Side Effects of Farxiga (dapagliflozin)

Farxiga (dapagliflozin), a sodium-glucose cotransporter (SGLT2) inhibitor, is a diabetes medication used to improve glycemia (blood glucose) control in patients with type 2 diabetes. 

SGLT2 is found in the kidney tubules and is responsible for reabsorbing the majority of glucose filtered out of the blood by the kidneys. By inhibiting SGLT2, Farxiga reduces the reabsorption of filtered glucose and consequently increases excretion of glucose in the urine. 

Farxiga is not recommended for use in patients with moderate to severe kidney disease.

No significant drug interactions have been reported with Farxiga use. 

Farxiga is not recommended during the second and third trimesters of pregnancy; it may harm a fetus. 

It is unknown if Farxiga is excreted in breast milk. Currently, the manufacturer does not recommend use of Farxiga while breastfeeding.

What are the common side effects of Farxiga?

Common side effects of Farxiga include

• vaginal yeast infections,
• yeast infections of the penis,
• nasopharyngitis (upper respiratory tract infections usually with associated sore throat, runny nose, nasal congestion, and sneezing), and
• changes in urination (urinary urgency, urinating more often and in larger amounts).

What are the serious side effects of Farxiga?

Serious side effects of Farxiga include

• low blood pressure (hypotension),
• kidney dysfunction,
• dehydration,
• low blood sugar (hypoglycemia) when co-administered with insulin or insulin secretagogues,
• increase in low-density lipoprotein cholesterol (LDL-C),
• bladder cancer, and
• hypersensitivity reactions.

Positive Urine Glucose Test

• Monitoring glycemic control with urine glucose tests is not recommended in patients taking SGLT2 inhibitors as SGLT2 inhibitors increase urinary glucose excretion and will lead to positive urine glucose tests.
• Use alternative methods to monitor glycemic control.

Interference With 1,5-Anhydroglucitol (1,5-AG) Assay

• Monitoring glycemic control with 1,5-AG assay is not recommended as measurements of 1,5-AG are unreliable in assessing glycemic control in patients taking SGLT2 inhibitors.
• Use alternative methods to monitor glycemic control.

The following important adverse reactions are described below and elsewhere in the labeling:

• Volume Depletion
• Ketoacidosis in Patients with Diabetes Mellitus
• Urosepsis and Pyelonephritis
• Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues
• Necrotizing Fasciitis of the Perineum (Fournier’s Gangrene)
• Genital Mycotic Infections

Clinical Trials Experience

• Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
• Farxiga has been evaluated in clinical trials in patients with type 2 diabetes mellitus and in patients with heart failure.
• The overall safety profile of Farxiga was consistent across the studied indications.
• Severe hypoglycemia and diabetic ketoacidosis (DKA) were observed only in patients with diabetes mellitus.

Clinical Trials In Patients With Type 2 Diabetes Mellitus

Pool of 12 Placebo-Controlled Studies for Farxiga 5 and 10 mg for Glycemic Control

• The data in Table 1 is derived from 12 glycemic control placebo-controlled studies in patients with type 2 diabetes mellitus ranging from 12 to 24 weeks.
• In 4 studies Farxiga was used as monotherapy, and in 8 studies Farxiga was used as add-on to background antidiabetic therapy or as combination therapy with metformin.
• These data reflect exposure of 2338 patients to Farxiga with a mean exposure duration of 21 weeks.
• Patients received placebo (N=1393), Farxiga 5 mg (N=1145), or Farxiga 10 mg (N=1193) once daily.
• The mean age of the population was 55 years and 2% were older than 75 years of age.
• Fifty percent (50%) of the population were male; 81% were White, 14% were Asian, and 3% were Black or African American.
• At baseline, the population had diabetes for an average of 6 years, had a mean hemoglobin A1c (HbA1c) of 8.3%, and 21% had established microvascular complications of diabetes.
• Baseline renal function was normal or mildly impaired in 92% of patients and moderately impaired in 8% of patients (mean eGFR 86 mL/min/1.73 m²).

Table 2 shows common adverse reactions associated with the use of Farxiga. These adverse reactions were not present at baseline, occurred more commonly on Farxiga than on placebo, and occurred in at least 2% of patients treated with either Farxiga 5 mg or Farxiga 10 mg.

Table 2: Adverse Reactions in Placebo-Controlled Studies of Glycemic Control Reported in =2% of Patients Treated with Farxiga

Pool of 13 Placebo-Controlled Studies for Farxiga 10 mg for Glycemic Control

• Farxiga 10 mg was also evaluated in a larger glycemic control placebo-controlled study pool in patients with type 2 diabetes mellitus.
• This pool combined 13 placebo-controlled studies, including 3 monotherapy studies, 9 add-on to background antidiabetic therapy studies, and an initial combination with metformin study.
• Across these 13 studies, 2360 patients were treated once daily with Farxiga 10 mg for a mean duration of exposure of 22 weeks.
• The mean age of the population was 59 years and 4% were older than 75 years.
• Fifty-eight percent (58%) of the population were male; 84% were White, 9% were Asian, and 3% were Black or African American.
• At baseline, the population had diabetes for an average of 9 years, had a mean HbA1c of 8.2%, and 30% had established microvascular disease.
• Baseline renal function was normal or mildly impaired in 88% of patients and moderately impaired in 11% of patients (mean eGFR 82 mL/min/1.73 m²).

Volume Depletion

• Farxiga causes an osmotic diuresis, which may lead to a reduction in intravascular volume.
• Adverse reactions related to volume depletion (including reports of dehydration, hypovolemia, orthostatic hypotension, or hypotension) in patients with type 2 diabetes mellitus for the 12-study and 13-study, short-term, placebo-controlled pools and for the DECLARE study are shown in Table 3.

Table 3: Adverse Reactions Related to Volume Depletion* in Clinical Studies in Patients with Type 2 Diabetes Mellitus with Farxiga

Hypoglycemia

• The frequency of hypoglycemia by study in patients with type 2 diabetes mellitus is shown in Table 4. Hypoglycemia was more frequent when Farxiga was added to sulfonylurea or insulin.

Table 4: Incidence of Severe Hypoglycemia* and Hypoglycemia with Glucose < 54 mg/dL^† in Controlled Glycemic Control Clinical Studies in Patients with Type 2 Diabetes Mellitus

• In the DECLARE study, severe events of hypoglycemia were reported in 58 (0.7%) out of 8574 patients treated with Farxiga and 83 (1.0%) out of 8569 patients treated with placebo.

Genital Mycotic Infections

• In the glycemic control trials, genital mycotic infections were more frequent with Farxiga treatment.
• Genital mycotic infections were reported in 0.9% of patients on placebo, 5.7% on Farxiga 5 mg, and 4.8% on Farxiga 10 mg, in the 12-study placebo-controlled pool.
• Discontinuation from study due to genital infection occurred in 0% of placebo-treated patients and 0.2% of patients treated with Farxiga 10 mg.
• Infections were more frequently reported in females than in males (see Table 1).
• The most frequently reported genital mycotic infections were vulvovaginal mycotic infections in females and balanitis in males.
• Patients with a history of genital mycotic infections were more likely to have a genital mycotic infection during the study than those with no prior history (10.0%, 23.1%, and 25.0% versus 0.8%, 5.9%, and 5.0% on placebo, Farxiga 5 mg, and Farxiga 10 mg, respectively).
• In the DECLARE study, serious genital mycotic infections were reported in <0.1% of patients treated with Farxiga and <0.1% of patients treated with placebo.
• Genital mycotic infections that caused study drug discontinuation were reported in 0.9% of patients treated with Farxiga and <0.1% of patients treated with placebo.

Hypersensitivity Reactions

• Hypersensitivity reactions (e.g., angioedema, urticaria, hypersensitivity) were reported with Farxiga treatment.
• In glycemic control studies, serious anaphylactic reactions and severe cutaneous adverse reactions and angioedema were reported in 0.2% of comparator-treated patients and 0.3% of Farxiga-treated patients.
• If hypersensitivity reactions occur, discontinue use of Farxiga; treat per standard of care and monitor until signs and symptoms resolve.

Ketoacidosis in Patients with Diabetes Mellitus

• In the DECLARE study, events of diabetic ketoacidosis (DKA) were reported in 27 out of 8574 patients in the Farxiga-treated group and 12 out of 8569

 patients in the placebo group. The events were evenly distributed over the study period.

Laboratory Tests

Increases in Serum Creatinine and Decreases in eGFR

• Initiation of SGLT2 inhibitors, including Farxiga causes a small increase in serum creatinine and decrease in eGFR.
• In patients with normal or mildly impaired renal function at baseline, these changes in serum creatinine and eGFR generally occur within weeks of starting therapy and then stabilize.
• Increases that do not fit this pattern should prompt further evaluation to exclude the possibility of acute kidney injury.
• The acute effect on eGFR reverses after treatment discontinuation, suggesting acute hemodynamic changes may play a role in the renal function changes observed with Farxiga.

Increase in Hematocrit

• In the pool of 13 placebo-controlled studies of glycemic control, increases from baseline in mean hematocrit values were observed in Farxiga-treated patients starting at Week 1 and continuing up to Week 16, when the maximum mean difference from baseline was observed.
• At Week 24, the mean changes from baseline in hematocrit were −0.33% in the placebo group and 2.30% in the Farxiga 10 mg group.
• By Week 24, hematocrit values >55% were reported in 0.4% of placebo-treated patients and 1.3% of Farxiga 10 mg-treated patients.

Increase in Low-Density Lipoprotein Cholesterol

• In the pool of 13 placebo-controlled studies of glycemic control, changes from baseline in mean lipid values were reported in Farxiga-treated patients compared to placebo-treated patients.
• Mean percent changes from baseline at Week 24 were 0.0% versus 2.5% for total cholesterol, and -1.0% versus 2.9% for LDL cholesterol in the placebo and Farxiga 10 mg groups, respectively.
• In the DECLARE study, mean changes from baseline after 4 years were 0.4 mg/dL versus -4.1 mg/dL for total cholesterol, and -2.5 mg/dL versus -4.4 mg/dL for LDL cholesterol, in Farxiga-treated and the placebo groups, respectively.

Decrease in Serum Bicarbonate

• In a study of concomitant therapy of Farxiga 10 mg with exenatide extended-release (on a background of metformin), four patients (1.7%) on concomitant therapy had a serum bicarbonate value of less than or equal to 13 mEq/L compared to one each (0.4%) in the Farxiga and exenatide-extended release treatment groups.

DAPA-HF Heart Failure Study

• No new adverse reactions were identified in the DAPA-HF heart failure study.

Postmarketing Experience

• Additional adverse reactions have been identified during postapproval use of Farxiga in patients with diabetes mellitus. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
  • Ketoacidosis
  • Acute Kidney Injury
  • Urosepsis and Pyelonephritis
  • Necrotizing Fasciitis of the Perineum (Fournier’s Gangrene)
  • Rash