Can dapagliflozin be given to an adult patient with chronic kidney disease (CKD) and impaired renal function, as indicated by a creatinine level of 3.8?

Can Dapagliflozin Be Given in CKD with Creatinine 3.8?

Yes, dapagliflozin can be initiated at 10 mg daily if the eGFR is ≥25 mL/min/1.73 m² for cardiovascular and renal protection, but you must first calculate the eGFR from the creatinine of 3.8 mg/dL to determine eligibility. 1

Critical First Step: Calculate eGFR

A serum creatinine of 3.8 mg/dL typically corresponds to an eGFR of approximately 15-25 mL/min/1.73 m² in most adults, which places this patient at the threshold or below the recommended initiation cutoff. 1

• If eGFR ≥25 mL/min/1.73 m²: Dapagliflozin 10 mg daily can be initiated for cardiovascular and renal protection. 1
• If eGFR 20-24 mL/min/1.73 m²: Initiation is generally not recommended by most guidelines, though KDIGO 2024 suggests SGLT2 inhibitors can be used down to eGFR ≥20 mL/min/1.73 m² in select cases with significant albuminuria (UACR ≥200 mg/g). 1
• If eGFR <20 mL/min/1.73 m²: Do not initiate dapagliflozin. 1

Indications at This Level of Renal Function

Dapagliflozin at this stage is NOT for glycemic control—it is for cardiovascular and renal protection. 1, 2

• The glucose-lowering effect is minimal or absent when eGFR <45 mL/min/1.73 m², but the cardiovascular and renal protective benefits remain intact down to eGFR 25 mL/min/1.73 m². 1, 3
• The DAPA-CKD trial demonstrated a 39% reduction in the composite outcome of sustained eGFR decline ≥50%, end-stage kidney disease, or renal/cardiovascular death in patients with eGFR 25-75 mL/min/1.73 m². 4, 5
• In the subgroup with stage 4 CKD (eGFR <30 mL/min/1.73 m²), dapagliflozin reduced the primary endpoint by 27% with no increased safety concerns. 4

Dosing Algorithm

Fixed dose of 10 mg once daily—no titration required or recommended. 1, 2

• This is the dose used in all major cardiovascular and renal outcome trials. 1, 3
• Do not reduce the dose based on eGFR alone, as the 10 mg dose provides the proven cardiovascular and renal benefits. 1, 3

Key Monitoring and Safety Considerations

Expected Initial eGFR Dip

• An acute, reversible decline in eGFR of 3-5 mL/min/1.73 m² within the first 2-4 weeks is expected and is not an indication to discontinue therapy. 6, 4
• Patients experiencing this initial eGFR dip actually had better long-term renal outcomes with slower subsequent eGFR decline (-1.58 vs -2.44 mL/min/1.73 m²/year). 6
• Recheck eGFR within 1-2 weeks after initiation to assess for excessive decline (>30% from baseline) in the context of volume depletion. 3

Volume Status Assessment

• Before initiating dapagliflozin, assess and correct volume depletion. 1, 2
• Consider reducing concurrent diuretic doses proactively to prevent excessive intravascular volume contraction, especially in elderly patients or those on loop diuretics. 3, 7
• If eGFR decreases >30% from baseline AND there are signs of hypovolemia, reduce diuretic doses first before considering dapagliflozin adjustment. 3

Sick Day Rules

• Withhold dapagliflozin during acute illness, particularly with fever, vomiting, diarrhea, or reduced oral intake. 1, 3
• Educate the patient to stop dapagliflozin immediately when sick and contact their healthcare provider. 3
• Monitor for euglycemic diabetic ketoacidosis, which can occur even with normal blood glucose levels. 3, 2

Continuation if eGFR Falls Below 25 mL/min/1.73 m²

• If already on dapagliflozin and eGFR falls below 25 mL/min/1.73 m², continue 10 mg daily until dialysis is initiated. 1
• This practice point reflects the ongoing benefit of dapagliflozin even as kidney function declines. 1

Common Pitfalls to Avoid

• Do not discontinue 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. 3
• Do not use creatinine alone to make the decision—always calculate eGFR using the CKD-EPI equation or equivalent. 1
• Do not reduce the dose to 5 mg for renal protection—the 10 mg dose is required for cardiovascular and renal benefits. 1, 2
• Do not forget to assess albuminuria (UACR)—the strongest evidence for benefit exists in patients with UACR ≥200 mg/g. 1

Additional Safety Monitoring

• Monitor for genital mycotic infections (occurs in ~6% of patients vs 1% on placebo) and educate about daily hygiene measures. 3, 7
• Assess for urinary tract infections, which may require temporary discontinuation. 3
• Withhold dapagliflozin at least 3 days before major surgery or procedures with prolonged fasting to prevent postoperative ketoacidosis. 1, 2