When to initiate Farxiga (dapagliflozin) for a patient with Chronic Kidney Disease (CKD) in their late 80s?

When to Initiate Farxiga (Dapagliflozin) in Late 80s Patients with CKD

Start dapagliflozin 10 mg once daily now if the patient has CKD with eGFR ≥25 mL/min/1.73 m² and albuminuria (UACR ≥200 mg/g), regardless of age in their late 80s, as this reduces mortality, cardiovascular events, and kidney failure progression even in octogenarians. 1, 2

Evidence Supporting Use in Elderly Patients

Age should not be a barrier to initiating dapagliflozin in patients in their late 80s with CKD. The DAPA-CKD trial specifically included octogenarians (patients ≥80 years), who comprised 25% of the study population, and demonstrated consistent benefits across all age groups without evidence of heterogeneity 1. The relative risk reduction for the primary composite outcome (≥50% sustained eGFR decline, end-stage kidney disease, or kidney/cardiovascular death) was uniform regardless of age, with no age-by-treatment interaction 1.

• Dapagliflozin reduced risks of mortality, cardiovascular events, and CKD progression in septuagenarians and octogenarians with the same magnitude of benefit as younger patients 1
• The safety profile was consistent across all age groups, with serious adverse events numerically lower in the dapagliflozin group compared to placebo even in the oldest patients 1

Specific Eligibility Criteria

Initiate dapagliflozin if the patient meets these criteria:

• eGFR 25-75 mL/min/1.73 m² (or ≥25 mL/min/1.73 m² per updated indications) 3, 4
• Urinary albumin-to-creatinine ratio ≥200 mg/g 4, 5
• Not on dialysis 3
• No contraindications (see below)

The drug is FDA-approved for risk reduction of sustained eGFR decline, kidney failure, cardiovascular death, and hospitalization for heart failure in adults with CKD at risk of progression 3.

Dosing in Late 80s Patients

Use dapagliflozin 10 mg once daily regardless of age. 3, 4

• For CKD or heart failure indications with eGFR 25 to <45 mL/min/1.73 m²: use 10 mg daily 3
• If eGFR <25 mL/min/1.73 m², initiation is not recommended, but may continue 10 mg in patients already on therapy 3
• No dose adjustment needed based on age alone 1

Benefits Specific to Elderly CKD Patients

The absolute benefits are substantial in octogenarians despite lower absolute kidney failure risk:

• While absolute risk of kidney composite endpoint was lowest in patients ≥80 years (3.0 vs 1.2 per 100 patient-years in placebo vs dapagliflozin groups), the relative risk reduction remained consistent 1
• Absolute risks of cardiovascular composite endpoint and all-cause mortality were actually higher in older patients, making the absolute benefit of treatment more pronounced for these outcomes 1
• Dapagliflozin reduced left ventricular mass index by -8.44 g/m² compared to placebo, providing mechanistic insight into early cardiovascular benefits 6

Frailty Considerations

Do not withhold dapagliflozin based on frailty status. The DAPA-CKD trial demonstrated consistent benefits across all frailty categories 2:

• In severely frail patients (frailty index >0.311, comprising 34.8% of participants): hazard ratio 0.64 (95% CI 0.49-0.83) for the primary endpoint 2
• Serious adverse events were numerically lower with dapagliflozin versus placebo even in severely frail patients (42.9% vs 47.8%) 2
• The relative benefit was consistent when using frailty index as a continuous variable 2

Diabetes Status Does Not Matter

Initiate dapagliflozin regardless of whether the patient has type 2 diabetes:

• Benefits were consistent in patients with type 2 diabetes (HR 0.64,95% CI 0.52-0.79) and without diabetes (HR 0.50,95% CI 0.35-0.72) with no interaction (p=0.24) 5
• This applies to all secondary outcomes including cardiovascular death/heart failure hospitalization and all-cause mortality 5

Cardiovascular Disease History

Prior cardiovascular disease does not change the indication—benefits are consistent:

• Dapagliflozin reduced the primary outcome equally in primary prevention (HR 0.61,95% CI 0.48-0.78) and secondary prevention groups (HR 0.61,95% CI 0.47-0.79) with p-interaction=0.90 4
• Benefits for heart failure hospitalization/cardiovascular death and all-cause mortality were also consistent regardless of cardiovascular disease history 4

Contraindications and Precautions

Do not initiate if:

• Patient is on dialysis (contraindicated) 3
• eGFR persistently <25 mL/min/1.73 m² (initiation not recommended, though continuation may be considered) 3
• History of serious hypersensitivity to dapagliflozin 3

Monitor for:

• Volume depletion, especially if the patient is on diuretics or has low blood pressure 3
• Genital mycotic infections (more common in elderly) 3
• Diabetic ketoacidosis if patient has diabetes (rare but serious) 3

Monitoring After Initiation

Follow-up schedule:

• Check eGFR and electrolytes within 2-4 weeks after initiation, then every 3-5 months for stage 3b CKD 7
• Monitor blood pressure as dapagliflozin may cause modest reductions 3
• Assess for volume depletion symptoms, particularly in the first weeks 3

Integration with Other CKD Therapies

Dapagliflozin complements, not replaces, standard CKD management:

• Continue ACE inhibitors or ARBs if already prescribed for albuminuria 7
• Maintain statin therapy (strongly recommended for patients >50 years with eGFR <60 mL/min/1.73 m²) 7, 8
• Continue blood pressure management targeting ≤130/80 mmHg if albuminuria present 7

Common Pitfall to Avoid

Ageism and therapeutic nihilism should not discourage use of dapagliflozin in octogenarians. 1 The evidence explicitly demonstrates that older women and men in their late 80s experience considerable benefit from this therapy, with consistent safety profiles across all age groups. The trial data specifically refute concerns about withholding treatment based solely on advanced age.