When can Dapagliflozin (Forxiga) be resumed in a patient recovering from Acute Kidney Injury (AKI) post Acute Coronary Syndrome (ACS) Non-ST-Elevation Myocardial Infarction (NSTEMI) with uncontrolled Type 2 Diabetes Mellitus (T2DM) on insulin?

When to Resume Dapagliflozin After AKI in Post-NSTEMI Patient with T2DM

Resume dapagliflozin once the patient is clinically stable with eGFR ≥25 mL/min/1.73 m², volume status is optimized, and oral intake has resumed—typically when AKI has resolved or is resolving and hemodynamic stability is achieved.

Key Criteria for Safe Resumption

Renal Function Requirements

• Dapagliflozin can be resumed when eGFR reaches ≥25 mL/min/1.73 m² 1, 2. The FDA label explicitly states that initiation is not recommended below 25 mL/min/1.73 m², but if eGFR falls below this threshold while on treatment, continuation is permitted 2.
• For cardiovascular and renal protection (not glycemic control), the threshold is eGFR ≥25 mL/min/1.73 m² 2.
• Monitor renal function for 2-3 days after any coronary procedures to ensure stability before resuming 1.

Clinical Stability Markers

The patient must meet these criteria before resumption 3, 2:

• Hemodynamically stable with systolic blood pressure >100 mmHg
• No requirement for IV vasopressors or inotropes
• No escalating doses of IV diuretics
• Volume status optimized (not volume depleted)
• Oral intake resumed
• No signs of ketoacidosis

Volume Status Assessment

• Before resuming, assess and correct any volume depletion 2. Patients recovering from AKI are at increased risk for volume depletion, particularly if elderly or on loop diuretics 2.
• Monitor for signs of hypotension and acute changes in creatinine after resumption 2.

Post-ACS NSTEMI Considerations

Cardiovascular Benefits Support Early Resumption

• SGLT2 inhibitors reduce cardiovascular death and heart failure hospitalization in post-ACS patients with diabetes 4. In the DECLARE-TIMI 58 trial, dapagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure (HR 0.83,95% CI 0.73-0.95) 4.
• Early initiation during or shortly after hospitalization for acute cardiac events reduces heart failure readmissions, with benefits accruing within days to weeks 3.
• Unnecessarily delaying resumption may result in missed therapeutic benefits 3.

Renal Protection in Post-Contrast Settings

• Dapagliflozin may actually protect against contrast-induced nephropathy and post-contrast AKI 5. In patients with T2DM and CKD undergoing coronary procedures, dapagliflozin use was associated with 81% lower risk of post-contrast AKI (HR 0.81,95% CI 0.69-0.95) 5.
• Real-world data show SGLT2 inhibitors are associated with lower, not higher, AKI risk compared to non-users 6.

Practical Resumption Algorithm

Step 1: Assess AKI Recovery Status

• Full recovery: Serum creatinine returned to baseline, no AKI criteria met 7
• Partial recovery: Fall in AKI stage (e.g., from stage 3 to stage 1) 7
• Either scenario permits resumption if eGFR ≥25 mL/min/1.73 m² 1, 2

Step 2: Verify Clinical Stability

• Systolic BP >100 mmHg without vasopressor support 3
• No IV diuretic escalation in past 24 hours 3
• Patient tolerating oral intake 2
• Euvolemic status confirmed 2

Step 3: Check for Contraindications

• Rule out ketoacidosis (particularly important given insulin use) 2. Check for nausea, vomiting, abdominal pain, or metabolic acidosis.
• Ensure no active urinary tract infection or urosepsis 2
• Verify no upcoming surgery or prolonged fasting planned 2

Step 4: Adjust Insulin Dosing

• Reduce insulin dose by 10-20% when resuming dapagliflozin to minimize hypoglycemia risk 2. SGLT2 inhibitors increase hypoglycemia risk when combined with insulin 2.
• Monitor blood glucose closely for first 48-72 hours after resumption 3.

Critical Safety Considerations

Ketoacidosis Risk Management

This patient on insulin is at elevated risk for euglycemic DKA 2:

• Educate about ketoacidosis symptoms (nausea, vomiting, abdominal pain, shortness of breath)
• Maintain at least low-dose insulin; never stop insulin completely 1
• Consider ketone monitoring if clinical situation warrants 2
• Withhold dapagliflozin during acute illness, surgery, or reduced caloric intake 2

Monitoring After Resumption

• Renal function: Check creatinine and eGFR within 1-2 weeks of resumption 1
• Volume status: Monitor for orthostatic hypotension or symptomatic volume depletion 2
• Glycemic control: Assess for hypoglycemia given insulin co-administration 2
• Urinary symptoms: Evaluate for urinary tract infections 2

Common Pitfalls to Avoid

• Do not wait for complete normalization of creatinine if eGFR is ≥25 mL/min/1.73 m² and patient is clinically stable 1, 2
• Do not withhold indefinitely due to fear of AKI recurrence—evidence suggests SGLT2 inhibitors may actually protect against AKI 5, 6
• Do not resume during active volume depletion or hemodynamic instability 2
• Do not forget to reduce insulin dose when resuming to prevent hypoglycemia 2
• Do not resume if patient has upcoming surgery or procedures requiring fasting without planning to withhold for ≥3 days beforehand 2

Timeline Expectations

In most recovering AKI patients post-NSTEMI, dapagliflozin can typically be resumed within 3-7 days if renal function stabilizes at eGFR ≥25 mL/min/1.73 m² and hemodynamic stability is achieved 3, 2. The cardiovascular and renal benefits of SGLT2 inhibitors in this population strongly support resumption as soon as safely feasible 1, 4, 5.