Can dapagliflozin be prescribed to an inpatient with type 2 diabetes (or heart failure with reduced ejection fraction or chronic kidney disease) who is euvolemic, has an estimated glomerular filtration rate ≥45 mL/min/1.73 m² (≥30 mL/min/1.73 m² for heart‑failure/CKD), and no acute illness predisposing to euglycemic ketoacidosis?

Inpatient Initiation of Dapagliflozin

Dapagliflozin can be safely initiated in hospitalized patients with type 2 diabetes, heart failure, or chronic kidney disease, provided they are hemodynamically stable, euvolemic, have an eGFR ≥25 mL/min/1.73 m², and are not acutely ill with conditions predisposing to ketoacidosis. 1

Evidence Supporting Inpatient Initiation

Safety and Tolerability Profile

• SGLT2 inhibitors demonstrate a robust safety profile in hospitalized patients, with minimal effects on blood pressure and no excess risk of symptomatic hypotension, even in patients with systolic blood pressure as low as 95 mmHg. 1

• Acute kidney injury rates are not increased with dapagliflozin initiation during hospitalization, even among patients with impaired baseline kidney function. 1

• Serious adverse events leading to drug discontinuation were numerically fewer with SGLT2 inhibitors than placebo in clinical trials. 1

Clinical Trial Evidence

• The DICTATE-AHF trial is specifically designed to assess early initiation of dapagliflozin within the first 24 hours of hospitalization for acute heart failure in patients with type 2 diabetes and eGFR ≥30 mL/min/1.73 m². 2

• The DAPA-ACT HF-TIMI 68 trial randomized 2,400 patients hospitalized with acute heart failure to dapagliflozin 10 mg versus placebo on hospital days 2–7, requiring patients to be stabilized with no increase in IV loop diuretics and no IV vasodilators or inotropes in the preceding 24 hours. 1

• The EMPULSE trial enrolled 530 patients hospitalized for acute heart failure on days 2–5, requiring stabilization with systolic blood pressure >100 mmHg, no IV vasodilators or increase in IV loop diuretics in 6 hours, and no IV inotropes in 24 hours. 1

Clinical Algorithm for Inpatient Initiation

Step 1: Confirm Eligibility Criteria

• Check eGFR: Must be ≥25 mL/min/1.73 m² for cardiovascular/renal protection indications (≥45 mL/min/1.73 m² if the primary goal is glycemic control). 3

• Assess volume status: Patient must be euvolemic; correct any volume depletion before initiating dapagliflozin. 3

• Verify hemodynamic stability: Ensure no IV vasodilators, inotropes, or escalating IV diuretics in the preceding 24 hours. 1

• Exclude acute illness predisposing to ketoacidosis: Do not initiate during acute illness with reduced oral intake, fever, vomiting, or diarrhea. 4

Step 2: Initiate Dapagliflozin

• Start dapagliflozin 10 mg orally once daily for heart failure or chronic kidney disease indications; no titration is required. 3

• For glycemic control in type 2 diabetes, start at 5 mg once daily and may increase to 10 mg once daily if additional glycemic control is needed. 3

Step 3: Adjust Concomitant Medications

• Reduce insulin doses by 20% if hemoglobin A1c <8.5% to mitigate hypoglycemia risk. 1

• Stop sulfonylureas if hemoglobin A1c <8.5%. 1

• Consider reducing concurrent diuretic doses to prevent excessive volume depletion, particularly in elderly patients or those on loop diuretics. 1, 4

• Continue ACE inhibitors or ARBs unchanged; do not withhold these agents when starting dapagliflozin. 1

Step 4: Monitor After Initiation

• Recheck eGFR within 1–2 weeks: An acute, reversible eGFR decline of 2–5 mL/min/1.73 m² is expected and should not prompt discontinuation. 4

• Monitor blood glucose closely for the first 2–4 weeks, especially if insulin or other glucose-lowering agents remain in use. 4

• Reassess volume status at follow-up, with particular attention to elderly patients or those on diuretics. 4

Key Advantages of Inpatient Initiation

• Failure to initiate SGLT2 inhibitors during hospitalization carries a >75% chance therapy will not be initiated within the next year, making the inpatient setting a critical opportunity for medication optimization. 1

• Multiple randomized trials support the effectiveness of in-hospital initiation for improving post-discharge medication use, without higher risk of medication discontinuation. 1

• Higher absolute risk reductions are expected with the higher clinical event rates following hospitalization for heart failure or acute kidney injury. 1

Safety Precautions and Patient Education

• Withhold dapagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis. 4, 3

• Counsel patients about genital mycotic infections, which occur in approximately 6% of dapagliflozin users versus 1% with placebo; emphasize daily hygiene. 4

• 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. 4

• Advise patients to temporarily withhold dapagliflozin during acute illness with reduced oral intake, fever, vomiting, or diarrhea. 4

• If dapagliflozin must be held temporarily, maintain a low-dose insulin regimen in insulin-requiring patients to prevent hyperglycemia. 4

Common Pitfalls to Avoid

• Do not discontinue dapagliflozin when eGFR falls below 45 mL/min/1.73 m²; cardiovascular and renal benefits persist even though glucose-lowering efficacy diminishes. 1, 4

• Do not stop the drug because of the expected initial eGFR dip in the first 2–4 weeks; this change is hemodynamic and reversible, not indicative of kidney injury. 4

• Do not defer initiation in favor of dose escalation of other guideline-directed medical therapies; dapagliflozin benefits are fully additive to effects of other therapies, and initiation should be prioritized above dose escalation. 1

• Do not withhold dapagliflozin due to concerns about hypoglycemia or diabetic ketoacidosis in patients without recurrent hypoglycemic or DKA events; rates of these complications were rare and not increased in clinical trials. 1

Contraindications to Inpatient Initiation

• eGFR <25 mL/min/1.73 m² (do not initiate, though may continue if already on treatment). 3

• Active dialysis. 5

• Type 1 diabetes mellitus (not indicated for glycemic control). 3

• Acute illness with reduced oral intake, fever, vomiting, or diarrhea. 4

• Hemodynamic instability requiring IV vasodilators, inotropes, or escalating IV diuretics. 1

• History of serious hypersensitivity reaction to dapagliflozin. 3