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SGLT2 Inhibitor (CKD — Renoprotective) Pregnancy: Contraindicated — avoid in pregnancy. Stop as soon as pregnancy confirmed.

Dapagliflozin (CKD Indication)

Brand names: Forxiga

Adult dose

Dose: 10 mg once daily
Route: Oral
Frequency: Once daily
Max: 10 mg/day
CKD with eGFR ≥25 mL/min and urine ACR ≥22.6 mg/mmol (200 mg/g), with or without type 2 diabetes. NICE NG203 recommends as add-on to standard care (ACEi/ARB + risk factor management). Source: BNF 90; NICE NG203.

Paediatric dose

Dose: Not licensed under 18 years for CKD indication N/A/kg
Route: N/A
Frequency: N/A
Max: N/A
Not licensed in paediatric CKD.

Dose adjustments

Renal

eGFR ≥25 mL/min: licensed (DAPA-CKD enrolled down to eGFR 25). eGFR 15–24 mL/min: continue if already established (benefit persists) but do not initiate. eGFR <15 mL/min: not recommended for new initiation. Glycaemic benefit ceases below eGFR 45, but renoprotection persists.

Hepatic

Severe hepatic impairment: increased dapagliflozin exposure — start at 5 mg and consider maximum 10 mg. Mild-moderate: no adjustment.

Paediatric weight-based calculator

Not licensed in paediatric CKD.

Clinical pearls

  • DAPA-CKD trial (NEJM 2020): dapagliflozin 10 mg reduced composite of ≥50% sustained eGFR decline, ESKD, or renal/CV death by 39% vs placebo (HR 0.61) in CKD eGFR 25–75 with ACR ≥200 mg/g — both diabetic AND non-diabetic CKD patients benefited equally. Trial was stopped early for overwhelming benefit.
  • DAPA-CKD vs EMPA-KIDNEY: both trials confirm class effect of SGLT2 inhibitors in CKD. DAPA-CKD used eGFR ≥25; EMPA-KIDNEY ≥20, extending indication to more severe CKD. Both show benefit regardless of diabetes status — establishing SGLT2 inhibitors as standard of care in proteinuric CKD.
  • Non-diabetic CKD benefit: DAPA-CKD subgroup analysis showed similar HR reduction in non-diabetic patients (IgA nephropathy, polycystic kidney disease, hypertensive CKD). SGLT2 inhibitor benefit is largely independent of glycaemic effects — tubuloglomerular feedback and haemodynamic mechanism.
  • Sick day rules for all SGLT2 inhibitors: 'SADMANS' drugs that should be temporarily stopped when unwell — Sulphonylureas, ACEi, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors. Stop dapagliflozin if: vomiting, reduced oral intake, diarrhoea, high fever, planned surgery (stop 3 days before). Restart when eating normally and well.
  • NICE NG203 recommendation: dapagliflozin 10 mg recommended as add-on to optimised ACEi/ARB for adults with CKD eGFR ≥25 and ACR ≥22.6 mg/mmol (or diabetes and ACR ≥3 mg/mmol). First SGLT2 inhibitor with NICE recommendation specifically for CKD. Source: BNF 90; Wheeler et al. NEJM 2020 (DAPA-CKD); NICE NG203.

Contraindications

  • eGFR <25 mL/min for initiation
  • Type 1 diabetes mellitus (euglycaemic DKA risk — not licensed for T1DM for glycaemic control)
  • Active urinary tract infection or recurrent UTI
  • Pregnancy and breastfeeding

Side effects

  • Genital mycotic infections (vulvovaginal candidiasis, penile candidiasis — 5–10%)
  • Urinary tract infections
  • Euglycaemic diabetic ketoacidosis (MHRA warning — sick day rules: stop if unwell/fasting/surgical)
  • Volume depletion and hypotension
  • Fournier's gangrene (rare — MHRA 2019 warning; necrotising fasciitis of genitalia)
  • Increased urinary frequency (osmotic diuresis)

Interactions

  • Loop and thiazide diuretics: additive volume depletion — monitor
  • Insulin and sulphonylureas: reduce dose when adding dapagliflozin
  • ACEi/ARB: synergistic renoprotection — monitor eGFR and potassium at initiation
  • NSAIDs: avoid in CKD — additive renal perfusion reduction

Monitoring

  • eGFR and serum electrolytes at baseline and 4 weeks after starting, then every 3–6 months
  • Urine ACR every 6 months
  • Blood pressure (often falls 3–5 mmHg)
  • Genital and urinary symptoms at each visit
  • Ketones if unwell (euglycaemic DKA precaution)

Reference: BNFc; BNF 90; Wheeler et al. NEJM 2020 (DAPA-CKD trial); NICE NG203; MHRA SPC Forxiga. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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