What is the workup and management for a patient on Jardiance (Empagliflozin) for Heart Failure with preserved Ejection Fraction (HFpEF) experiencing persistent severe hypoglycemia?

From the Guidelines

For a patient on empagliflozin (Jardiance) for HFpEF experiencing persistent severe hypoglycemia, the medication should be temporarily discontinued while urgent evaluation is performed. The workup should include:

• Confirming true hypoglycemia with laboratory glucose measurements and assessing for symptoms
• Comprehensive medication review to identify potential interactions (especially with insulin or sulfonylureas) 1
• Evaluation of renal function, as SGLT2 inhibitors like empagliflozin are recommended for patients with DM and HF if eGFR >30 mL/min/1.73 m2 1
• Liver function tests
• Assessment for other causes of hypoglycemia such as adrenal insufficiency or insulinoma Management includes:
• Immediate treatment of hypoglycemia with oral glucose (15-20g) if the patient is conscious, or IV dextrose if severe
• After stabilization, empagliflozin should be held until the cause is identified
• SGLT2 inhibitors like empagliflozin typically don't cause hypoglycemia when used alone, so an underlying cause or medication interaction is likely present 1
• If empagliflozin is determined to be contributory, alternative heart failure therapies such as ARNIs, beta-blockers, or mineralocorticoid receptor antagonists should be considered, as there is concordance amongst guidelines for management of HFpEF on the use of diuretics for symptomatic relief, SGLT2 inhibitors to provide prognostic benefit, and involvement of the wider MDT to provide holistic care 1 Close monitoring with home glucose checks and follow-up within 1-2 weeks is essential, and patients should be educated about hypoglycemia symptoms and management, including carrying glucose tablets and wearing medical identification.

From the FDA Drug Label

The incidence of hypoglycemia by study is shown in Table 3. The incidence of hypoglycemia increased when JARDIANCE was administered with insulin or sulfonylurea [see Warnings and Precautions (5. 5)] Hypoglycemia: Consider lowering the dose of insulin secretagogue or insulin to reduce the risk of hypoglycemia when initiating JARDIANCE (5.5)

The management of persistent severe hypoglycemia in a patient on Jardiance (Empagliflozin) for Heart Failure with preserved Ejection Fraction (HFpEF) includes:

• Lowering the dose of insulin secretagogue or insulin to reduce the risk of hypoglycemia
• Monitoring and treating hypoglycemia promptly
• Considering the patient's overall clinical situation and adjusting the treatment plan as needed 2
• Assessing and correcting volume status in patients with renal impairment, the elderly, in patients with low systolic blood pressure, and in patients on diuretics 2 The workup for persistent severe hypoglycemia may include:
• Assessing renal function and adjusting the treatment plan accordingly
• Monitoring for signs and symptoms of hypoglycemia and other adverse reactions
• Evaluating the patient's medication regimen and making adjustments as needed to minimize the risk of hypoglycemia 2 2

From the Research

Workup for Persistent Severe Hypoglycemia

• The workup for a patient on Jardiance (Empagliflozin) for Heart Failure with preserved Ejection Fraction (HFpEF) experiencing persistent severe hypoglycemia should include:
  • Checking the patient's blood glucose levels to confirm hypoglycemia
  • Reviewing the patient's medication list to identify any potential causes of hypoglycemia
  • Assessing the patient's renal function, as empagliflozin is contraindicated in patients with severe renal impairment 3
  • Evaluating the patient's cardiac function, as HFpEF can increase the risk of hypoglycemia

Management of Hypoglycemia

• The management of hypoglycemia in a patient on Jardiance for HFpEF should include:
  • Immediate treatment with glucose or glucagon to correct the hypoglycemia
  • Adjustment of the patient's medication regimen to prevent future episodes of hypoglycemia
  • Consideration of alternative antidiabetic medications that have a lower risk of hypoglycemia, such as SGLT2 inhibitors 4
  • Close monitoring of the patient's blood glucose levels and renal function to prevent future episodes of hypoglycemia

Considerations for SGLT2 Inhibitors

• SGLT2 inhibitors, such as empagliflozin, have been shown to have a low risk of hypoglycemia compared to other antidiabetic medications 5, 4
• However, SGLT2 inhibitors can increase the risk of genital infections and diabetic ketoacidosis, and should be used with caution in patients with a history of these conditions 6, 3
• The use of SGLT2 inhibitors in patients with HFpEF has been shown to reduce the risk of cardiovascular hospitalization and kidney injury 7