increase to 25 mg daily if needed for additional glycemic control, though cardiovascular benefits are achieved at 10 mg 3
Canagliflozin
- Starting dose: 100 mg orally once daily 1
- May increase to 300 mg daily if needed for glycemic control in patients with eGFR ≥60 mL/min/1.73 m² 1
Clinical Considerations
Efficacy in CKD 1/2
- SGLT2 inhibitors maintain full glucose-lowering efficacy in early CKD stages 1, 5
- Cardiovascular and renal protective benefits are preserved regardless of baseline kidney function 1, 6
- These medications slow eGFR decline and reduce albuminuria even in early CKD 7, 6
Monitoring Recommendations
- Assess renal function before initiating therapy and periodically thereafter 1, 2
- Monitor for volume depletion, especially when used with diuretics 1, 2
- Consider proactive dose reduction of diuretics in patients at high risk of volume depletion 1
Safety Considerations
- Initial eGFR dip (5-10%) is common after starting therapy and does not indicate kidney injury 7, 6
- This initial eGFR reduction is associated with long-term kidney protection 7
- Risk of genital mycotic infections is increased; counsel on genital hygiene 1
- Risk of euglycemic diabetic ketoacidosis exists, particularly in insulin-dependent patients 1, 8
Sick Day Protocol
- Consider temporarily withholding SGLT2 inhibitors during acute illness, prolonged fasting, or surgical procedures 1, 2
- Resume treatment once the patient has recovered and is eating and drinking normally 1
Special Situations
Concomitant Medications
- When initiating SGLT2 inhibitors, consider reducing doses of insulin or sulfonylureas to prevent hypoglycemia 1, 3
- SGLT2 inhibitors can be safely combined with metformin in CKD stages 1/2 1
Non-diabetic CKD
- SGLT2 inhibitors provide renal protection even in non-diabetic CKD patients 6, 9
- Dapagliflozin 10 mg daily has been specifically studied and approved for non-diabetic CKD 6, 9
Common Pitfalls to Avoid
- Failing to monitor for volume depletion, especially when combined with diuretics 1, 2
- Not providing patient education about potential genital mycotic infections 1
- Overlooking the need for sick day protocols during acute illness 1, 8
- Discontinuing therapy due to initial eGFR dip, which is actually associated with long-term kidney protection 7