Generic Name

Invokana

Mechanism

• Inhibits renal SGLT2 in the proximal tubule → ↓ glucose reabsorption (≈90 % of filtered glucose)
• Glucosuria lowers plasma glucose, reduces HbA1c, and promotes modest weight loss.
• Lowers post‑prandial glucose without affecting insulin secretion, thus minimal risk of hypoglycemia when used alone.

Pharmacokinetics

• Absorption: Rapid, peak plasma concentration 2–4 h post‑dose; bioavailability ~70 % with food.
• Distribution: 60 % protein‑bound; large volume of distribution (~80 L).
• Metabolism: Primarily glucuronidation (UGT1A3, UGT1A8) → inactive metabolites; minimal CYP450 involvement.
• Elimination: 80 % excreted unchanged in urine, 20 % fecal.
• Half‑life: ~13 h (steady‑state ~24 h).
• Dose adjustment: No adjustment needed in mild‑moderate renal impairment; contraindicated if CrCl < 30 mL/min.

Indications

• Adjunct to diet and exercise for glycemic control in T2DM.
• FDA‑approved dose: 100 mg orally once daily; may increase to 300 mg once daily if tolerated and no renal dysfunction.
• Evidence for cardiovascular risk reduction (CAN SURE study) in high‑risk patients.

Contraindications

• Contraindicated: Severe renal impairment (CrCl < 30 mL/min), end‑stage renal disease, or dialysis.
• Warnings:
• Genitourinary infections (vaginal, urinary tract) → prophylaxis or prompt treatment.
• Volume depletion → caution in heart failure, dehydration, or diuretic use.
• Euglycemic diabetic ketoacidosis (DKA) → educate on signs; monitor ketones in high‑risk situations.
• Hypoglycemia only when combined with insulin or sulfonylureas.
• Hyperuricemia / gout → monitor uric acid; consider allopurinol if recurrent.
• Cancer: Possible increased risk of bladder cancer; monitor symptoms, consider discontinuation if suspicious.

Dosing

• Starting dose: 100 mg once daily, orally, with or without food.
• Titration: After 4 weeks, if HbA1c ≥ 1 % above target and no renal contraindication, increase to 300 mg once daily.
• Administration tip: Take in the morning to reduce nocturia.
• Missed dose: Skip; do not double dose next day.
• Special populations: No dose adjustment in mild‑moderate hepatic impairment; avoid in severe renal disease.

Adverse Effects

Monitoring

• Baseline & every 3 months: HbA1c, serum creatinine, eGFR, uric acid.
• Renal function: CrCl < 30 mL/min → discontinue.
• Volume status: Check BP, weight; advise adequate hydration.
• Ketone monitoring: In patients with reduced oral intake, recent surgery, or high insulin‑to‑canagliflozin ratio.
• Urinary tract/genital health: Evaluate symptoms, culture if indicated.
• Pregnancy: Category B; avoid during pregnancy and lactation.

Clinical Pearls

• “Rule of 300”: When HbA1c remains ≥ 1 % above target after 4 weeks, increase from 100 mg to 300 mg—no renal dose adjustment needed until eGFR < 30 mL/min.
• Early DKA detection: Even with near‑normal glucose, patients on canagliflozin may develop ketoacidosis—emphasize ketone testing if symptoms arise.
• Gout caution: Canagliflozin increases uric acid; pre‑emptive allopurinol in patients with prior gout flares reduces risk.
• Weight loss synergy: Pair with a low‑carb diet for enhanced weight loss; monitor caloric intake to avoid dehydration.
• Cardiovascular edge: In high‑risk T2DM patients (≥ 2 CV risk factors), consider Invokana for its proven 22 % relative risk reduction in major adverse cardiovascular events (MACE).
• Avoid in elderly on diuretics: Combined diuretic and SGLT2 inhibitor therapy heightens volume depletion risk—adjust fluid and BP monitoring accordingly.

*Use this drug card as a quick reference for evidence‑based practice and student review.*