What key counselling points should be given to a patient with type 2 diabetes who is starting empagliflozin (Jardiance)?

Key Counselling Points for Empagliflozin

Patients starting empagliflozin must be counselled about recognizing ketoacidosis symptoms (nausea, vomiting, abdominal pain, fatigue, difficulty breathing) and instructed to stop the medication immediately and seek emergency care if these occur, even when blood glucose is below 250 mg/dL 1.

Critical Safety Warnings

Ketoacidosis Risk

• Can occur even with normal blood glucose levels (<250 mg/dL), making it particularly dangerous 1
• Stop empagliflozin immediately if symptoms develop: nausea, vomiting, abdominal pain, tiredness, or labored breathing
• Higher risk during illness, surgery, or reduced food/fluid intake
• Check urine ketones if symptoms occur, even with normal glucose readings

Dehydration and Volume Depletion

• Empagliflozin causes fluid loss through increased urination 1
• Patients at highest risk: those taking diuretics, on low-sodium diets, with kidney problems, or age ≥65 years 2, 1
• Maintain adequate daily fluid intake
• Watch for dizziness, lightheadedness, or weakness, especially when standing (orthostatic hypotension)
• Contact provider immediately if unable to maintain normal food/fluid intake due to illness, vomiting, or diarrhea

Infection Risks

Genital Mycotic Infections

• Common side effect, particularly in women and uncircumcised men 1
• Symptoms in women: vaginal itching, discharge, odor
• Symptoms in men: redness, rash, or swelling of penis or foreskin
• Usually straightforward to treat but requires medical attention 3

Urinary Tract Infections

• Can be serious; seek medical attention for symptoms of UTI 1

Fournier's Gangrene (Rare but Serious)

• Necrotizing infection of the perineum
• Seek immediate medical attention for: pain, tenderness, redness, or swelling of genitals or area between genitals and rectum, especially with fever >100.4°F 1

Hypoglycemia Risk

• Low inherent risk when used alone due to insulin-independent mechanism 4, 3
• Risk increases significantly when combined with insulin or sulfonylureas 2, 1
• Dose reduction of insulin or sulfonylurea may be required 2
• Learn to recognize hypoglycemia symptoms: shakiness, sweating, rapid heartbeat, confusion

Dosing and Administration

• Take once daily, with or without food
• If dose missed: Take as soon as remembered; do not double the next dose 1
• Starting dose typically 10 mg daily; may increase to 25 mg if needed 2

Renal Function Considerations

• Can be initiated if eGFR >30 mL/min/1.73 m² (though older FDA labeling stated ≥45) 5
• Cardiovascular and renal benefits extend down to eGFR of 30 mL/min/1.73 m² 2
• Do not initiate if eGFR persistently <45 mL/min/1.73 m² per older FDA guidance 2
• Glucose-lowering effect diminishes with declining kidney function, but cardiovascular/renal benefits persist 2

Expected Effects

Beneficial Effects

• Increased urination and urinary glucose (this is expected) 1
• Weight loss of 2-3 kg typical 2, 6
• Modest blood pressure reduction 4, 3
• Does not compromise muscle mass or strength despite weight loss 6

Laboratory Changes

• Elevated glucose in urinalysis is expected and normal 1

Special Populations

Pregnancy and Breastfeeding

• Not recommended during pregnancy; report pregnancy to provider immediately 1
• Do not breastfeed while taking empagliflozin 1

Elderly Patients (≥65 years)

• Higher risk of dehydration 1
• Effective and well-tolerated in elderly adults without compromising muscle mass 6

When to Contact Healthcare Provider

Immediately seek medical attention for:

• Symptoms of ketoacidosis (nausea, vomiting, abdominal pain, fatigue, breathing difficulty)
• Signs of Fournier's gangrene (genital/perineal pain, redness, swelling with fever)
• Severe dehydration symptoms
• Inability to maintain fluid intake

Contact provider for:

• Symptoms of genital or urinary tract infections
• Persistent dizziness or lightheadedness
• Allergic reactions (rash, hives, swelling)
• Recurrent hypoglycemia if on insulin or sulfonylureas

Common Pitfalls to Avoid

• Do not stop medication during illness without provider guidance, but be vigilant for ketoacidosis symptoms
• Do not assume normal blood glucose rules out ketoacidosis - this is a unique danger with SGLT2 inhibitors
• Ensure adequate hydration, especially during hot weather, exercise, or illness
• No increased amputation or bone fracture risk with empagliflozin (unlike canagliflozin) 2