Do Not Discontinue Jardiance Based on A1C <6.5% Alone
You should NOT discontinue Jardiance (empagliflozin) simply because your A1C is below 6.5%, especially if you have cardiovascular disease, heart failure, or chronic kidney disease. The cardiovascular and kidney protective benefits of SGLT2 inhibitors like Jardiance are independent of their glucose-lowering effects and persist regardless of A1C levels 1, 2, 3.
Why Jardiance Should Be Continued Despite Low A1C
Cardiovascular and Kidney Protection is Independent of Glucose Control
The most critical point is that Jardiance provides mortality and morbidity benefits that have nothing to do with lowering blood sugar 4, 5. In the EMPA-REG OUTCOME trial, empagliflozin reduced:
- Cardiovascular death by 38%
- Heart failure hospitalization by 35%
- All-cause mortality by 32%
These benefits occurred regardless of baseline A1C levels and were maintained even when A1C was well-controlled 4, 6.
Current Guidelines Prioritize Organ Protection Over Glucose Targets
The 2025 ADA Standards explicitly state that SGLT2 inhibitors should be continued for cardiovascular and kidney benefit until dialysis or transplantation, even when glucose-lowering effect is minimal 1. The 2020 KDIGO guidelines similarly recommend SGLT2 inhibitors be used regardless of A1C targets in patients with type 2 diabetes and CKD 3.
The 2022 Mayo Clinic diabetic kidney disease guideline algorithm shows that SGLT2 inhibitors are recommended regardless of HbA1c when patients have cardiovascular disease, heart failure, or chronic kidney disease 2.
When to Consider Medication Adjustment
The A1C <6.5% Deintensification Guidance Applies to Different Medications
The American College of Physicians guidance about deintensifying therapy at A1C <6.5% specifically refers to medications that cause hypoglycemia or have unfavorable risk-benefit ratios at lower A1C levels 7. This includes:
- Sulfonylureas
- Insulin
- Other medications without proven cardiovascular/kidney benefits
This guidance does NOT apply to SGLT2 inhibitors, which do not cause hypoglycemia when used alone and provide benefits beyond glucose control 7, 8.
What You Should Actually Deintensify
If your A1C is <6.5%, you should instead consider:
- Reducing or stopping sulfonylureas (high hypoglycemia risk)
- Reducing insulin doses (hypoglycemia and weight gain risk)
- Stopping DPP-4 inhibitors (no mortality/morbidity benefit) 8
Keep the Jardiance and metformin 1, 3, 9.
Clinical Decision Algorithm
Continue Jardiance if ANY of these apply:
- History of cardiovascular disease (prior MI, stroke, peripheral artery disease)
- Heart failure (any ejection fraction)
- Chronic kidney disease (eGFR 20-90 mL/min/1.73 m²)
- High cardiovascular risk (multiple risk factors)
Consider discontinuation ONLY if ALL of these are true:
- A1C <6.5% AND
- No cardiovascular disease AND
- No heart failure AND
- No chronic kidney disease AND
- eGFR >90 mL/min/1.73 m² AND
- No other diabetes medications causing hypoglycemia
Even then, continuation may still be appropriate given the preventive benefits 5.
Important Caveats
Jardiance Efficacy Decreases at Lower eGFR
The glucose-lowering effect of Jardiance is minimal when eGFR <45 mL/min/1.73 m², but you should continue it for cardiovascular and kidney protection until dialysis 1, 4. The FDA label states not to initiate if eGFR <45, but if already on it, continue for organ protection 10.
Monitor for Adverse Effects
While continuing Jardiance, monitor for:
- Genital mycotic infections (more common in women)
- Volume depletion (especially if on diuretics)
- Urinary tract infections
- Diabetic ketoacidosis (rare, but stop during illness/surgery) 10
The 2025 Paradigm Shift
Modern diabetes management prioritizes preventing heart attacks, strokes, kidney failure, and death over achieving specific A1C targets 1, 5. The 2025 ADA algorithm explicitly shows SGLT2 inhibitors on the left side addressing "mitigation of diabetes-related complications and end-organ effects" separate from the glucose management pathway 1.
Bottom line: An A1C <6.5% is not a reason to stop Jardiance. The drug is protecting your heart and kidneys independent of its glucose-lowering effects.