Is Jardiance (Empagliflozin) suitable for a patient with anuria and cardiomyopathy?

From the Guidelines

Jardiance (empagliflozin) is not recommended for anuric patients with cardiomyopathy due to its mechanism of action relying on kidney function. The medication works by increasing glucose excretion through the kidneys, which would not be effective in anuric patients who are not producing urine. Although SGLT2 inhibitors like Jardiance have shown significant cardiovascular benefits in patients with functioning kidneys, as seen in the EMPA-REG OUTCOME trial 1, these benefits may be limited in anuric patients.

For cardiomyopathy management in anuric patients, alternative medications such as beta-blockers (e.g., carvedilol, metoprolol), ACE inhibitors (e.g., lisinopril, enalapril), ARBs (e.g., losartan, valsartan), or aldosterone antagonists (e.g., spironolactone) would be more appropriate, depending on the specific type of cardiomyopathy and other patient factors, as recommended by the 2023 chronic coronary disease guideline-at-a-glance 1. These medications address the underlying cardiac dysfunction without requiring kidney filtration for their primary mechanism of action.

Key considerations in managing anuric patients with cardiomyopathy include:

• Close monitoring of fluid status
• Adjustment of diuretics as needed given the anuric state
• Consultation with a nephrologist and cardiologist to develop an appropriate treatment plan, taking into account the latest guidelines and evidence, such as the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1.

The patient's treatment plan should prioritize minimizing morbidity, mortality, and improving quality of life, considering the complex clinical scenario of anuric patients with cardiomyopathy.

From the FDA Drug Label

The efficacy and safety of JARDIANCE have not been established in patients with severe renal impairment, with ESRD, or receiving dialysis. JARDIANCE is not expected to be effective in these patient populations [see Dosage and Administration (2.2), Contraindications (4) and Warnings and Precautions (5.1,5.3)].

Anuric patients have severe renal impairment, which is equivalent to end-stage renal disease (ESRD). Given that JARDIANCE is not expected to be effective in patients with severe renal impairment or ESRD, its use in an anuric patient with cardiomyopathy is not recommended 2.

From the Research

Considerations for Using Jardiance in Anuric Patients with Cardiomyopathy

• The use of Jardiance (empagliflozin) in patients with cardiomyopathy has been studied in several trials, which have shown a reduction in cardiovascular death and hospitalization for heart failure 3, 4, 5.
• However, the studies did not specifically address the use of Jardiance in anuric patients, who have a significantly impaired renal function.
• A study on the effects of empagliflozin on renal oxygenation and blood pressure control in nondiabetic normotensive subjects found that empagliflozin increased glucosuria and decreased blood pressure, but did not affect renal oxygenation 6.
• Another study compared the cost-effectiveness of empagliflozin with other SGLT2 inhibitors and standard of care in patients with type 2 diabetes and established cardiovascular disease, and found that empagliflozin was cost-effective in reducing cardiovascular death and hospitalization for heart failure 7.
• The use of Jardiance in patients with heart failure, including those with reduced ejection fraction, has been shown to reduce the risk of cardiovascular death and hospitalization for worsening heart failure, regardless of the presence or absence of diabetes 4, 5.
• However, the safety and efficacy of Jardiance in anuric patients with cardiomyopathy are not well established, and its use in this population should be approached with caution.

Potential Risks and Benefits

• Potential benefits of using Jardiance in anuric patients with cardiomyopathy include a reduction in cardiovascular death and hospitalization for heart failure.
• Potential risks include an increased risk of genital tract infections, kidney failure, and diabetic ketoacidosis, as well as the potential for volume depletion and a fall in blood pressure, especially during co-administration with other diuretics or antihypertensive drugs 3.
• The diuretic effect of empagliflozin may be reduced in anuric patients, which could affect its efficacy in reducing cardiovascular risk.

Clinical Decision-Making

• The decision to use Jardiance in an anuric patient with cardiomyopathy should be made on a case-by-case basis, taking into account the individual patient's clinical characteristics, medical history, and potential risks and benefits.
• Close monitoring of the patient's renal function, blood pressure, and electrolyte levels is recommended, as well as regular assessment of the patient's cardiovascular risk factors and overall clinical condition.