What are the dosing recommendations for Farxiga (dapagliflozin) in patients with impaired renal function?

Farxiga (Dapagliflozin) Renal Dosing

For glycemic control, do not initiate Farxiga if eGFR <45 mL/min/1.73 m², but for cardiovascular and renal protection, use 10 mg daily if eGFR ≥25 mL/min/1.73 m². 1

Dosing Based on Indication and Renal Function

For Glycemic Control in Type 2 Diabetes

• eGFR ≥45 mL/min/1.73 m²: Start with 5 mg once daily, may increase to 10 mg once daily if additional glycemic control is needed 1
• eGFR <45 mL/min/1.73 m²: Do not initiate or use for glycemic control—Farxiga is likely ineffective due to its mechanism of action (requires adequate renal glucose filtration) 2, 1

For Cardiovascular and Renal Protection (Heart Failure, CKD)

• eGFR ≥25 mL/min/1.73 m²: Use fixed dose of 10 mg once daily for heart failure, chronic kidney disease, or cardiovascular risk reduction 2, 1
• eGFR <25 mL/min/1.73 m²: Do not initiate, but if already on treatment, may continue 10 mg daily until dialysis is required 2, 1
• Dialysis patients: Contraindicated 2

Critical Distinction: Glycemic vs. Cardio-Renal Benefits

The glucose-lowering efficacy of Farxiga diminishes as eGFR declines below 45 mL/min/1.73 m², but cardiovascular and renal protective benefits persist down to eGFR 25 mL/min/1.73 m². 2, 3 This is why dosing recommendations differ based on treatment indication—the DAPA-CKD trial demonstrated a 39% reduction in the composite outcome of sustained eGFR decline, end-stage kidney disease, or renal/cardiovascular death in patients with eGFR 25-75 mL/min/1.73 m², regardless of diabetes status 4.

Pre-Initiation Assessment

• Assess renal function (eGFR and creatinine) before starting Farxiga and periodically thereafter 3, 1
• Evaluate volume status and correct volume depletion before initiation, especially in elderly patients, those on diuretics, or with low systolic blood pressure 3, 1
• Consider reducing concurrent diuretic doses when initiating Farxiga to prevent excessive volume depletion 3

Monitoring After Initiation

• Recheck eGFR within 1-2 weeks after starting Farxiga—an initial transient eGFR dip of 3-5 mL/min/1.73 m² is expected and typically reverses 3
• If eGFR decreases >30% from baseline AND signs of hypovolemia are present, reduce diuretic doses first before adjusting Farxiga 3
• Do not discontinue Farxiga solely because eGFR falls below 45 mL/min/1.73 m²—cardiovascular and renal protective benefits persist even when glycemic efficacy is lost 3

Temporary Interruption

• Withhold Farxiga at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis 3, 1
• Hold Farxiga during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent diabetic ketoacidosis and volume depletion 3
• Resume only after patient is clinically stable and has resumed normal oral intake 1

Common Pitfalls to Avoid

• Do not assume Farxiga is contraindicated at eGFR <45 mL/min/1.73 m²—it remains indicated for heart failure and CKD protection down to eGFR 25 mL/min/1.73 m² 2, 1
• Do not stop Farxiga when eGFR declines during treatment—the initial eGFR dip is hemodynamic and reversible, and patients with this dip actually have better long-term renal outcomes 3
• Do not use Farxiga for glycemic control in advanced CKD (eGFR <45 mL/min/1.73 m²)—switch to insulin or GLP-1 receptor agonists for glucose management while continuing Farxiga for cardio-renal protection if eGFR ≥25 mL/min/1.73 m² 2, 3

Safety Considerations

• Monitor for genital mycotic infections (occur in ~6% vs. 1% with placebo) and urinary tract infections 3
• Educate patients about euglycemic diabetic ketoacidosis risk, which can occur even with normal blood glucose levels, especially during illness or fasting 3, 1
• Maintain at least low-dose insulin in insulin-requiring patients even when Farxiga is held during illness to prevent ketoacidosis 3