Version July 2025
Dosage guidance:
Clinical considerations: Correct hypovolemia, if present, prior to initiating therapy. Patients may require a gradual dose reduction of insulin and/or insulin secretagogues (sulfonylureas, meglitinides) to reduce the risk of hypoglycemia when used in combination (Ref).
Chronic kidney disease (adjunctive agent):
Note: Used to reduce the risk of chronic kidney disease progression in patients with persistent proteinuria (eg, urine albumin-to-creatinine ratio [UACR] >300 mg/g) despite receiving optimized treatment with (or having an intolerance to) an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. Benefits were consistently demonstrated in patients with or without type 2 diabetes mellitus (Ref). For patients with type 2 diabetes, some experts also use this regimen with lower levels of urine albumin excretion (eg, UACR ≤300 mg/g); benefits and harms may be more closely balanced due to smaller absolute benefit (Ref).
Oral: 10 mg once daily (Ref).
Diabetes mellitus, type 2, treatment:
Note: May be used as an adjunctive agent or alternative monotherapy for patients in whom initial therapy with lifestyle intervention and metformin failed or those who cannot take metformin. May be preferred in patients with atherosclerotic cardiovascular disease (ASCVD), heart failure, or diabetic kidney disease given demonstrated cardiovascular and renal benefits (Ref).
Hyperglycemia: Oral: Initial: 5 mg once daily; may increase to 10 mg once daily after 4 to 12 weeks if needed to achieve glycemic goals (Ref).
Heart failure: Note: In patients with type 2 diabetes mellitus and established ASCVD, multiple risk factors for ASCVD, or heart failure with reduced ejection fraction, dapagliflozin has been shown to reduce the risk of heart failure hospitalization (Ref). In patients with type 2 diabetes mellitus and heart failure with reduced ejection fraction, dapagliflozin has also been shown to reduce the risk of cardiovascular death (Ref).
Oral: 10 mg once daily (Ref).
Diabetic kidney disease: Note: Studies showing renal benefit were conducted in patients with severely increased albuminuria (eg, urinary albumin excretion >300 mg/day) (Ref). Some experts also use dapagliflozin in patients without severely increased albuminuria; benefits and harms may be more closely balanced due to smaller absolute benefit (Ref). Because SGLT2 inhibitors have less glycemic benefit as eGFR declines, another agent may be needed to achieve glycemic goals (Ref).
Oral: 10 mg once daily (Ref).
Heart failure:
Note: Should be considered for use in combination with other evidence-based therapies as part of an optimal medical regimen for heart failure (Ref). Benefits were consistently demonstrated in patients with or without type 2 diabetes, regardless of ejection fraction (Ref).
Oral: 10 mg once daily (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 Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function:
eGFR ≥45 mL/minute/1.73 m2: No dosage adjustment necessary.
eGFR 25 to <45 mL/minute/1.73 m2:
Chronic kidney disease: No dosage adjustment necessary.
Diabetes mellitus, type 2:
Hyperglycemia: The US manufacturer does not recommend use; recommendations regarding indicated level of eGFR for initiation or continued use may vary in other countries (Ref).
Heart failure: No dosage adjustment necessary.
Diabetic kidney disease: No dosage adjustment necessary.
Heart failure: No dosage adjustment necessary.
eGFR <25 mL/minute/1.73 m2:
Chronic kidney disease: The manufacturer's labeling does not recommend initiation of therapy; however, patients previously established on dapagliflozin may continue 10 mg once daily.
Diabetes mellitus, type 2:
Hyperglycemia: The US manufacturer does not recommend use.
Heart failure: The manufacturer's labeling does not recommend initiation of therapy; however, patients previously established on dapagliflozin may continue 10 mg once daily.
Diabetic kidney disease: The manufacturer's labeling does not recommend initiation of therapy; however, patients previously established on dapagliflozin may continue 10 mg once daily.
Heart failure: The manufacturer's labeling does not recommend initiation of therapy; however, patients previously established on dapagliflozin may continue 10 mg once daily.
Hemodialysis, intermittent (thrice weekly): Unlikely to be significantly dialyzable (highly protein bound): Avoid use (Ref).
Peritoneal dialysis: Unlikely to be significantly dialyzable (highly protein bound): Avoid use (Ref).
CRRT: Avoid use (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): Avoid use (Ref).
No dosage adjustment necessary; use caution if initiating in severe impairment (has not been studied).
Refer to adult dosing.
(For additional information see "Dapagliflozin: Pediatric drug information")
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: 5 mg once daily; may increase to 10 mg once daily if glycemic targets not achieved after an adequate trial (in pediatric trial, doses were assessed after 12 weeks) (Ref).
Diabetes mellitus, type 2: Children ≥10 years and Adolescents: Oral:
eGFR ≥45 mL/minute/1.73 m2: No dosage adjustment necessary.
eGFR <45 mL/minute/1.73 m2: Not recommended (likely to be ineffective).
Children ≥10 years and Adolescents: Oral:
No dosage adjustment necessary; use caution if initiating in severe impairment (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 dapagliflozin may cause reversible kidney-related adverse events (eg, increased serum creatinine, decreased estimated GFR [eGFR]) during the first 2 weeks of therapy, the DAPA-CKD trial showed an overall reduction in the risk of sustained decline in the eGFR ≥50%, end-stage kidney disease, or death from renal or cardiovascular outcomes in patients who received dapagliflozin (Ref). A post hoc analysis of the DAPA-CKD trial found that patients who had acute reductions in eGFR >10% after 2 weeks of dapagliflozin therapy had slower rates of long-term eGFR decline compared with patients who experienced a less pronounced decline or increase in eGFR, suggesting an acute reduction in eGFR with dapagliflozin initiation is not associated with higher rates of chronic kidney disease progression (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 with dapagliflozin specifically, 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, dapagliflozin 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 DAPA-CKD study, administration of dapagliflozin 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 fractures occurred in patients with type 2 diabetes mellitus and moderate renal impairment (eGFR 30 to 60 mL/minute/1.73 m2) in one randomized controlled trial (Ref); however, a second randomized controlled trial did not confirm a similar increased risk in patients with type 2 diabetes mellitus and eGFR 45 to 60 mL/minute/1.73 m2 (Ref). In the overall population, dapagliflozin does not appear to increase risk of fractures, though longer-term data may be necessary to clarify risk (Ref).
Hypersensitivity reactions, including angioedema, urticaria, anaphylaxis, and skin rash, have been reported in patients receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors (Ref).
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 dapagliflozin
• 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 dapagliflozin, 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 dapagliflozin (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, 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, alcohol abuse, acute febrile illness, surgery, ketogenic diet, volume depletion, 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). Trials involving dapagliflozin have not consistently shown an increased risk of lower limb amputation associated with its use (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. Incidences are for adults and may include dapagliflozin used as add-on therapy.
1% to 10%:
Endocrine & metabolic: Dyslipidemia (3%), hypovolemia (1% to 3%) (table 1)
|
Drug (Dapagliflozin) |
Placebo |
Dose |
Indication |
Number of Patients (Dapagliflozin) |
Number of Patients (Placebo) |
|---|---|---|---|---|---|
|
3% |
2% |
10 mg/day |
Cardiovascular disease |
8,574 |
8,569 |
|
1% |
0.7% |
10 mg/day |
Glycemic control |
2,360 |
2,295 |
|
0.8% |
0.4% |
10 mg/day |
Glycemic control |
1,193 |
1,393 |
|
0.6% |
0.4% |
5 mg/day |
Glycemic control |
1,145 |
1,393 |
Gastrointestinal: Nausea (3%)
Genitourinary: Dysuria (2%), genitourinary fungal infection (3% to 8%; including vulvovaginal candidiasis [females], balanitis [males]), (table 2) increased urine output (3% to 4%), urinary tract infection (6%; including pyelonephritis, urinary tract infection with sepsis)
|
Drug (Dapagliflozin) |
Placebo |
Population |
Dose |
Indication |
Number of Patients (Dapagliflozin) |
Number of Patients (Placebo) |
|---|---|---|---|---|---|---|
|
8% |
2% |
Females |
5 mg/day |
Glycemic control |
1,145 |
1,393 |
|
7% |
2% |
Females |
10 mg/day |
Glycemic control |
1,193 |
1,393 |
|
3% |
0.3% |
Males |
5 mg/day |
Glycemic control |
1,145 |
1,393 |
|
3% |
0.3% |
Males |
10 mg/day |
Glycemic control |
1,193 |
1,393 |
Hematologic & oncologic: Increased hematocrit (1%)
Infection: Influenza (3%)
Neuromuscular & skeletal: Back pain (4%), limb pain (2%)
Respiratory: Nasopharyngitis (7%)
<1%:
Endocrine & metabolic: Ketoacidosis (including diabetic ketoacidosis, euglycemia ketoacidosis)
|
Drug (Dapagliflozin) |
Placebo |
Indication |
|---|---|---|
|
0.3% |
0.1% |
Cardiovascular disease |
Hypersensitivity: Hypersensitivity reaction (including anaphylaxis, angioedema)
Frequency not defined: Endocrine & metabolic: Increased LDL cholesterol
Postmarketing:
Dermatologic: Skin rash, Sweet syndrome (Ref)
Endocrine & metabolic: Hypercalcemia (Ref), hypernatremia (Ref)
Gastrointestinal: Acute pancreatitis (Ref)
Hepatic: Hepatic injury (acute-on-chronic-liver failure) (Ref))
Infection: Necrotizing fasciitis (perineum) (Ref)
Neuromuscular & skeletal: Bone fracture (Ref)
Renal: Acute kidney injury (Ref), decreased estimated GFR (eGFR) (Ref), increased serum creatinine (Ref)
History of serious hypersensitivity (eg, anaphylaxis, angioedema) to dapagliflozin 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 Drug Safety Communication 2017).
• Renal impairment: Glycemic efficacy may be decreased in patients with renal impairment.
Special populations:
• Older adults: Older adults may be predisposed to renal impairment or failure.
Other warnings/precautions:
• Appropriate use: Not for use in patients with diabetic ketoacidosis or to improve glycemic control in patients with type 1 diabetes mellitus. Not for use for treatment of chronic kidney disease in patients with polycystic kidney disease, or in those who currently require or with a recent history of immunosuppressive therapy for kidney disease.
• Hospitalized patients: Use of SGLT2 inhibitors for glycemic control is not routinely recommended for hospitalized patients (ADA 2023).
• Surgical procedures: In patients with diabetes mellitus, consider temporary discontinuation 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:
Farxiga: 5 mg, 10 mg
Generic: 5 mg, 10 mg
Yes
Tablets (Dapagliflozin Propanediol Oral)
5 mg (per each): $22.13
10 mg (per each): $22.13
Tablets (Farxiga Oral)
5 mg (per each): $23.99
10 mg (per each): $23.99
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Forxiga: 5 mg, 10 mg
Generic: 5 mg, 10 mg
Oral: Administer with or without food.
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).
Oral: Administer with or without food.
Surgical procedures: Withhold dapagliflozin 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.
An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/202293s030lbl.pdf#page=53, must be dispensed with this medication.
Chronic kidney disease: To reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression. Benefits were demonstrated in patients with nondiabetic kidney disease (eg, IgA nephropathy, focal segmental glomerulosclerosis [FSGS]) and diabetic kidney disease (Heerspink 2020; Wheeler 2021; Wheeler 2022).
Limitations of use: Dapagliflozin is not recommended in patients with polycystic kidney disease, or in those who currently require or with a recent history of immunosuppressive therapy for kidney disease.
Diabetes mellitus, type 2, treatment: As an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients ≥10 years of age with type 2 diabetes mellitus; risk reduction of hospitalization for heart failure in adults with type 2 diabetes mellitus and established cardiovascular disease or multiple cardiovascular risk factors.
Heart failure: Risk reduction of cardiovascular mortality, hospitalization for heart failure, and urgent heart failure visit in adults with heart failure.
Farxiga has been confused with Fetzima
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]).
Dapagliflozin is identified in the Screening Tool of Older Person's Prescriptions (STOPP) criteria as a potentially inappropriate medication in older adults (≥65 years of age) with symptomatic hypotension (O’Mahony 2023).
Substrate of OAT1/3, P-glycoprotein (Minor), UGT1A9; 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.
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
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
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
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
Pegvisomant: May increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
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
Ritodrine: May decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
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
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 dapagliflozin 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 dapagliflozin are currently recommended to treat diabetes mellitus in pregnancy (ADA 2023).
It is not known if dapagliflozin is present in breast milk.
Due to the potential for serious adverse reactions in the breastfeeding infant, breastfeeding is not recommended by the manufacturer.
Individualized medical nutrition therapy (MNT) based on ADA recommendations is an integral part of therapy.
Blood glucose; renal function (baseline and periodically during treatment); 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; volume status (eg, weight, BP, hematocrit, electrolytes; baseline and periodically during treatment) and signs/symptoms of hypotension; if signs/symptoms of ketoacidosis (eg, nausea/vomiting, abdominal pain, malaise, shortness of breath), confirm diagnosis by direct measurement of blood ketones and arterial pH (measurement of serum bicarbonate or urinary ketones may not be adequate) (AACE [Handelsman 2016]).
HbA1c: Monitor at least twice yearly in patients who have stable glycemic control and are meeting treatment goals; monitor quarterly in patients in whom treatment goals have not been met, or with therapy change. 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 (ADA 2023; KDIGO 2020).
Recommendations for glycemic control in patients with diabetes:
Nonpregnant adults (AACE [Samson 2023], ADA 2023):
HbA1c: <7% (a more aggressive [<6.5%] or less aggressive [<8%] HbA1c goal may be targeted based on patient-specific characteristics). Note: In patients using a continuous glucose monitoring system, a goal of time in range >70% with time below range <4% is recommended and is similar to a goal HbA1c <7%.
Preprandial capillary blood glucose: 80 to 130 mg/dL (SI: 4.4 to 7.2 mmol/L) (more or less stringent goals may be appropriate based on patient-specific characteristics).
Peak postprandial capillary blood glucose (~1 to 2 hours after a meal): <180 mg/dL (SI: <10 mmol/L) (more or less stringent goals may be appropriate based on patient-specific characteristics).
Older adults (≥65 years of age) (ADA 2023):
Note: Consider less strict targets in patients who are using insulin and/or insulin secretagogues (sulfonylureas, meglitinides) (ES [LeRoith 2019]).
HbA1c: <7% to 7.5% (healthy); <8% (complex/intermediate health). Note: Individualization may be appropriate based on patient and caregiver preferences and/or presence of cognitive impairment. In patients with very complex or poor health (ie, limited remaining life expectancy), consider making therapy decisions based on avoidance of hypoglycemia and symptomatic hyperglycemia rather than HbA1c level.
Preprandial capillary blood glucose: 80 to 130 mg/dL (SI: 4.4 to 7.2 mmol/L) (healthy); 90 to 150 mg/dL (SI: 5 to 8.3 mmol/L) (complex/intermediate health); 100 to 180 mg/dL (SI: 5.6 to 10 mmol/L) (very complex/poor health).
Bedtime capillary blood glucose: 80 to 180 mg/dL (SI: 4.4 to 10 mmol/L) (healthy); 100 to 180 mg/dL (SI: 5.6 to 10 mmol/L) (complex/intermediate health); 110 to 200 mg/dL (SI: 6.1 to 11.1 mmol/L) (very complex/poor health).
Classification of hypoglycemia (ADA 2023):
Level 1: 54 to 70 mg/dL (SI: 3 to 3.9 mmol/L); hypoglycemia alert value; initiate fast-acting carbohydrate (eg, glucose) treatment.
Level 2: <54 mg/dL (SI: <3 mmol/L); threshold for neuroglycopenic symptoms; requires immediate action.
Level 3: Hypoglycemia associated with a severe event characterized by altered mental and/or physical status requiring assistance.
By inhibiting sodium-glucose cotransporter 2 (SGLT2) in the proximal renal tubules, dapagliflozin 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. Dapagliflozin also reduces sodium reabsorption and increases sodium delivery to the distal tubule, which may decrease cardiac preload/afterload, downregulate sympathetic activity, and decrease intraglomerular pressure.
Duration: Following discontinuation, urinary glucose excretion returns to baseline within ~3 days for the 10 mg dose.
Protein binding: ~91%.
Metabolism: Primarily mediated by UGT1A9 to an inactive metabolite (dapagliflozin 3-O-glucuronide); CYP-mediated metabolism (minor).
Bioavailability: 78%.
Half-life elimination: ~12.9 hours.
Time to peak, plasma: 2 hours.
Excretion: Urine (75%; <2% as parent drug); feces (21%; ~15% as parent drug).
Altered kidney function: Patients with mild, moderate, or severe impairment had higher systemic exposure compared to patients with normal renal function.
Hepatic function impairment: In patients with severe impairment (Child-Pugh class C), mean Cmax and AUC were increased up to 40% and 67%, respectively.
