What is the proper administration and monitoring protocol for a patient with type 2 diabetes taking dapagliflozin (10 mg)?

How to Take Dapagliflozin 10 mg

Standard Dosing and Administration

Take dapagliflozin 10 mg orally once daily, at the same time each day, with or without food. 1 The medication can be taken in the morning or evening based on patient preference, as timing does not affect efficacy. 2

• No dose titration is required – 10 mg once daily is the fixed dose for cardiovascular protection, heart failure, and chronic kidney disease indications. 3, 1
• For glycemic control in type 2 diabetes, the starting dose may be 5 mg once daily, with possible increase to 10 mg once daily if additional glucose lowering is needed. 1
• Peak plasma concentrations occur within 2 hours of administration, with a half-life of approximately 12.9 hours. 4

Critical Pre-Treatment Assessment

Before starting dapagliflozin, the following must be evaluated:

• Check kidney function (eGFR) – Do not initiate if eGFR <25 mL/min/1.73 m² for cardiovascular/renal indications, or if eGFR <45 mL/min/1.73 m² for glycemic control. 3, 1
• Assess volume status – Correct any volume depletion before starting therapy, particularly in elderly patients or those on diuretics. 3, 1
• Recheck eGFR within 1-2 weeks after initiation, as a transient dip of 3-5 mL/min/1.73 m² is expected and reversible. 3

Monitoring During Treatment

Routine Monitoring Schedule

• Recheck eGFR within 1-2 weeks after starting dapagliflozin to assess for expected initial decline. 3
• Monitor eGFR every 3-6 months if eGFR is 45-59 mL/min/1.73 m², or annually if eGFR ≥60 mL/min/1.73 m². 3
• Assess volume status at each visit, especially in patients on concurrent diuretics. 3

Safety Monitoring

• Monitor for genital mycotic infections (occur in approximately 6% of patients vs 1% on placebo) – daily hygienic measures may reduce risk. 3, 5
• Monitor for urinary tract infections (occur in 8-14% of patients vs 6% on placebo). 3, 5
• Watch for signs of volume depletion, particularly in elderly patients (≥65 years) who have higher rates of hypotension. 6

Sick Day Management Rules

Temporarily discontinue dapagliflozin during any acute illness, particularly when experiencing reduced food and fluid intake, fever, vomiting, or diarrhea. 3

• Stop dapagliflozin immediately when sick and contact your healthcare provider. 3
• Monitor for diabetic ketoacidosis (DKA) even with normal blood glucose levels – check blood or urine ketones if you develop malaise, nausea, or vomiting. 3
• If on insulin, maintain at least low-dose insulin even when dapagliflozin is held, as complete insulin cessation increases DKA risk. 3
• Resume dapagliflozin only after recovery from acute illness and normal oral intake is re-established. 3

Surgical and Procedural Considerations

Withhold dapagliflozin for at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis. 7, 3, 1

• Resume dapagliflozin when clinically stable and oral intake has resumed. 1
• This precaution applies to all SGLT2 inhibitors due to increased risk of diabetic and euglycemic ketoacidosis in the perioperative period. 7

Continuation with Declining Kidney Function

If eGFR falls below 25 mL/min/1.73 m² during treatment, continue dapagliflozin 10 mg daily until dialysis is required, as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost. 3, 1

• Do not discontinue dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m² – the cardiovascular and renal benefits remain. 3
• Glucose-lowering efficacy diminishes as eGFR declines, but cardiovascular and kidney benefits are preserved. 6

Drug Interactions and Combination Therapy

• No dose adjustment needed when combining with metformin, DPP-4 inhibitors (sitagliptin, linagliptin), GLP-1 receptor agonists, or cardiovascular medications. 3, 4
• Consider reducing concurrent diuretic doses when starting dapagliflozin to prevent excessive volume depletion. 3
• If on sulfonylureas, adjust doses based on glucose monitoring to prevent hypoglycemia. 3
• The combination of metformin, DPP-4 inhibitors, and dapagliflozin has low hypoglycemia risk, with no preemptive dose reduction needed. 3

Common Pitfalls to Avoid

• Do not stop dapagliflozin when eGFR drops below 45 mL/min/1.73 m² if the indication is cardiovascular or renal protection – benefits persist at lower eGFR levels. 3
• Do not continue dapagliflozin during acute illness – the risk of DKA and volume depletion significantly increases. 3
• Do not use dapagliflozin for glycemic control if eGFR <45 mL/min/1.73 m² – it is likely ineffective due to its mechanism of action. 3, 1
• Patients on high-dose loop diuretics require careful monitoring when starting dapagliflozin due to enhanced natriuresis. 8

Patient Education Essentials

• Take at the same time each day to maintain consistent drug levels. 1
• Maintain adequate hydration, especially during hot weather or exercise. 3
• Stop the medication and seek immediate medical attention if you develop symptoms of DKA (nausea, vomiting, abdominal pain, unusual fatigue) or severe genital/urinary infections. 3
• Practice daily genital hygiene to reduce infection risk. 3
• Inform all healthcare providers that you are taking dapagliflozin, especially before any surgical procedures. 7, 1