Is Dapagliflozin (Forxiga) suitable for diabetic control in patients with impaired renal function, specifically an estimated Glomerular Filtration Rate (eGFR) of 20?

Dapagliflozin is Not Recommended for Diabetic Control with eGFR of 20

Dapagliflozin should not be used for glycemic control in patients with an eGFR of 20 mL/min/1.73 m² as it is ineffective for this purpose at this level of renal function. 1, 2

Rationale for Not Using Dapagliflozin for Glycemic Control

• Dapagliflozin is contraindicated for glycemic control when eGFR is <30 mL/min/1.73 m² according to dosing guidelines 1
• The glucose-lowering efficacy of dapagliflozin decreases substantially with declining renal function, making it ineffective for glycemic control in patients with eGFR <45 mL/min/1.73 m² 2
• At an eGFR of 20 mL/min/1.73 m², the drug's mechanism of action (inhibition of renal sodium-glucose cotransporter-2) is significantly impaired, resulting in minimal glycemic benefit 1

Alternative Uses of Dapagliflozin in Advanced CKD

While dapagliflozin should not be used for glycemic control at an eGFR of 20 mL/min/1.73 m², it may still have other benefits:

• Dapagliflozin can be considered for cardiovascular and renal protection in patients with eGFR ≥20 mL/min/1.73 m² regardless of glycemic control needs 1
• The DAPA-CKD trial demonstrated that dapagliflozin reduces the risk of kidney disease progression, end-stage kidney disease, and cardiovascular death in patients with eGFR as low as 25 mL/min/1.73 m² 2, 3
• Benefits include reduced risk of hospitalization for heart failure and slowing the rate of eGFR decline, even in patients with advanced CKD 4, 3

Alternative Medications for Glycemic Control in Advanced CKD

For patients with eGFR of 20 mL/min/1.73 m² who need medication for glycemic control, consider:

• GLP-1 receptor agonists like liraglutide or semaglutide, which have demonstrated cardiovascular benefits and can be used with eGFR >30 mL/min/1.73 m² 1
• Insulin therapy, which remains effective regardless of kidney function and can be dose-adjusted based on clinical response 1
• DPP-4 inhibitors, which may require dose adjustment but can be used in advanced CKD 1

Monitoring and Safety Considerations

If dapagliflozin is used for cardiovascular or renal protection (not glycemic control) in a patient with eGFR of 20 mL/min/1.73 m²:

• Monitor renal function regularly, with increased frequency as eGFR declines 2
• Assess volume status before starting treatment and correct any volume depletion 2
• Be vigilant for potential adverse effects including genital mycotic infections, urinary tract infections, and volume depletion 2
• Consider temporarily withholding dapagliflozin during acute illness or before major surgery 2

Clinical Decision Algorithm

1. For patients with eGFR of 20 mL/min/1.73 m²:

   • DO NOT use dapagliflozin for glycemic control 1
   • Consider dapagliflozin only for cardiovascular/renal protection 1

2. For glycemic control in these patients:

   • Use insulin as primary therapy if needed 1
   • Consider GLP-1 receptor agonists if eGFR improves to >30 mL/min/1.73 m² 1

3. If using dapagliflozin for cardio-renal protection:

   • Start at 10 mg daily 2
   • Monitor renal function every 3 months 2
   • Discontinue if patient starts dialysis 5

In conclusion, while dapagliflozin should not be used specifically for diabetic control at an eGFR of 20 mL/min/1.73 m², it may still offer cardiovascular and renal benefits. However, the patient should be closely monitored, and alternative agents should be used for glycemic management.