What is the recommended dose of Invokana (canagliflozin) for type 2 diabetes treatment?

Invokana (Canagliflozin) Dosing for Type 2 Diabetes

Standard Starting Dose

The recommended starting dose of Invokana is 100 mg orally once daily, taken before the first meal of the day. 1

Dose Titration for Glycemic Control

• For patients requiring additional glucose lowering beyond the 100 mg dose, Invokana may be increased to a maximum of 300 mg once daily. 1
• The 300 mg dose is appropriate only in patients with eGFR ≥60 mL/min/1.73 m² who need more intensive glycemic control. 2, 1
• For cardiovascular and renal protection indications, the 100 mg dose is sufficient and should not be increased, as higher doses do not provide additional cardiovascular or renal benefits. 2, 1

Dosing Based on Renal Function

eGFR ≥60 mL/min/1.73 m²

• No dose adjustment required. 2
• May use up to 300 mg daily if additional glycemic control is needed. 1

eGFR 30 to <60 mL/min/1.73 m²

• Maximum dose is 100 mg once daily. 2, 1
• Do not exceed 100 mg daily in this population. 2

eGFR <30 mL/min/1.73 m²

• Initiation is not recommended. 1
• Exception: Adult patients already taking Invokana with albuminuria >300 mg/day may continue 100 mg once daily for renal and cardiovascular protection (reducing risk of ESKD, doubling of serum creatinine, CV death, and heart failure hospitalization). 1, 3

Indication-Specific Dosing

For Cardiovascular Risk Reduction

• Use 100 mg once daily to reduce risk of major adverse cardiovascular events (CV death, nonfatal MI, nonfatal stroke) in adults with type 2 diabetes and established cardiovascular disease. 1

For Diabetic Nephropathy with Albuminuria

• Use 100 mg once daily to reduce risk of ESKD, doubling of serum creatinine, CV death, and hospitalization for heart failure in adults with diabetic nephropathy and albuminuria >300 mg/day. 1, 3

Drug Interaction Adjustments

When co-administering with UGT enzyme inducers (rifampin, phenytoin, phenobarbital, ritonavir): 1

• If eGFR ≥60 mL/min/1.73 m²: Increase from 100 mg to 200 mg once daily in patients tolerating the lower dose (maximum 300 mg daily). 1
• If eGFR <60 mL/min/1.73 m²: Increase to maximum 200 mg once daily in patients tolerating 100 mg. 1

Critical Safety Considerations

Pre-Surgery Protocol

• Discontinue Invokana at least 3 days before planned surgery or procedures with prolonged fasting to prevent postoperative ketoacidosis. 2, 1
• Resume only when patient is clinically stable and has resumed oral intake. 1

Concomitant Glucose-Lowering Medications

• If HbA1c is well-controlled at baseline or patient has frequent hypoglycemia, reduce or stop sulfonylureas/glinides when starting Invokana. 2
• Consider reducing total daily insulin dose by approximately 20% when initiating Invokana to prevent hypoglycemia. 2

Volume Status

• Correct volume depletion before initiating Invokana. 1
• Consider stopping or reducing diuretic dose if applicable, as Invokana may contribute to intravascular volume contraction. 2

Pediatric Dosing (Ages 10-17 Years)

• The recommended starting dose is 100 mg once daily for glycemic control. 1
• May increase to 300 mg daily if additional glycemic control is needed and eGFR ≥60 mL/min/1.73 m². 1
• Same renal function-based dose modifications apply as in adults. 1

Common Pitfalls to Avoid

• **Do not initiate Invokana in patients with eGFR <30 mL/min/1.73 m²** (except for continuation in those with albuminuria >300 mg/day already on therapy). 1
• Do not use doses >100 mg daily when eGFR is 30-59 mL/min/1.73 m², as efficacy is reduced and safety is not established at higher doses in this population. 2, 1
• Do not increase to 300 mg for cardiovascular or renal protection, as the 100 mg dose provides equivalent benefits for these outcomes. 2
• Do not forget to assess renal function before initiation and periodically thereafter, as efficacy decreases with declining kidney function. 1