Is it okay to give dapagliflozin (Forxiga) to a patient with leucocytosis (elevated white blood cell count) and type 2 diabetes?

Dapagliflozin Use in Patients with Leucocytosis

Yes, leucocytosis alone is not a contraindication to dapagliflozin, but you must first identify and address the underlying cause of the elevated white blood cell count before initiating therapy.

Critical Assessment Required Before Initiation

The presence of leucocytosis (WBC 29,000) demands immediate investigation to rule out active infection, which would temporarily contraindicate dapagliflozin use. The key distinction is whether this represents:

• Active infection requiring treatment - Hold dapagliflozin until resolved 1
• Chronic inflammatory state or stress response - May proceed with caution after evaluation
• Hematologic disorder - Requires specialist input but not an absolute contraindication

When to Withhold Dapagliflozin

Do not initiate dapagliflozin if the leucocytosis indicates:

• Active urinary tract infection, as SGLT2 inhibitors increase UTI risk and can precipitate sepsis in patients with bladder outlet obstruction 2
• Systemic infection requiring hospitalization, as intercurrent illness increases risk of euglycemic diabetic ketoacidosis and volume depletion 1
• Fever, vomiting, or diarrhea accompanying the leucocytosis 1
• Any acute illness with reduced oral intake 1

When Dapagliflozin May Be Appropriate

Once active infection is excluded, dapagliflozin remains indicated if the patient has:

• Type 2 diabetes with cardiovascular disease or high cardiovascular risk, where dapagliflozin reduces cardiovascular events 3
• Heart failure, where dapagliflozin lowers hospitalization risk 3
• Chronic kidney disease with eGFR ≥25 mL/min/1.73 m² and albuminuria, where dapagliflozin reduces progression 3

Specific Infection-Related Risks to Monitor

Genital mycotic infections occur in approximately 6% of patients on SGLT2 inhibitors versus 1% on placebo, and leucocytosis may indicate increased susceptibility 1

Urinary tract infections are more common with dapagliflozin, and the drug should be used with extreme caution in patients with recurrent UTIs or bladder outlet obstruction 2

Euglycemic diabetic ketoacidosis can occur even with normal glucose levels during intercurrent illness, presenting with nonspecific symptoms like malaise and nausea 1

Clinical Algorithm for Decision-Making

1. Investigate leucocytosis immediately: Check urinalysis, blood cultures if febrile, chest X-ray if respiratory symptoms present
2. If active infection identified: Treat infection first, hold dapagliflozin until resolved and WBC normalizing 1
3. If no active infection: Assess volume status, correct any depletion before starting dapagliflozin 1
4. Check renal function: Ensure eGFR ≥25 mL/min/1.73 m² for cardiovascular/renal indications, or ≥45 mL/min/1.73 m² for glycemic control 1
5. Initiate at 10 mg once daily if cardiovascular or renal protection is the goal 1
6. Recheck within 1-2 weeks: Monitor for infection development, volume status, and renal function 1

Essential Patient Education

Counsel patients to stop dapagliflozin immediately and contact you if they develop fever, dysuria, genital symptoms, or any signs of infection 1. This is particularly critical given the baseline leucocytosis suggesting potential immune activation or infection susceptibility.

Common Pitfall to Avoid

Do not assume leucocytosis is simply "stress-related" without thorough evaluation. The case report of E. coli septicemia in a patient on dapagliflozin with unrecognized bladder outlet obstruction demonstrates the serious consequences of overlooking infection risk 2. Similarly, the report of acute tubular necrosis requiring 4 weeks of dialysis emphasizes the need for careful monitoring 4.