Should I stop Jardiance (empagliflozin) in a patient with fluid overload who has become confused?

Yes, Stop Jardiance Immediately in This Patient

You must discontinue Jardiance (empagliflozin) immediately in a patient with fluid overload who has developed confusion. New confusion is a severe symptom requiring urgent medical attention and mandates stopping SGLT2 inhibitors according to current sick day guidance 1.

Why This is Critical

The combination of fluid overload and confusion represents a dangerous clinical scenario:

• Confusion signals severe illness: The 2023 consensus sick day medication guidance explicitly identifies "reduced level of consciousness or new confusion" as a symptom severe enough to warrant immediate healthcare provider contact (100% expert agreement) and potential emergency care (96% agreement) 1.

• SGLT2 inhibitors must be stopped during acute illness: The same guideline recommends temporarily stopping SGLT2 inhibitors like empagliflozin during sick days with 96% expert consensus 1. These medications should remain discontinued for up to 3 days or until symptoms resolve 1.

• Volume depletion paradox: While this patient has fluid overload, the confusion may indicate:

  • Severe electrolyte disturbances (particularly hypernatremia from volume depletion in certain compartments)
  • Acute kidney injury from intravascular volume depletion despite total body fluid excess
  • Worsening clinical status requiring immediate evaluation

The FDA Warning Supports This Decision

The FDA label for Jardiance explicitly warns that empagliflozin can cause intravascular volume depletion, which may manifest as acute changes in creatinine and has been associated with acute kidney injury requiring hospitalization 2. The label specifically states that volume status should be corrected before initiating or continuing therapy 2.

Clinical Context: The Paradox of Fluid Overload

A critical caveat: fluid overload does not protect against SGLT2 inhibitor-induced volume depletion. A case report documented severe hypernatremic dehydration and unconsciousness in a care-dependent patient on empagliflozin, despite the patient being bedridden 3. The mechanism involves:

• Persistent glucosuria causing osmotic diuresis
• Inability to replace water losses (especially in confused or dependent patients)
• Progressive intravascular volume depletion even when total body water appears elevated

What to Do Next

1. Stop Jardiance immediately - do not wait for further evaluation 1

2. Assess urgently for:

   • Serum sodium (hypernatremia risk from osmotic diuresis) 3
   • Renal function (acute kidney injury) 2
   • Ketones if diabetic (euglycemic DKA risk) 1
   • Blood pressure and orthostatic changes 2

3. Seek immediate medical attention because confusion with fluid overload suggests:

   • Possible hyponatremia (from fluid overload)
   • Possible hypernatremia (from SGLT2i-induced water loss)
   • Uremia from acute kidney injury
   • Other serious metabolic derangements

4. Resume only after:

   • Confusion has completely resolved
   • Volume status is normalized
   • Renal function is stable
   • Patient can maintain adequate oral fluid intake 1
   • Typically wait 24-48 hours after normal eating/drinking resumes 1

Important Pitfall to Avoid

Do not assume fluid overload protects against SGLT2 inhibitor complications. The 2021 Lancet guideline on hospital diabetes management explicitly states they do not recommend routine use of SGLT2 inhibitors in hospitalized patients, citing risks of euglycemic DKA and genitourinary infections 4. Confusion in the setting of any acute illness is an absolute indication to stop these medications temporarily.

The patient's inability to communicate thirst or independently replace fluid losses (implied by confusion) makes continued SGLT2 inhibitor therapy particularly dangerous 3.