Version July 2025
Dosage guidance:
Clinical considerations: Correct hypovolemia, if present, prior to initiating therapy. May require a gradual dose reduction of insulin and/or insulin secretagogues (eg, sulfonylureas) to avoid hypoglycemia.
Diabetes mellitus, type 2, treatment: Children ≥10 years and Adolescents: Oral: Initial: 100 mg once daily; may increase to 300 mg if glycemic targets not achieved after an adequate trial (in pediatric trial, doses were assessed after 12 weeks, consistent with studies of other SGLT2 inhibitors) (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Diabetes mellitus, type 2:
Children ≥10 years and Adolescents: Oral:
eGFR ≥60 mL/minute/1.73 m2: No dosage adjustment necessary.
eGFR 30 to <60 mL/minute/1.73 m2: Maximum daily dose: 100 mg once daily.
eGFR <30 mL/minute/1.73 m2: Not recommended (likely to be ineffective).
Children ≥10 years and Adolescents: Oral:
Mild to moderate impairment: No dosage adjustment necessary.
Severe impairment: Use not recommended (has not been studied).
(For additional information see "Canagliflozin: Drug information")
Dosage guidance:
Clinical considerations: Correct hypovolemia, if present, prior to initiation. May require a gradual dose reduction of insulin and/or insulin secretagogues (sulfonylureas, meglitinides) to avoid hypoglycemia (Ref).
Diabetes mellitus, type 2, treatment:
Note: May be used as an adjunctive agent or alternative monotherapy for select patients, including those in whom initial therapy with lifestyle intervention and metformin failed, or who cannot take metformin. May be preferred in patients with atherosclerotic cardiovascular disease, heart failure, or diabetic kidney disease given demonstrated cardiovascular and renal benefits (Ref).
Hyperglycemia: Oral: Initial: 100 mg once daily prior to first meal of the day; may increase to 300 mg once daily after 4 to 12 weeks if needed to achieve glycemic goals (Ref).
Atherosclerotic cardiovascular disease: Oral: 100 or 300 mg once daily. Note: Risk reduction for major adverse cardiovascular events has been demonstrated in patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease (Ref).
Diabetic kidney disease: Oral: 100 mg once daily prior to the first meal of the day in patients with urinary albumin excretion >300 mg/day; no further dose titration is necessary for renal benefit. Note: Some experts also use this regimen off label in patients without severely increased albuminuria (eg, urinary albumin excretion ≤300 mg/day); benefits and harms may be more closely balanced due to smaller absolute benefit (Ref). Because sodium-glucose cotransporter 2 inhibitors have less glycemic benefit as eGFR declines, another agent may be needed to achieve glycemic goals (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function:
eGFR ≥60 mL/minute/1.73 m2: No dosage adjustment necessary.
eGFR 30 to <60 mL/minute/1.73 m2: 100 mg once daily.
eGFR <30 mL/minute/1.73 m2 with:
Urinary albumin excretion >300 mg/day: The manufacturer's labeling does not recommend initiation of therapy; however, patients previously established on canagliflozin may continue 100 mg once daily.
Urinary albumin excretion ≤300 mg/day: The manufacturer's labeling does not recommend initiation of therapy in patients without severely increased albuminuria. Canagliflozin should not be initiated in patients with an eGFR <25 to 30 mL/minute/1.73 m2; in patients previously established on canagliflozin, some experts continue use off label at a dose of 100 mg once daily (Ref).
Hemodialysis, intermittent (thrice weekly): Not dialyzable: Avoid use (Ref).
Peritoneal dialysis: Unlikely to be dialyzable (highly protein bound): Avoid use (Ref).
CRRT: Avoid use (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): Avoid use (Ref).
Mild-to-moderate impairment (Child-Pugh class A, B): No dosage adjustment necessary.
Severe impairment (Child-Pugh class C): Use not recommended (has not been studied).
Cases of acute kidney injury (AKI) have been reported in patients receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors (specifically canagliflozin and dapagliflozin), including cases that have required hospitalization and dialysis (Ref). While canagliflozin may cause reversible kidney-related adverse events (eg, increased serum creatinine, decreased estimated GFR [eGFR]) during the first weeks of therapy, an overall reduction in the risk of AKI and kidney-related serious adverse events was demonstrated in patients who received canagliflozin during the CREDENCE trial (Ref). As evidence mounts for the positive effects of these agents on long-term kidney outcomes and a possible reduction in the incidence of AKI, clinicians will need to weigh the potential risk of AKI with the overall benefit of these agents (Ref).
Mechanism: Dose-related; related to the pharmacologic action. SGLT2 inhibition causes increased excretion of glucose and sodium, thereby resulting in an osmotic diuresis; the subsequent hyperosmolarity and volume contraction may increase the risk of AKI. Glucose in the urine may be reabsorbed by glucose transporters in exchange for uric acid, resulting in uricosuria and associated crystal-dependent and -independent damage. Lastly, SGLT2 inhibition results in increased fructose generation; the metabolism of fructose may lead to increased uric acid, oxidative stress, and the release of chemokines, thus causing local tubular injury and inflammation (Ref).
On the other hand, canagliflozin may confer some protection against AKI. Proposed mechanisms based on animal studies regarding the beneficial effects of SGLT2 inhibition on AKI include improved kidney cortical oxygen tension, tubular cell integrity, and tubular albumin reabsorption (Ref); in addition, improved cardiac function may be related to improved kidney function (Ref).
Onset: Varied. With regard to decreases in eGFR, in the CREDENCE study, administration of canagliflozin caused early decline in eGFR which tended to stabilize after ~4 weeks (Ref).
Risk factors:
• Preexisting risk factors for AKI (eg, hypovolemia, chronic kidney insufficiency, heart failure, use of concomitant medications [eg, diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs]).
An increased incidence of bone fracture was reported in the CANVAS clinical trial program (comprised of the CANVAS and CANVAS-R trials). The similarly designed CANVAS-R trial (n=5,812) did not show an increased fracture risk when analyzed separately from the CANVAS trial (n=4,330); reasons for these conflicting data within the CANVAS program are not clear (Ref). Meta-analyses and pooled analyses (excluding CANVAS trial) have not demonstrated a risk of increased fractures (Ref), and fracture risk was not increased in the CREDENCE trial (Ref).
Onset: Delayed; fractures were observed as early as 12 weeks after treatment initiation in the CANVAS trial (Ref).
Canagliflozin may cause increased serum potassium. In the CREDENCE trial, use of canagliflozin 100 mg daily in patients with a mean eGFR ~56 ± 18 mL/minute/1.73 m2 did not increase the risk of hyperkalemia compared to placebo (Ref).
Risk factors:
• Impaired kidney function (Ref)
• Higher doses (eg, 300 mg daily) (Ref)
• Concomitant use of potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers (Ref)
Hypersensitivity reactions, including angioedema, urticaria, anaphylaxis and skin rash, have been reported in patients receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors.
Mechanism: Not clearly established. Multiple potential mechanisms including:
• Non–dose-related; immunologic: IgE-mediated or direct mast cell stimulation (Ref)
• Dose-related; related to the pharmacologic action: Elevated levels of bradykinin (Ref)
Onset: Varied; generally occurs hours to days after treatment initiation.
Risk factors:
• Prior serious hypersensitivity reaction to canagliflozin
• Cross-reactivity: Although other SGLT2 have also been associated with hypersensitivity reactions, there are no reports of cross-reactions between these agents
Sodium-glucose cotransporter 2 (SGLT2) inhibitors may cause events consistent with hypovolemia, including symptomatic hypotension, syncope, and dehydration (Ref). Overall, a reduction in both systolic and diastolic blood pressure (-4 to -6/-1 to -2 mm Hg) has been documented for SGLT2 inhibitors (Ref).
Mechanism: Dose-related; related to the pharmacologic action. Inhibition of SGLT2 causes an increase in the excretion of glucose and sodium, thereby resulting in an osmotic diuresis and intravascular volume contraction (Ref).
Onset: Varied; timing is impacted by volume status (eg, reduced oral intake, fluid losses) and concomitant use of medications known to impact volume status or blood pressure (eg, diuretics, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs]) (Ref).
Risk factors:
• Kidney impairment (ie, eGFR <60 mL/minute/1.73 m2)
• Older adults
• Concomitant use of antihypertensives (eg, diuretics, ACE inhibitors, ARBs)
• Preexisting low systolic blood pressure
• Reduced oral intake or increased fluid losses
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, including canagliflozin, have been associated with an increased risk of genitourinary fungal infection (eg, vulvovaginal mycotic infection, vulvovaginal candidiasis, vulvovaginitis, candida balanitis, balanoposthitis) and, to a lesser extent, urinary tract infections, including severe cases of urinary tract infection with sepsis and pyelonephritis requiring hospitalization (Ref). These events are generally mild in intensity, respond to treatment, and do not lead to discontinuation (Ref). Additionally, rare but serious and potentially fatal cases of necrotizing fasciitis (perineum) (ie, Fournier gangrene) have been reported (Ref).
Mechanism: Dose-related; related to the pharmacologic action. Patients with diabetes are more prone to urinary tract and genital infections, potentially due to glucosuria-induced bacterial growth, increased adherence of bacteria to the uroepithelium, and altered immune function (Ref). Because SGLT2 inhibitors increase urinary excretion of glucose, it has been hypothesized that these agents further increase the risk of these infections (Ref).
Onset: Varied; available literature suggests that the increased risk of genital infection may be apparent within the first month of SGLT2 inhibitor therapy and remain elevated throughout the course of therapy (Ref); Fournier gangrene may have an average onset of 9 months (range: 5 days to 49 months) (Ref).
Risk factors:
• Diabetes and/or uncontrolled hyperglycemia (Ref)
• Older adults
• Prior history of these types of infections (Ref)
• Females (Ref)
• Uncircumcised males (increased risk for genital infections) (Ref)
Cases of ketoacidosis have been reported in patients with type 1 and type 2 diabetes mellitus receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors, including canagliflozin (Ref).
In some cases, patients have presented with normal or only modestly elevated blood glucose (<250 mg/dL), which can lead to misdiagnosis, prevent timely initiation of treatment, and negatively influence duration of illness (Ref). In addition, SGLT2 inhibitor-mediated increases in urinary glucose loss may persist for several days after discontinuation which may impact duration of illness in patients who develop ketoacidosis (Ref).
Mechanism: Dose-related; related to the pharmacologic action. Several mechanisms have been proposed centered on increased ketone body production and reabsorption. Because SGLT2 inhibitors decrease urinary excretion of ketone bodies and decrease blood glucose in an insulin-independent manner, plasma glucose and urine ketone concentrations may be lower than what is typically expected in classic presentations of diabetic ketoacidosis (Ref).
Onset: Varied; timing is often impacted by the onset of metabolically stressful events (eg, surgery, extensive exercise, myocardial infarction [MI], stroke, severe infections, prolonged fasting) (Ref).
Risk factors:
• Patients with diabetes who are insulin deficient (eg, latent autoimmune diabetes in adults, type 1 diabetes, or some patients with long-standing type 2 diabetes) (Ref)
• Metabolically stressful events (eg, surgery, extensive exercise, MI, stroke, severe infections, prolonged fasting) (Ref)
• Presence of other risk factors that may predispose a patient to ketoacidosis (eg, pancreatic insulin deficiency, dose decreases or missed doses of insulin, caloric restriction, ketogenic diet, alcohol abuse, acute febrile illness, volume depletion, surgery, or any other extreme stress event)
• History of pancreatitis or pancreatic surgery
There are conflicting data involving the risk of lower limb amputations with sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy; canagliflozin, specifically, has been of concern (Ref). Canagliflozin was associated with almost a 2-fold increased risk of lower limb amputations compared to placebo in the CANVAS and CANVAS-R trials, which included patients with type 2 diabetes at high cardiovascular risk (Ref). However, no difference between placebo and canagliflozin was observed in the CREDENCE trial with regards to amputation risk; although the trial was terminated early due to kidney and cardiovascular benefit (Ref).
During the CANVAS and CANVAS-R trials, amputations observed involved the toe, midfoot, or less frequently the leg (above or below the knee); lower limb infections, gangrene, and diabetic foot ulcers were the most common precipitating factors (Ref).
Mechanism: Not clearly established (Ref).
Risk factors:
• Preexisting risk factors for amputation (eg, prior amputation, peripheral vascular disease, neuropathy, diabetic foot ulcers, cardiovascular disease) (Ref)
• Age ≥65 years (Ref)
• Lack of preventative foot care
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults.
>10%: Infection: Genitourinary fungal infection (females: 11% to 12%; males: 4%; patients who developed infections were more likely to experience recurrence) (table 1)
|
Drug (Canagliflozin) |
Placebo |
Population |
Dose |
Indication |
|---|---|---|---|---|
|
12% |
3% |
Females |
300 mg/day |
Glycemic control |
|
11% |
3% |
Females |
100 mg/day |
Glycemic control |
|
4% |
0.7% |
Males |
300 mg/day |
Glycemic control |
|
4% |
0.7% |
Males |
100 mg/day |
Glycemic control |
1% to 10%:
Cardiovascular: Hypotension (3%) (table 2)
|
Drug (Canagliflozin) |
Placebo |
Dosage Form |
Indication |
Comments |
|---|---|---|---|---|
|
3% |
2% |
100 mg/day |
Reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure |
In patients with type 2 diabetes mellitus and diabetic nephropathy with albuminuria |
Endocrine & metabolic: Hypoglycemia (4%), hypovolemia (2% to 3%) (table 3), increased serum potassium (eGFR 45 to <60 mL/minute/1.73 m2: >5.4 mEq/L: 5% to 9%; ≥6.5 mEq/L: 1%) (table 4), increased thirst (2% to 3%)
|
Drug (Canagliflozin) |
Placebo and Active Comparator |
Dose |
Indication |
|---|---|---|---|
|
3% |
2% |
300 mg/day |
Glycemic control |
|
2% |
2% |
100 mg/day |
Glycemic control |
|
Drug (Canagliflozin) |
Placebo |
Dosage Form |
Indication |
Comments |
|---|---|---|---|---|
|
9% |
5% |
300 mg/day |
Glycemic control |
Patient population: eGFR 45 to <60 mL/minute/1.73 m2; increased serum potassium defined as increases in serum potassium to >5.4 mEq/L and 15% above baseline |
|
5% |
5% |
100 mg/day |
Glycemic control |
Patient population: eGFR 45 to <60 mL/minute/1.73 m2; increased serum potassium defined as increases in serum potassium to >5.4 mEq/L and 15% above baseline |
|
1% |
0.4% |
300 mg/day |
Glycemic control |
Patient population: eGFR 45 to <60 mL/minute/1.73 m2; increased serum potassium defined as increases in serum potassium to ≥6.5 mEq/L |
|
0% |
0.4% |
100 mg/day |
Glycemic control |
Patient population: eGFR 45 to <60 mL/minute/1.73 m2; increased serum potassium defined as increases in serum potassium to ≥6.5 mEq/L |
Gastrointestinal: Abdominal pain (2%), constipation (2%)
Genitourinary: Increased urine output (5%), urinary tract infection (6%), vulvovaginal pruritus (2% to 3%)
Hematologic & oncologic: Increased hemoglobin (3% to 4%)
Hypersensitivity: Hypersensitivity reaction (4%; severe hypersensitivity reaction: <1%)
Nervous system: Asthenia (1%), falling (2%)
Neuromuscular & skeletal: Limb injury (toe, foot, lower limb amputations: 2% to 4%)
<1%:
Dermatologic: Skin photosensitivity
Gastrointestinal: Pancreatitis
Genitourinary: Phimosis
Frequency not defined: Endocrine & metabolic: Hypercholesterolemia (non-HDL), increased LDL cholesterol
Postmarketing:
Dermatologic: Pruritus (Vasapollo 2018)
Endocrine & metabolic: Hypercalcemia (Marsi 2021), ketoacidosis (Sloan 2018)
Genitourinary: Urinary tract infection with sepsis (Gupta 2018)
Hypersensitivity: Anaphylaxis, angioedema
Infection: Necrotizing fasciitis (perineum) (Elbeddini 2020)
Neuromuscular & skeletal: Bone fracture (Zhou 2019), decreased bone mineral density (Fralick 2019)
Renal: Acute kidney injury (Phadke 2020), decreased estimated GFR (eGFR) (FDA 2016), Fanconi syndrome (Khan 2019), increased serum creatinine (FDA 2016), pyelonephritis (Gupta 2018)
Serious hypersensitivity (eg, anaphylaxis, angioedema) to canagliflozin or any component of the formulation.
Disease-related concerns:
• Bariatric surgery: Presurgical assessment of the indication for use, symptoms, and goals of therapy should be documented to enable postsurgical assessment. Several case reports indicate increased risk of euglycemic diabetic ketoacidosis (DKA) with SGLT2 inhibitors after bariatric surgery; precipitating factors may include decreased caloric intake, decreased carbohydrate diet, dehydration, and/or decreased insulin dose (Iqbal 2020; Kapila 2021; Morace 2024; Smith 2021). Also, bariatric surgery may improve glycemic control, allowing discontinuation of SGLT2 inhibitors (Gokhare Viswanath 2023). Providers should weigh the risks and benefits of SGLT2 inhibitor use and minimize precipitating factors for euglycemic DKA before using SGLT2 inhibitors postoperatively (Gokhare Viswanath 2023).
• Infection, acute: Discontinue therapy if any of the following occur: signs and symptoms of new infection (including osteomyelitis), new pain or tenderness, or sores/ulcers involving the lower limbs (FDA Safety Communication 2017).
• Renal impairment: Glycemic efficacy may be decreased in renal impairment. Dosage adjustment may be required, see "Dosing: Altered Kidney Function" for more information.
Special populations:
• Older adult: Patients ≥65 years of age may have an increased risk of symptoms related to intravascular volume depletion (eg, hypotension, orthostatic hypotension, dizziness, syncope, and dehydration) during therapy, especially with the 300 mg dose; patients ≥75 years of age may experience a more pronounced risk. HbA1c reductions may be less in patients >65 years of age compared to younger patients.
Other warnings/precautions:
• Appropriate use: Not for use in patients with diabetic ketoacidosis or for glycemic control in patients with type 1 diabetes mellitus.
• Hospitalized patients: Use of SGLT2 inhibitors is not routinely recommended for glycemic control in hospitalized patients (ADA 2023).
• Surgical procedures: Consider temporary discontinuation of therapy at least 3 days prior to surgery; ensure risk factors for ketoacidosis are resolved prior to reinitiating therapy.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Invokana: 100 mg, 300 mg
No
Tablets (Invokana Oral)
100 mg (per each): $23.94
300 mg (per each): $23.94
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Invokana: 100 mg, 300 mg
Oral: May be administered with or without food; however, it is recommended to be administered prior to the first meal of the day (may reduce postprandial hyperglycemia due to delayed intestinal glucose absorption).
Surgical procedures: Withhold canagliflozin for at least 3 days, if possible, prior to major surgery or procedures which require prolonged fasting; therapy may resume when patient is stable and has resumed oral intake.
Oral: May be administered with or without food. It is recommended to take before the first meal of the day (may reduce postprandial hyperglycemia via delayed intestinal glucose absorption).
Bariatric surgery: Hold SGLT2 inhibitors for at least 72 hours prior to surgery (Ref). Clinicians should weigh risks and benefits of restarting SGLT2 inhibitors given increased risk of delayed onset euglycemic diabetic ketoacidosis after bariatric surgery (Ref).
Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).
An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/204042s041s042lbl.pdf#page=48, must be dispensed with this medication.
Adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus (FDA approved in ages ≥10 years and adults); risk reduction of major cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke) in patients with type 2 diabetes mellitus and established cardiovascular disease (FDA approved in adults); risk reduction of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in patients with type 2 diabetes mellitus and diabetic nephropathy with albuminuria >300 mg/day (FDA approved in adults).
Beers Criteria: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are identified in the Beers Criteria as potentially inappropriate medications to be used with caution in patients 65 years and older due to increased risk of urogenital infections, especially in women during the first month of use. In addition, a higher risk of euglycemic diabetic ketoacidosis has been observed in older adults (Beers Criteria [AGS 2023]).
Substrate of CYP3A4 (Minor), MRP2, P-glycoprotein (Minor), UGT1A9, UGT2B4; Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
Alpha-Lipoic Acid: May increase hypoglycemic effects of Antidiabetic Agents. Risk C: Monitor
Androgens: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Beta-Blockers (Beta1 Selective): May increase adverse/toxic effects of Antidiabetic Agents. Specifically, beta-blockers may mask the hypoglycemic symptoms of antidiabetic agents. Risk C: Monitor
Beta-Blockers (Nonselective): May increase hypoglycemic effects of Antidiabetic Agents. Beta-Blockers (Nonselective) may increase adverse/toxic effects of Antidiabetic Agents. Specifically, beta-blockers may mask the hypoglycemic symptoms of antidiabetic agents. Risk C: Monitor
Bortezomib: May increase therapeutic effects of Antidiabetic Agents. Bortezomib may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Digoxin: Canagliflozin may increase serum concentration of Digoxin. Risk C: Monitor
Direct Acting Antiviral Agents (HCV): May increase hypoglycemic effects of Antidiabetic Agents. Risk C: Monitor
Etilefrine: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Fosphenytoin: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Guanethidine: May increase hypoglycemic effects of Antidiabetic Agents. Risk C: Monitor
Hyperglycemia-Associated Agents: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Hypoglycemia-Associated Agents: Antidiabetic Agents may increase hypoglycemic effects of Hypoglycemia-Associated Agents. Risk C: Monitor
Insulin: Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors may increase hypoglycemic effects of Insulin. Management: Consider a decrease in insulin dose when initiating therapy with a sodium-glucose cotransporter 2 inhibitor and monitor patients for hypoglycemia. Risk D: Consider Therapy Modification
Lithium: Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors may decrease serum concentration of Lithium. Risk C: Monitor
Loop Diuretics: Canagliflozin may increase hypotensive effects of Loop Diuretics. Risk C: Monitor
Maitake: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Monoamine Oxidase Inhibitors: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Nirmatrelvir and Ritonavir: May decrease serum concentration of Canagliflozin. Risk C: Monitor
Pegvisomant: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
PHENobarbital: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Phenytoin: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Primidone: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Prothionamide: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Quinolones: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Quinolones may decrease therapeutic effects of Agents with Blood Glucose Lowering Effects. Specifically, if an agent is being used to treat diabetes, loss of blood sugar control may occur with quinolone use. Risk C: Monitor
Reproterol: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
RifAMPin: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Ritodrine: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Ritonavir: May decrease serum concentration of Canagliflozin. Management: Consider increasing canagliflozin dose to 200 mg/day in patients tolerating 100 mg/day. A further increase to 300 mg/day can be considered in patients with an estimated glomerular filtration rate (GFR) of 60 mL/min/1.73 m2 or greater. Risk D: Consider Therapy Modification
Salicylates: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Selective Serotonin Reuptake Inhibitor: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Sulfonylureas: Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors may increase hypoglycemic effects of Sulfonylureas. Management: Consider a decrease in sulfonylurea dose when initiating therapy with a sodium-glucose cotransporter 2 (SGLT2) inhibitor and monitor patients for hypoglycemia. Risk D: Consider Therapy Modification
Thiazide and Thiazide-Like Diuretics: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Individualized medical nutrition therapy (MNT) based on ADA recommendations is an integral part of therapy.
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are not recommended for patients with type 2 diabetes mellitus planning to become pregnant. Patients who could become pregnant should use effective contraception during therapy. Transition to a preferred therapy should be initiated prior to conception and contraception should be continued until glycemic control is achieved (ADA 2023; Alexopoulos 2019; Egan 2020)
Due to adverse effects on renal development observed in animal studies, the manufacturer does not recommend use of canagliflozin during the second and third trimesters of pregnancy.
Poorly controlled diabetes during pregnancy can be associated with an increased risk of adverse maternal and fetal outcomes, including diabetic ketoacidosis, preeclampsia, spontaneous abortion, preterm delivery, delivery complications, major malformations, stillbirth, and macrosomia. To prevent adverse outcomes, prior to conception and throughout pregnancy, maternal blood glucose and HbA1c should be kept as close to target goals as possible but without causing significant hypoglycemia (ADA 2023; Blumer 2013).
Agents other than canagliflozin are currently recommended to treat diabetes mellitus in pregnancy (ADA 2023).
Blood glucose; kidney function (baseline and as clinically indicated); volume status (eg, weight, BP, hematocrit, electrolytes; baseline and periodically during treatment) and signs/symptoms of hypotension; monitor for genital mycotic infections and urinary tract infection; monitor for signs/symptoms of necrotizing fasciitis (eg, fever and malaise along with genital or perianal pain, tenderness, erythema, swelling), hypersensitivity reactions; monitor for signs/symptoms of ketoacidosis (eg, nausea/vomiting, abdominal pain, malaise, shortness of breath); if present, monitor ketones regardless of blood glucose concentrations.
HbA1c: Monitor every 3 months; some recommendations suggest at least twice yearly may be considered in patients who have stable glycemic control and are meeting treatment goals (Ref). Note: In patients prone to glycemic variability (eg, patients with insulin deficiency), or in patients whose HbA1c is discordant with serum glucose levels or symptoms, consider evaluating HbA1c in combination with blood glucose levels and/or a glucose management indicator (Ref).
Plasma Blood Glucose and HbA1c Goals for Patients with Diabetes: Note: Postprandial blood glucose should be measured when there is a discrepancy between preprandial blood glucose concentrations and HbA1c values and to help assess glycemia for patients who receive basal/bolus or pump regimens. It is usually drawn 1 to 2 hours after starting a meal and is considered to be the "peak."
Children and Adolescents:
Blood glucose:
Type 2 diabetes:
Fasting plasma glucose: 70 to 110 mg/dL (SI: 3.9 to 6.1 mmol/L) (Ref).
Postprandial glucose: 70 to 140 mg/dL (SI: 3.9 to 7.8 mmol/L) (Ref).
HbA1c: <7%; target should be individualized; a more stringent goal (<6.5%) may be reasonable if it can be achieved without significant hypoglycemia and is reasonable in many patients with type 2 diabetes; less aggressive goals (<7.5%) may be appropriate in patients who are at increased risk of hypoglycemia (Ref).
By inhibiting sodium-glucose cotransporter 2 (SGLT2) in the proximal renal tubules, canagliflozin reduces reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose (RTG). SGLT2 is the main site of filtered glucose reabsorption; reduction of filtered glucose reabsorption and lowering of RTG result in increased urinary excretion of glucose, thereby reducing plasma glucose concentrations.
Onset of action: Within 24 hours (dose-dependent)
Duration of action: Suppression of the renal threshold for glucose (RTG) occurs throughout the 24-hour dosing interval; maximal RTG suppression occurred with the 300 mg dose (RTG decreased from baseline of ~240 mg/dL to a mean of 70 to 90 mg/dL over 24 hours).
Absorption: Not affected by food; however, administration prior to the first meal of the day may delay intestinal glucose absorption, thereby reducing postprandial hyperglycemia.
Distribution: Vdss: 83.5 L (intravenous administration)
Protein binding: 99% mainly to albumin
Metabolism: Major metabolism through O-glucuronidation by UGT1A9 and UGT2B4 to two inactive metabolites; minor oxidative metabolism (~7%) through CYP3A4.
Bioavailability: ~65%
Half-life elimination: Apparent terminal half-life: 100 mg dose: 10.6 hours; 300 mg dose: 13.1 hours
Time to peak, plasma: 1 to 2 hours
Excretion: Feces (41.5% as unchanged drug, 7% as hydroxylated metabolite, 3.2% as O-glucuronide metabolite); urine ~33% (30.5% as O-glucuronide metabolites, <1% as unchanged drug)
