What is the recommended dose when switching between empagliflozin (Jardiance) and dapagliflozin (Farxiga)?

SGLT2 Inhibitor Switching: Empagliflozin to Dapagliflozin Dosing

When switching between empagliflozin (Jardiance) and dapagliflozin (Farxiga), use a fixed dose of 10 mg once daily for dapagliflozin regardless of the prior empagliflozin dose (whether 10 mg or 25 mg), as this is the only approved dose for cardiovascular and renal protection. 1, 2

Direct Dose Conversion Algorithm

For patients on empagliflozin 10 mg daily:

• Switch directly to dapagliflozin 10 mg once daily 1, 2
• No titration period required 3
• Continue all other medications unchanged initially 3

For patients on empagliflozin 25 mg daily:

• Switch to dapagliflozin 10 mg once daily (the only available therapeutic dose) 1, 2
• Monitor glucose more closely for 2-4 weeks, as you are effectively reducing SGLT2 inhibitor exposure 3
• Consider adjusting other glucose-lowering medications if needed based on monitoring 3

Critical Renal Function Considerations

The primary reason for switching is often declining renal function, so verify eGFR before making the switch:

• If eGFR ≥45 mL/min/1.73 m²: Both drugs can be used; switch to dapagliflozin 10 mg daily 1, 4
• If eGFR 25-44 mL/min/1.73 m²: Dapagliflozin 10 mg daily is appropriate; empagliflozin should be discontinued per FDA labeling 1, 4
• If eGFR 20-24 mL/min/1.73 m²: Dapagliflozin 10 mg daily can be continued if already on therapy; initiation not recommended 1, 2
• If eGFR <20 mL/min/1.73 m²: Neither drug should be initiated, but dapagliflozin may be continued until dialysis if tolerated 1, 2

Important Clinical Context

The FDA label for empagliflozin states it should not be initiated when eGFR <45 mL/min/1.73 m² and should be discontinued if eGFR falls persistently below 45 mL/min/1.73 m². 4 This is the most common reason for switching to dapagliflozin, which has broader renal dosing flexibility down to eGFR 20-25 mL/min/1.73 m². 1, 2

Retrospective data from 111 patients switching from dapagliflozin to empagliflozin showed that 70.3% maintained or improved glycemic control at 6 months with no significant change in renal function. 3 While this study examined the reverse direction, it demonstrates that switching between these agents is generally safe and effective when done at equivalent therapeutic doses.

Safety Precautions During the Switch

Volume status assessment:

• Evaluate for signs of volume depletion before switching 4
• Consider reducing concurrent diuretic doses temporarily, especially if eGFR is declining 1, 2
• Monitor blood pressure and orthostatic vital signs in the first 1-2 weeks 4

Glucose monitoring:

• Check fasting glucose and consider continuous glucose monitoring for 1-2 weeks after switching 3
• If switching from empagliflozin 25 mg to dapagliflozin 10 mg, you may see slightly less glucose-lowering effect 5
• Adjust sulfonylurea or insulin doses as needed to prevent hypoglycemia 1, 2

Renal function monitoring:

• Recheck eGFR within 2-4 weeks after switching 2, 4
• An initial eGFR dip of 3-5 mL/min/1.73 m² is expected and reversible 2
• If eGFR drops >30% from baseline with signs of hypovolemia, reduce diuretics first before discontinuing the SGLT2 inhibitor 2

Common Pitfalls to Avoid

Do not attempt to "dose-match" by using higher doses of dapagliflozin. Dapagliflozin only comes in a 10 mg therapeutic dose for cardiovascular and renal protection. 1, 2 There is no 25 mg equivalent dose available.

Do not discontinue dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m² after switching. The cardiovascular and renal protective benefits persist even when glycemic efficacy is lost at lower eGFR levels. 1, 2 This is actually the advantage of dapagliflozin over empagliflozin in advanced CKD.

Do not forget to counsel patients about sick day rules. Both drugs should be held during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent ketoacidosis and volume depletion. 2 Withhold at least 3 days before major surgery or prolonged fasting. 2

Do not overlook the need to maintain at least low-dose insulin in insulin-requiring patients during sick days, even when the SGLT2 inhibitor is held. Complete insulin cessation increases diabetic ketoacidosis risk. 2