What are the management rules for patients taking dapagliflozin (Forxiga) when they are sick?

Dapagliflozin Sick Day Management Rules

Hold dapagliflozin during acute illness to prevent diabetic ketoacidosis and volume depletion. 1, 2

When to Withhold Dapagliflozin

Temporarily discontinue dapagliflozin during any acute illness, particularly when patients experience:

• Reduced food and fluid intake 1
• Fever, vomiting, or diarrhea 1
• Dehydration or signs of volume depletion 1, 3
• Any intercurrent illness requiring hospitalization 1
• Planned major surgery or procedures with prolonged fasting (withhold at least 3 days prior) 2, 3

Critical Monitoring During Illness

Monitor for diabetic ketoacidosis (DKA) even with normal blood glucose levels ("euglycemic DKA"), as this is a serious risk during illness in patients taking SGLT2 inhibitors. 1, 3

Check blood or urine ketones if patients develop:

• Malaise, nausea, or vomiting 1
• Abdominal pain 1
• Any symptoms of metabolic acidosis 1, 3

Assess volume status carefully, as the diuretic effect of dapagliflozin combined with illness-related fluid losses significantly increases risk of hypovolemia. 1, 3

Patient Education Requirements

Counsel patients to stop dapagliflozin immediately when they become sick and contact their healthcare provider. 1

Educate patients on specific triggers that necessitate drug discontinuation:

• Reduced ability to eat or drink normally 1
• Alcohol consumption during illness 1
• Any condition causing dehydration 1, 3

Instruct patients to seek immediate medical attention if they develop symptoms of DKA (nausea, vomiting, abdominal pain, unusual fatigue) or severe genital/urinary infections. 1, 2

Insulin Management During Sick Days

Maintain at least low-dose insulin in insulin-requiring individuals even when dapagliflozin is held, as complete insulin cessation increases DKA risk. 1

Do not reduce insulin doses excessively when holding dapagliflozin during illness, as this combination significantly elevates ketoacidosis risk. 1

When to Restart Dapagliflozin

Resume dapagliflozin only after:

• Patient has recovered from acute illness 1
• Normal oral intake is re-established 1
• Volume status is normalized 3
• No signs of ketoacidosis remain 3
• At least 3 days have passed since major surgery or procedures 2, 3

Additional Safety Considerations

Consider proactive dose reduction of concurrent diuretics in patients at high risk for volume depletion before illness occurs. 1

The risk of volume depletion is particularly elevated in:

• Elderly patients 3
• Patients with baseline renal impairment 3
• Those with low systolic blood pressure 3
• Patients already on diuretic therapy 1, 3