Dapagliflozin and cognitive impairment: pharmacological mechanisms, translational evidence, and future directions

Cognitive impairment increasingly emerges at the intersection of type 2 diabetes mellitus, vascular brain injury, chronic kidney disease, heart failure, and neurodegeneration, prompting interest in therapies that modify shared metabolic and inflammatory drivers of brain vulnerability. Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor widely used in type 2 diabetes and cardiorenal disease, has attracted attention as a candidate modulator of cognitive decline because its established peripheral pharmacology extends beyond glucose lowering to include natriuresis, blood pressure reduction, weight loss, improved insulin resistance, reduced oxidative and inflammatory stress, and favorable cardiorenal effects. In this review, we examine the pharmacological basis by which these systemic actions could influence the neurovascular unit, mitochondrial homeostasis, glial activation, autophagy-related signaling, and synaptic plasticity pathways implicated in cognitive impairment. We summarize preclinical evidence suggesting that dapagliflozin can improve cognitive performance and modulate pathways such as AMPK-mTOR, Wnt/β-catenin, CREB/BDNF, oxidative stress responses, and neuroinflammatory signaling in experimental models, while also critically evaluating the limitations of these models. We then assess the current human evidence, distinguishing observational studies that suggest lower dementia risk from randomized clinical evidence that has not yet established a definitive cognition-related benefit. We argue that dapagliflozin should currently be viewed not as a proven cognitive therapeutic, but as a mechanistically plausible metabolic-neurovascular intervention whose relevance may be greatest in metabolically vulnerable phenotypes. Finally, we outline key translational challenges, including uncertainty regarding direct central target engagement, the need for biomarker-enriched trial designs, and the importance of integrating pharmacological, vascular, and neurodegenerative frameworks in future studies.