Should You Hold Dapagliflozin in Acute Stroke Patients?
No, you should not routinely hold dapagliflozin in stroke patients, but you should temporarily discontinue it during the acute phase if the patient is unable to maintain oral intake, has significant volume depletion, or requires prolonged fasting for procedures. 1
Acute Phase Management (First 3-7 Days)
Temporarily hold dapagliflozin if:
- Patient is NPO or has reduced oral intake 1
- Patient has nausea, vomiting, or diarrhea (implement sick day protocol) 2
- Patient requires major procedures or surgery with prolonged fasting 1
- Patient shows signs of volume depletion requiring aggressive diuresis adjustment 2
Resume dapagliflozin when:
Long-Term Continuation After Stroke
Dapagliflozin should be continued or restarted after the acute phase because stroke patients with type 2 diabetes derive substantial cardiovascular and mortality benefits from SGLT2 inhibitors. 2
Evidence Supporting Continuation:
Patients with prior ischemic stroke were specifically included in major SGLT2 inhibitor trials, with stroke history being part of the definition of established cardiovascular disease 2
DECLARE-TIMI 58 demonstrated cardiovascular safety in patients with established atherosclerotic disease (which includes prior stroke), showing reduction in cardiovascular death or heart failure hospitalization (HR 0.83,95% CI 0.73-0.95) 2
Post-stroke patients with diabetes and prior MI showed particularly robust benefits with dapagliflozin, with a 16% relative risk reduction in MACE and 2.6% absolute risk reduction 3
Emerging preclinical evidence suggests SGLT2 inhibitors may actually promote post-stroke functional recovery in diabetic patients through metabolic and neurovascular mechanisms 4
Critical Safety Monitoring During Resumption
Monitor for these specific complications when restarting:
Diabetic ketoacidosis risk: Educate patients on early recognition; implement "STOP DKA" protocol (stop SGLT2 inhibitor, test for ketones, maintain fluid/carbohydrate intake, insulin) 2
Volume status: Consider reducing diuretic doses if patient is on concurrent diuretics to prevent hypovolemia 2
Insulin adjustment: If patient is on insulin, reduce total daily dose by approximately 20% when restarting dapagliflozin to prevent hypoglycemia 1
Foot care: Ensure daily hygiene and regular foot examinations, particularly in patients with peripheral neuropathy or vascular disease 2
Special Considerations for Stroke Patients
Antiplatelet therapy interactions: Stroke patients are typically on antiplatelet therapy (aspirin, clopidogrel, or dual antiplatelet therapy for 21-90 days post-stroke) 2, 5, 6. Dapagliflozin does not have significant drug interactions with antiplatelet agents and can be safely co-administered.
Renal function: Dapagliflozin can be used with eGFR ≥25 mL/min/1.73 m² 2. However, it is not recommended for glycemic control when eGFR <45 mL/min/1.73 m², though cardiovascular and renal benefits may still apply 2
Heart failure consideration: Many stroke patients have concurrent heart failure or are at high risk. Dapagliflozin reduces heart failure hospitalization and cardiovascular death regardless of diabetes status, making continuation particularly important 2, 1
Common Pitfalls to Avoid
Do not permanently discontinue dapagliflozin simply because a patient had a stroke—the cardiovascular benefits are substantial in this high-risk population 2
Do not restart too early if patient cannot maintain adequate oral intake or has ongoing acute illness 2, 1
Do not forget to adjust insulin/sulfonylurea doses when restarting to prevent hypoglycemia 1
Do not ignore volume status—stroke patients may have altered fluid management needs, and dapagliflozin causes osmotic diuresis 2