Safety of Dapagliflozin (Farxiga) with BMI 36 and Stage 3a CKD
Yes, dapagliflozin is safe and strongly recommended for patients with stage 3a CKD (eGFR 45-59 mL/min/1.73 m²) and BMI of 36, as it provides significant cardiovascular and renal protection regardless of body weight. 1
Dosing and Initiation
Start dapagliflozin 10 mg once daily for cardiovascular and renal protection. 1 This fixed dose requires no adjustment based on your kidney function level, as stage 3a CKD (eGFR 45-59 mL/min/1.73 m²) is well above the minimum threshold for initiation (eGFR ≥25 mL/min/1.73 m²). 1, 2
- For glycemic control specifically, dapagliflozin can be initiated at 5 mg daily if eGFR ≥45 mL/min/1.73 m², with possible increase to 10 mg if additional glucose lowering is needed. 1
- However, the 10 mg dose is preferred as it provides maximal cardiovascular and renal benefits that extend beyond glucose control. 1
Evidence for Renal and Cardiovascular Benefits
The DAPA-CKD trial specifically included large numbers of patients with stage 3a kidney disease and demonstrated robust benefits:
- Dapagliflozin reduced the risk of kidney disease progression (≥50% sustained eGFR decline, end-stage kidney disease, or renal/cardiovascular death) by 39%. 1
- Cardiovascular death or heart failure hospitalization was reduced by 29%. 1
- These benefits were consistent regardless of baseline cardiovascular disease status or diabetes presence. 3
The American Diabetes Association guidelines specifically state that SGLT2 inhibitors like dapagliflozin should be considered for patients with type 2 diabetes and CKD who require additional therapy, as they reduce risks of CKD progression, cardiovascular events, and hypoglycemia. 4
Weight and BMI Considerations
Your BMI of 36 is actually an advantage rather than a contraindication:
- Dapagliflozin typically produces weight loss of 1-3 kg, which is beneficial for patients with elevated BMI. 4, 5
- No dose adjustment or special precautions are needed based on body weight for dapagliflozin. 1
- The cardiovascular and renal benefits are preserved across all body weight categories. 1
Safety Monitoring and Precautions
Before starting dapagliflozin, assess the following:
- Check baseline eGFR and recheck within 1-2 weeks after initiation. 1 An initial eGFR dip of 3-5 mL/min/1.73 m² is expected and reversible. 1
- Assess volume status before starting. 1 If you're on diuretics, consider reducing the diuretic dose to prevent excessive volume depletion. 1
- Monitor for genital mycotic infections (occurs in ~6% of patients). 1, 6 Daily genital hygiene can reduce this risk. 1
Critical Safety Rules ("Sick Day Rules")
Temporarily stop dapagliflozin during any acute illness, especially with fever, vomiting, diarrhea, or reduced oral intake. 1 This prevents diabetic ketoacidosis and volume depletion. 1
- Withhold dapagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting. 1
- Resume only after you've recovered and normal eating/drinking is re-established. 1
Common Pitfalls to Avoid
- Do not discontinue dapagliflozin if your eGFR falls below 45 mL/min/1.73 m² during treatment. 1 The cardiovascular and renal protective benefits persist even when glucose-lowering efficacy diminishes. 1
- Do not assume the medication is only for diabetes control. 1 The renal and cardiovascular benefits are independent of glucose lowering and occur even in non-diabetic patients. 1
- If you develop urinary tract infections or genital infections, these can be treated without necessarily stopping dapagliflozin, though consultation with your physician is essential. 6
Expected Adverse Effects
The most common side effects from clinical trials include:
- Genital mycotic infections (more common in women): ~6% vs 1% with placebo. 6
- Urinary tract infections: similar rates to placebo in most studies. 6
- Increased urination (polyuria): expected due to mechanism of action. 6
- Hypoglycemia risk is low unless combined with insulin or sulfonylureas. 4