Dapagliflozin (Farxiga, Forxiga)
Dapagliflozin is an SGLT2 inhibitor with indications spanning T2DM glycemic control, heart failure across the ejection-fraction spectrum, and CKD regardless of diabetes status. Its evidence base (DAPA-HF, DELIVER, DAPA-CKD) established SGLT2 inhibitors as a cardio-renal-metabolic class.
- Mechanism of action
- Selective inhibition of sodium-glucose cotransporter 2 in the proximal tubule, producing glycosuria, natriuresis, modest blood pressure reduction, and neurohormonal modulation.
- Administration route
- Oral, once daily
FDA-approved indications (2026)
Type 2 diabetes
Glycemic control in adults and pediatrics ≥10 years.
Heart failure
Reduction of CV death and HF hospitalization across the EF spectrum (HFrEF — DAPA-HF; HFpEF/HFmrEF — DELIVER).
Chronic kidney disease
Reduction of kidney function decline, kidney failure, CV death, and HF hospitalization in CKD with or without T2DM (DAPA-CKD).
Dosing: adult, renal, and hepatic
| Population | Dose |
|---|---|
| T2DM / HF / CKD | 10 mg PO once daily. For glycemic control only, may start at 5 mg. |
| Renal impairment | Initiate if eGFR ≥25 mL/min/1.73 m² for CKD/HF indications. Do not initiate for glycemic benefit at eGFR <45. Continue until dialysis. |
| Hepatic impairment | No dose adjustment in mild/moderate. Use caution in severe hepatic impairment; benefit/risk evaluation. |
Contraindications and boxed warnings
Contraindications
- Serious hypersensitivity to dapagliflozin.
- Dialysis.
2026 guideline and pivotal trial position
2026 ACC/AHA/HFSA heart failure guidance positions SGLT2 inhibitors as one of the four pillars of GDMT across the EF spectrum. KDIGO 2024 lists dapagliflozin as a first-line agent in CKD with proteinuria regardless of diabetic status. ADA 2026 co-recommends SGLT2 inhibitors with GLP-1 RAs for T2DM with CV/renal disease.
DAPA-HF
26% RRR in CV death or worsening HF in HFrEF.
DELIVER
18% RRR in CV death or worsening HF in HFmrEF/HFpEF (EF >40%).
DAPA-CKD
39% RRR in composite kidney outcome in CKD with or without diabetes.
Cross-system reasoning
Dapagliflozin's benefit extends from cardiology (HF hospitalization reduction) to nephrology (kidney function preservation) to endocrinology (glycemic control and modest weight loss). In a patient with HFpEF and CKD stage 3b without diabetes, dapagliflozin is still indicated — a decision that crosses cardiology-nephrology lines. Recognize euglycemic DKA risk (hold perioperatively or during prolonged fasting), genitourinary infection screening, and modest volume-depletion effect that may warrant diuretic dose reduction at initiation.
Key references
- FDA Label — Farxiga (dapagliflozin)
- McMurray JJV, et al. DAPA-HF (NEJM 2019)PMID: 31535829
- Solomon SD, et al. DELIVER (NEJM 2022)PMID: 36027570
- Heerspink HJL, et al. DAPA-CKD (NEJM 2020)PMID: 32970396
Related clinical reading
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This reference is for US-licensed physicians and is not a substitute for the full FDA prescribing information. Dosing in special populations, drug interactions, and emerging safety information should be verified against the current manufacturer label and society guidelines before prescribing.