Dapagliflozin with metformin

How it works

Dapagliflozin increases urinary glucose excretion by inhibiting renal SGLT2-mediated reabsorption, while metformin lowers hepatic gluconeogenesis and improves insulin sensitivity.

Prescribing in practice

• The most important safety point is risk of euglycaemic diabetic ketoacidosis from dapagliflozin and lactic acidosis from metformin; apply sick-day rules and withhold during acute illness, dehydration, or perioperatively.
• Dapagliflozin predisposes to genital mycotic and urinary infections and rare Fournier's gangrene, and both components have renal-function thresholds that govern initiation and continuation.
• Volume depletion and hypotension can occur, especially in the elderly or those on diuretics.

Monitoring

Monitor renal function, HbA1c, hydration and weight, and watch for ketoacidosis symptoms even with normal blood glucose.

Counselling the patient

• Stop the medicine and seek urgent help if acutely unwell or dehydrated, or if you develop nausea, vomiting, abdominal pain, or breathlessness.
• Report genital itching or soreness and maintain good genital hygiene.
• Take with food to limit gastrointestinal upset.

Evidence & guidelines

NICE recommends SGLT2 inhibitors in type 2 diabetes, with dapagliflozin's broader cardiorenal benefits demonstrated in trials such as DAPA-HF and DAPA-CKD.