Should This Patient Be Started on Farxiga (Dapagliflozin)?
Yes, this non-diabetic 35-year-old African American male with hypertension, GFR 54 mL/min/1.73 m², and creatinine 1.67 mg/dL should be started on Farxiga (dapagliflozin) 10 mg daily to reduce the risk of progressive kidney disease, cardiovascular death, and hospitalization for heart failure.
Rationale Based on Renal Function
Dapagliflozin is specifically indicated for chronic kidney disease with GFR ≥25 mL/min/1.73 m², regardless of diabetes status. 1 This patient's GFR of 54 mL/min/1.73 m² falls well within the approved range for initiation.
- The landmark DAPA-CKD trial demonstrated that dapagliflozin reduced the composite outcome of sustained ≥50% decline in eGFR, end-stage kidney disease, or renal/cardiovascular death by 39% (HR 0.61,95% CI 0.51-0.72, NNT=19) in patients with chronic kidney disease 1
- The benefit was identical in patients without diabetes (HR 0.61) compared to those with diabetes, making diabetes status irrelevant to the decision 2
- Dapagliflozin slowed the rate of eGFR decline from -2.85 to -1.09 mL/min/1.73 m² per year, providing long-term kidney protection 3
Safety Considerations at This GFR Level
The patient's GFR of 54 mL/min/1.73 m² is above the threshold where dapagliflozin requires caution or dose adjustment. 4
- Dapagliflozin should be used with caution in patients with moderate renal insufficiency (GFR 30-50 mL/min), but this patient is above that threshold 5
- A mild, transient drop in eGFR may occur after initiation, but this is followed by long-term kidney protection 5
- The FDA label confirms safety and efficacy in patients with eGFR 45 to <60 mL/min/1.73 m² 4
Cardiovascular and Mortality Benefits
Beyond kidney protection, dapagliflozin reduces cardiovascular death and all-cause mortality in patients with chronic kidney disease. 2
- The composite of cardiovascular death or heart failure hospitalization was reduced by 29% (HR 0.71,95% CI 0.55-0.92) 1
- All-cause mortality was reduced by 31% (HR 0.69,95% CI 0.53-0.88) 1
- These benefits occurred regardless of cardiovascular disease history at baseline 2
Practical Implementation
Start dapagliflozin 10 mg once daily without dose titration required. 5
- Unlike other heart failure medications, SGLT2 inhibitors do not affect blood pressure, heart rate, or potassium levels significantly 5
- No dose adjustment or up-titration is needed 5
- Benefits occur within weeks of initiation 5
- Monitor for genital mycotic infections (more common) and assess for volume depletion, particularly since the patient is on losartan 4
Monitoring After Initiation
Check renal function 2-4 weeks after starting dapagliflozin to document the expected transient eGFR dip. 5
- A small initial decline in eGFR is expected and does not indicate harm 5
- Continue therapy unless eGFR drops below 25 mL/min/1.73 m² 1
- Monitor for signs of volume depletion, especially in combination with losartan and if diuretics are added 4
Key Contraindications to Rule Out
Ensure the patient does not have active bladder cancer or diabetic ketoacidosis risk factors before initiating. 4, 6