What is the recommended dose of dapagliflozin (SGLT2 inhibitor) for adults with type 2 diabetes mellitus?

Dapagliflozin Dosing for Type 2 Diabetes

For glycemic control in adults with type 2 diabetes, start dapagliflozin at 5 mg orally once daily and increase to 10 mg once daily if additional glucose lowering is needed, but only use this medication if eGFR is ≥45 mL/min/1.73 m² since it becomes ineffective below this threshold for glycemic control. 1

Standard Dosing for Glycemic Control

• Starting dose: 5 mg orally once daily 1
• Maximum dose for glycemic control: 10 mg orally once daily if additional glucose lowering is required 1
• The dose can be taken in the morning or evening 2

Renal Function-Based Dosing Algorithm

For Glycemic Control in Type 2 Diabetes:

• eGFR ≥45 mL/min/1.73 m²: Use standard dosing (5-10 mg daily) 1
• eGFR <45 mL/min/1.73 m²: Do NOT use dapagliflozin for glycemic control—it is ineffective due to its mechanism of action 1
• eGFR <30 mL/min/1.73 m²: Contraindicated for glycemic control 3

For Cardiovascular/Renal Protection (Non-Glycemic Indications):

• Fixed dose: 10 mg orally once daily regardless of baseline glucose control 3, 4, 1
• eGFR ≥25 mL/min/1.73 m²: Safe to initiate at 10 mg daily 1
• eGFR <25 mL/min/1.73 m²: Do NOT initiate, but may continue 10 mg daily if already on treatment and eGFR falls below this threshold 1

Critical Dosing Considerations

When to Use 10 mg Fixed Dose (Not for Glycemic Control):

Use 10 mg once daily for these specific indications in patients with type 2 diabetes: 3, 1

• Reducing risk of hospitalization for heart failure in patients with established cardiovascular disease or multiple cardiovascular risk factors
• Reducing risk of cardiovascular death and heart failure hospitalization
• Chronic kidney disease with eGFR 25-75 mL/min/1.73 m² and albuminuria (UACR ≥200 mg/g) to slow kidney disease progression

Concomitant Medication Adjustments:

• If patient is on insulin: Reduce total daily insulin dose by approximately 20% when initiating dapagliflozin to prevent hypoglycemia 3, 4
• If patient is on sulfonylureas or meglitinides: Consider dose reduction or discontinuation to minimize hypoglycemia risk 3

Perioperative Management

• Withhold dapagliflozin for at least 3 days before major surgery or procedures requiring prolonged fasting to prevent diabetic ketoacidosis 3, 4, 1
• Resume only when patient is clinically stable and has resumed oral intake 1

Common Pitfalls to Avoid

Do Not Use for Glycemic Control When:

• eGFR <45 mL/min/1.73 m²—the glucose-lowering effect is minimal due to reduced filtered glucose load 1
• Patient has type 1 diabetes—significantly increases risk of diabetic ketoacidosis 1

Monitor For:

• Genital mycotic infections (2-13% incidence vs 0-8% with placebo) 5
• Urinary tract infections (more common than placebo) 6, 2, 5
• Volume depletion—assess and correct before initiating, especially in elderly patients or those on diuretics 3, 1
• Diabetic ketoacidosis—rare but serious, even with normal glucose levels 4, 1

Evidence Quality Note

The 10 mg fixed dose for cardiovascular and renal protection is supported by high-quality outcome trials (DAPA-HF, DECLARE-TIMI 58, DAPA-CKD) showing 26-39% risk reductions in major endpoints 3. The FDA labeling clearly distinguishes between glycemic control dosing (5-10 mg with eGFR restrictions) and cardiovascular/renal protection dosing (fixed 10 mg with different eGFR thresholds) 1.