Can I discontinue Farxiga (dapagliflozin) in a patient with chronic kidney disease (CKD) stage 3a and uncontrolled diabetes due to cost concerns?

Do Not Discontinue Farxiga in This Patient

You should continue Farxiga (dapagliflozin) in this patient despite cost concerns, as it provides critical kidney and cardiovascular protection that extends far beyond glucose control in CKD stage 3a. 1 The benefits of SGLT2 inhibitors on morbidity and mortality in patients with CKD are independent of their glucose-lowering effects and are maintained even when eGFR falls below 30 mL/min/1.73 m². 1

Why Farxiga Must Be Continued

Kidney Protection Benefits

• KDIGO 2020 guidelines explicitly recommend SGLT2 inhibitors as first-line therapy for all patients with type 2 diabetes, CKD, and eGFR ≥30 mL/min/1.73 m² (1A recommendation). 1
• This patient has an eGFR of 47 mL/min/1.73 m² (CKD stage 3a), which is well within the range where dapagliflozin provides maximum benefit. 1
• In the DAPA-CKD trial, dapagliflozin reduced the primary outcome (≥50% eGFR decline, ESKD, or renal/cardiovascular death) by 39% in CKD patients. 2
• Dapagliflozin reduced all-cause mortality by 31% in CKD patients. 2
• The cardiovascular and kidney benefits were seen across all categories of albuminuria and CKD (eGFR as low as 30-44 mL/min/1.73 m²), despite reduced glucose-lowering efficacy at lower eGFR. 1

Cardiovascular Protection

• Dapagliflozin decreased the cardiovascular composite outcome by 29% in CKD patients. 2
• The cardiovascular and kidney benefits were out of proportion to HbA1c reductions, indicating these effects are not fully attributable to glucose lowering. 1
• This patient has multiple cardiovascular risk factors (hypertension on 4 medications, hyperlipidemia on dual therapy, history of stroke). 1

Continuation Even with Declining eGFR

• Once initiated, SGLT2 inhibitors should be continued even if eGFR falls below 30 mL/min/1.73 m², as long as they are well tolerated and kidney replacement therapy is not imminent. 1
• The initial eGFR decline (3-5 mL/min/1.73 m² in first 4 weeks) is hemodynamic, reversible, and not a reason to discontinue therapy, as long-term eGFR preservation has been demonstrated with continuation. 1

Alternative Medications to Discontinue Instead

Glipizide Should Be Reduced or Discontinued

• This patient's HbA1c of 8.6% with glucose 3+ in urine suggests poor glycemic control, but glipizide (a sulfonylurea) increases hypoglycemia risk without providing kidney or cardiovascular protection. 1
• KDIGO guidelines explicitly state that when cost is a concern, sulfonylureas are among the lowest-cost options but lack the cardiorenal benefits of SGLT2 inhibitors. 1
• The patient is already on insulin (Lantus and Humalog), making glipizide redundant and increasing hypoglycemia risk. 1
• Recommendation: Discontinue glipizide 10 mg and optimize insulin dosing instead. 1

Consider Adjusting Other Medications

• The patient is on 4 antihypertensive medications (amlodipine, lisinopril, metoprolol, chlorthalidone). 1
• SGLT2 inhibitors can facilitate reduction of diuretics due to their own diuretic effect, potentially allowing chlorthalidone dose reduction. 1
• This could offset some medication costs while maintaining blood pressure control. 1

Addressing Cost Concerns

Financial Assistance Options

• KDIGO guidelines explicitly acknowledge that cost should guide selection of additional drugs when needed, but SGLT2 inhibitors are recommended as first-line therapy alongside metformin. 1
• Patient assistance programs are available for dapagliflozin through AstraZeneca. 3
• Generic SGLT2 inhibitors may become available, though dapagliflozin specifically has the strongest evidence in CKD. 2

Cost-Effectiveness Perspective

• The robust renal and cardiovascular benefits of dapagliflozin are expected to outweigh potential risks and costs by preventing dialysis, hospitalizations, and cardiovascular events. 2
• Preventing progression to ESKD (which this medication does) is far more cost-effective than paying for dialysis. 2

Practical Management Algorithm

1. Continue Farxiga 10 mg daily 1
2. Discontinue glipizide 10 mg to reduce medication burden and cost 1
3. Optimize insulin dosing to achieve HbA1c target of <7-8% (individualized based on age and comorbidities) 1
4. Consider adding GLP-1 receptor agonist if glycemic targets not met with metformin, SGLT2i, and insulin, as GLP-1 RAs provide additional cardiovascular and kidney benefits 1
5. Monitor for SGLT2 inhibitor side effects: genital mycotic infections, volume depletion, and educate on sick day rules 1
6. Consider reducing chlorthalidone dose if blood pressure well-controlled, to offset costs and reduce volume depletion risk 1

Critical Pitfalls to Avoid

• Do not discontinue SGLT2 inhibitors due to initial eGFR decline (3-5 mL/min/1.73 m² drop is expected and hemodynamic). 1
• Do not prioritize short-term medication costs over long-term outcomes when the medication prevents dialysis and death. 2
• Do not continue sulfonylureas when SGLT2 inhibitors are available, as sulfonylureas lack cardiorenal benefits and increase hypoglycemia risk. 1
• Do not fail to educate the patient on the life-saving benefits of SGLT2 inhibitors beyond glucose control. 1
• Do not forget to assess for patient assistance programs before discontinuing essential medications. 1