What is the recommended dosing for dapagliflozin (Forxiga) in patients with type 2 diabetes or heart failure?

Dapagliflozin Dosing

The recommended dose of dapagliflozin is 10 mg orally once daily for heart failure, chronic kidney disease, and cardiovascular risk reduction in type 2 diabetes; for glycemic control alone, start with 5 mg once daily and increase to 10 mg if needed for additional glucose lowering. 1, 2

Dosing by Indication

Type 2 Diabetes (Glycemic Control)

• Start with 5 mg once daily in adults and pediatric patients ≥10 years old 2
• Increase to 10 mg once daily if additional glycemic control is needed 1, 2
• Do not initiate if eGFR <45 mL/min/1.73 m² for glycemic control—the drug is likely ineffective due to its mechanism of action at this level of renal function 1, 3, 2

Heart Failure (Any Ejection Fraction)

• Fixed dose of 10 mg once daily regardless of diabetes status 1, 2
• This applies to both reduced and preserved ejection fraction heart failure 1, 4, 5
• Do not initiate if eGFR <25 mL/min/1.73 m², but may continue if eGFR falls below this threshold during treatment 3, 2

Chronic Kidney Disease

• Fixed dose of 10 mg once daily for patients with eGFR ≥25 mL/min/1.73 m² and albuminuria (UACR ≥200 mg/g) 1, 3, 2
• Benefits demonstrated regardless of diabetes status 6
• May continue 10 mg daily even if eGFR falls below 25 mL/min/1.73 m² during treatment until dialysis is required 3, 2

Cardiovascular Risk Reduction in Type 2 Diabetes

• 10 mg once daily for patients with established cardiovascular disease or multiple cardiovascular risk factors 1, 2

Critical Renal Function Thresholds

For glycemic control:

• eGFR ≥45 mL/min/1.73 m²: No dose adjustment needed 1, 2
• eGFR <45 mL/min/1.73 m²: Not recommended for initiation (ineffective for glucose lowering) 3, 2

For cardiovascular/renal protection:

• eGFR ≥25 mL/min/1.73 m²: Standard 10 mg dose 3, 2
• eGFR <25 mL/min/1.73 m²: Do not initiate, but continue if already on treatment 3, 2

Important Safety Considerations

Perioperative Management

• Withhold for at least 3 days before major surgery or procedures requiring prolonged fasting to prevent ketoacidosis 3, 2
• Resume only when clinically stable and oral intake has resumed 2

Sick Day Rules

• Temporarily discontinue during acute illness, particularly with fever, vomiting, diarrhea, or reduced oral intake 3
• Monitor for euglycemic diabetic ketoacidosis even with normal blood glucose 3
• Resume only after recovery and normal oral intake is re-established 3

Volume Status

• Assess and correct volume depletion before initiating dapagliflozin 2
• Use caution in elderly patients, those on diuretics, or with low systolic blood pressure 3
• Consider reducing concurrent diuretic doses when starting dapagliflozin 3

Monitoring Requirements

• Check eGFR before initiation and periodically thereafter 3, 2
• Expect a transient eGFR dip of 3-5 mL/min/1.73 m² within 1-4 weeks of starting treatment—this is reversible and does not indicate harm 3
• Recheck eGFR within 1-2 weeks after initiation 3
• Monitor for genital mycotic infections (occurs in ~6% vs 1% with placebo) and urinary tract infections 1, 3

Common Pitfalls to Avoid

• Do not discontinue dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m²—cardiovascular and renal protective benefits persist even when glycemic efficacy is lost 3
• Do not reduce insulin doses excessively when adding dapagliflozin in insulin-requiring patients, as this increases ketoacidosis risk 3
• Do not use for glycemic control in patients with eGFR <45 mL/min/1.73 m²—it won't work for glucose lowering at this level 3, 2