Canagliflozin
INVOKANA
What it isSGLT2 inhibitor producing urinary glucose and sodium loss; type 2 diabetes and diabetic kidney disease.
Why this oneThe dedicated CREDENCE trial established its renal protection in diabetic nephropathy before that benefit became a class standard.
What limits itAmputation and fracture signals distinguish it from other gliflozins. Euglycemic ketoacidosis requires holding it during acute illness and before surgery.
FDA-approved for
- type 2 diabetes (2013)
- diabetic nephropathy (CREDENCE) (2019)
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Glycemic control, type 2 diabetes mellitus | Adults & children ≥10y | 100 mg QD (before first meal) | 100 mg QD | 300 mg QD (if eGFR ≥60) |
| Reduce MACE risk (T2DM + established CVD) | Adults | 100 mg QD | 100 mg QD | 100 mg QD |
| Reduce ESKD/CV risk (diabetic nephropathy, albuminuria >300 mg/day) | Adults | 100 mg QD | 100 mg QD | 100 mg QD |
Renal eGFR 30–<60: max 100 mg QD; eGFR <30: do not initiate (may continue 100 mg QD if albuminuria >300 mg/day)
Hepatic Mild–moderate: no adjustment; severe: not recommended
Instructions
- Take once daily before the first meal of the day
- Assess renal function and correct volume depletion before initiating
- Withhold at least 3 days before surgery or procedures with prolonged fasting
- With UGT inducers (rifampin, phenytoin, phenobarbital, ritonavir): increase dose per renal function (max 300 mg; max 200 mg if eGFR <60)
- Missed dose: take as soon as possible; do not double up
Cautions
- Diabetic ketoacidosis (including in type 2 diabetes) — assess regardless of glucose level
- Lower limb amputation — highest risk with prior amputation, PVD, neuropathy
- Volume depletion / acute kidney injury
- Genitourinary infections including urosepsis, pyelonephritis, and necrotizing fasciitis of the perineum (Fournier's gangrene)
- Hypoglycemia with insulin or insulin secretagogues
- Hypersensitivity reactions (angioedema, anaphylaxis)
- Bone fracture
Adverse reactions
- Female genital mycotic infections
- Urinary tract infection
- Increased urination
- Male genital mycotic infections
- Thirst
- Constipation
- Nausea
Pregnancy Not recommended during the second and third trimesters (juvenile animal adverse renal effects)
Lactation Not recommended while breastfeeding
NO BOXED WARNINGS
Principal riskEuglycemic ketoacidosis; amputation and fracture signals
Cost, est. cash$300–$1,000/month
Generic entry2028 est.
Classes and tags
Clinical profile
Legacy pregnancy categoryMultiple / indication-, trimester- or formulation-dependent
Defining liabilityGenital infection, volume depletion and euglycemic ketoacidosis; fracture/amputation concerns are patient-specific.
Mechanism of action: Canagliflozin ballicule
Open Canagliflozin in the interactive console ↗
Memory aids: mascots and interaction avatars
SGLT2 inhibitor theme
