Dapagliflozin Can Replace Empagliflozin in This Clinical Scenario
Both dapagliflozin and empagliflozin are interchangeable for cardiovascular and renal protection in your 71-year-old patient with coronary artery disease, recent PCI, normal LVEF, and elevated NT-proBNP, as they demonstrate equivalent efficacy in reducing cardiovascular death and heart failure hospitalization across the full spectrum of heart failure. 1
Evidence Supporting Interchangeability
Equivalent Clinical Outcomes
Dapagliflozin and empagliflozin provide equivalent reductions in mortality and morbidity across the full spectrum of heart failure and should be considered interchangeable, with the choice guided by formulary availability and cost 1
Both agents carry Class I, Level A recommendations from the American College of Cardiology, American Heart Association, and Heart Failure Society of America for heart failure therapy, regardless of diabetes status 1
A prospective crossover study in 25 patients with stable chronic heart failure demonstrated that empagliflozin and dapagliflozin showed comparable effects on NT-proBNP levels and clinical outcomes, supporting their interchangeable use 2
Specific Relevance to Your Patient's Profile
Patients with heart failure and history of myocardial infarction face higher risk of disease progression, yet dapagliflozin consistently and safely reduces the risk of cardiovascular death or worsening heart failure regardless of previous MI 3
In the pooled DAPA-HF and DELIVER analysis, dapagliflozin reduced the primary outcome (cardiovascular death or worsening HF) by 17% in patients with previous MI (HR 0.83,95% CI 0.72-0.96), with consistent benefits on key secondary outcomes 3
The benefit of empagliflozin on cardiac outcomes is preserved across the wide range of baseline NT-proBNP evaluated in EMPEROR-Preserved, and the same holds true for dapagliflozin 4
Practical Prescribing Considerations
Dosing
Start dapagliflozin 10 mg once daily—this is the fixed dose for all cardiovascular and renal indications, with no titration required 1, 5
The standard dose is identical whether the patient has diabetes or not, and requires no adjustment based on blood pressure, heart rate, or potassium levels 1
Renal Function
Dapagliflozin can be initiated if eGFR ≥25 mL/min/1.73 m² for cardiovascular and renal protection 6, 5
If eGFR falls below 25 mL/min/1.73 m² during treatment, dapagliflozin 10 mg daily may be continued until dialysis is required 6
An acute, reversible eGFR dip of 2–5 mL/min/1.73 m² within the first 2–4 weeks is expected and should not prompt discontinuation 6
Medication Interactions
Continue ACE inhibitors or ARBs (candesartan in this case) unchanged when initiating dapagliflozin; more than 99% of DAPA-CKD participants were on renin-angiotensin-aldosterone system blockers, and the combination showed additive protection 6
Consider reducing concurrent diuretic doses at initiation to avoid excessive volume depletion, particularly in elderly patients 6
Safety Profile
Common Adverse Effects
Genital mycotic infections occur in approximately 6% of dapagliflozin users versus 1% with placebo; advise daily hygiene to reduce risk 6
Hypotension may occur in approximately 5.7% of patients, especially those with volume depletion 1
Critical Safety Precautions
Withhold dapagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis 6
Temporarily discontinue during acute illness with reduced oral intake, fever, vomiting, or diarrhea 6
Warn about euglycemic diabetic ketoacidosis and instruct patients to seek immediate care for unexplained malaise, nausea, vomiting, or abdominal pain even when blood glucose is normal 6
Monitoring After Initiation
Re-measure eGFR 1–2 weeks after starting dapagliflozin; the expected hemodynamic dip is reversible and does not indicate kidney injury 6
Re-assess volume status at follow-up, with particular attention to elderly patients or those on diuretics 6
Monitor for signs of volume depletion (hypotension, dizziness) and symptoms of heart failure progression 1
Common Pitfalls to Avoid
Do not discontinue dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m²; cardiovascular and renal benefits persist despite loss of glycemic efficacy 6
Do not stop dapagliflozin in response to the expected early eGFR dip; the change is hemodynamic and reversible, not indicative of kidney injury 6
Do not reduce the dapagliflozin dose below 10 mg for cardiovascular or renal indications, even at lower eGFR levels; all outcome trials used the fixed 10 mg dose 6