What is the recommended dose of Farxiga (dapagliflozin) for patients with Chronic Kidney Disease (CKD)?

Farxiga Dosing for Chronic Kidney Disease

For patients with CKD, the recommended dose of Farxiga (dapagliflozin) is 10 mg orally once daily, which can be initiated when eGFR is ≥25 mL/min/1.73 m² for cardiovascular and renal protection, regardless of diabetes status. 1, 2, 3

Dosing Algorithm Based on eGFR and Indication

For Cardiovascular and Renal Protection (Primary Indication in CKD)

• eGFR ≥25 mL/min/1.73 m²: Start dapagliflozin 10 mg once daily 1, 2, 3
• eGFR <25 mL/min/1.73 m²: Do not initiate dapagliflozin 1, 3
• If eGFR falls below 25 during treatment: Continue 10 mg daily until dialysis is required 1, 2, 3

For Glycemic Control (Secondary Consideration)

• eGFR ≥45 mL/min/1.73 m²: Start 5 mg once daily, may increase to 10 mg if additional glycemic control needed 1, 2, 3
• eGFR <45 mL/min/1.73 m²: Not recommended for glycemic control (ineffective due to mechanism of action) 1, 2, 3

Evidence Supporting This Dosing Strategy

The DAPA-CKD trial demonstrated that dapagliflozin 10 mg daily reduced the primary composite outcome (sustained eGFR decline ≥50%, end-stage kidney disease, or renal/cardiovascular death) by 39% (HR 0.61,95% CI 0.51-0.72) in patients with CKD and eGFR 25-75 mL/min/1.73 m². 2, 4

• The kidney-specific composite outcome was reduced by 44% (HR 0.56,95% CI 0.45-0.68) 2, 4
• Cardiovascular death or heart failure hospitalization was reduced by 29% (HR 0.71,95% CI 0.55-0.92) 2, 4
• All-cause mortality was reduced by 31% (HR 0.69,95% CI 0.53-0.88) 4
• Benefits were consistent in patients with and without type 2 diabetes 5, 4

Critical Monitoring and Safety Considerations

Initial eGFR Changes

• Expect a transient eGFR decline of 2-5 mL/min/1.73 m² within the first 1-4 weeks after initiation, which is reversible and not an indication to discontinue. 2
• Check eGFR and creatinine within 1-2 weeks after starting dapagliflozin 2
• This initial dip is hemodynamic and actually predicts better long-term renal outcomes 2

Volume Status Assessment

• Assess volume status before initiating dapagliflozin and correct any volume depletion 2, 3
• Consider reducing concurrent diuretic doses to prevent excessive volume depletion 2
• Monitor closely for intravascular volume contraction, especially in elderly patients or those on diuretics 2

Sick Day Management (Critical Safety Point)

Withhold dapagliflozin during acute illness, particularly with fever, vomiting, diarrhea, or reduced oral intake. 2

• Monitor for euglycemic diabetic ketoacidosis (DKA), which can occur even with normal blood glucose levels 2, 3
• Check blood or urine ketones if patients develop malaise, nausea, or vomiting 2
• Resume dapagliflozin only after recovery and normal oral intake is re-established 2

Surgical Considerations

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

Common Pitfalls to Avoid

Do Not Discontinue Based on eGFR Alone

Do not stop dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m², as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost. 2

• The drug's renal and cardiovascular benefits are preserved at lower eGFR levels, even though glucose-lowering efficacy decreases 2

Genital Mycotic Infections

• Genital mycotic infections occur in approximately 6% of patients versus 1% on placebo 2
• Educate patients about daily hygienic measures to reduce this risk 2

Hyperkalemia Management

• Dapagliflozin actually reduces the risk of hyperkalemia and may facilitate use of mineralocorticoid receptor antagonists 2

Special Populations

Patients with Albuminuria

• Dapagliflozin is strongly recommended (1A evidence) for adults with CKD and UACR ≥200 mg/g when eGFR ≥20 mL/min/1.73 m². 1, 2
• Benefits extend to patients with UACR ≥30 mg/g, though evidence is strongest for UACR ≥200 mg/g 2

Patients with Heart Failure

• Use 10 mg once daily for heart failure (with or without reduced ejection fraction), regardless of eGFR level down to 25 mL/min/1.73 m² 2

Non-Diabetic CKD

• The same 10 mg daily dose applies to patients without diabetes, as benefits were consistent regardless of diabetes status. 5, 4