From the Guidelines
In patients with diabetes and chronic kidney disease (CKD) who are on empagliflozin and experience a drop in GFR to <20 mL/min/1.73m², switching to dapagliflozin is not indicated. Both empagliflozin and dapagliflozin are SGLT2 inhibitors that are not recommended for initiation when eGFR falls below 20 mL/min/1.73m², as stated in the guidelines 1. If a patient has been tolerating empagliflozin well for over a year, there is no clinical advantage to switching to dapagliflozin at this advanced stage of kidney disease. Current guidelines suggest discontinuing SGLT2 inhibitors when eGFR falls below 20 mL/min/1.73m² due to diminished glycemic efficacy and potential safety concerns, as supported by the evidence from the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report 1. The kidney-protective effects of these medications are thought to be less pronounced at very low GFR levels, and the risk-benefit ratio changes. Instead, the treatment approach should shift toward:
- Optimizing other medications like ACE inhibitors or ARBs for kidney protection
- Adjusting antihyperglycemic therapy that remains effective at low GFR (such as insulin, certain DPP-4 inhibitors, or GLP-1 receptor agonists)
- Preparing for potential renal replacement therapy if kidney function continues to decline, as recommended in the guidelines for glycemic monitoring and management in advanced CKD 1. Recent studies, including the EMPA-KIDNEY trial, have demonstrated the benefits of SGLT2 inhibitors in patients with CKD, but these benefits are most pronounced in patients with higher eGFR levels 1. Therefore, discontinuing empagliflozin and switching to alternative therapies is the most appropriate course of action when eGFR falls below 20 mL/min/1.73m².
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Indication to Switch to Dapagliflozin
- There is no direct evidence to suggest switching to dapagliflozin if GFR drops to <20 in a patient with diabetes and CKD who has been on empagliflozin for more than 1 year 2, 3, 4, 5, 6.
- Empagliflozin has been shown to have beneficial effects on chronic kidney disease, including reducing the risk of progression in this pathology 2, 4, 6.
- Dapagliflozin has also been shown to have beneficial effects on chronic kidney disease, with a 44% reduced risk of progression in this pathology 2.
- However, the decision to switch to dapagliflozin should be based on individual patient characteristics and clinical judgment, as there is no clear evidence to support switching to dapagliflozin solely based on a GFR drop to <20 3, 5.
- It is essential to consider the patient's overall clinical profile, including their response to empagliflozin, potential side effects, and other comorbidities, before making any changes to their treatment regimen 4, 6.
Considerations for Switching to Dapagliflozin
- The patient's kidney function and overall health status should be carefully evaluated before considering a switch to dapagliflozin 2, 3, 4.
- The potential benefits and risks of switching to dapagliflozin should be weighed against the potential benefits and risks of continuing empagliflozin 5, 6.
- Close monitoring of the patient's kidney function, blood pressure, and other relevant parameters is crucial when considering a switch to dapagliflozin 2, 4.