Can empagliflozin (Jardiance) be initiated in a patient in their late 80s with type 2 diabetes mellitus and chronic kidney disease?

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Last updated: October 1, 2026 • View editorial policy

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Can You Start Jardiance on a Patient in Their Late 80s or Older Who Has Diabetes and Chronic Kidney Disease?

Yes, you can and should initiate empagliflozin (Jardiance) in patients in their late 80s with type 2 diabetes and chronic kidney disease, provided their eGFR is ≥20 mL/min/1.73 m² and they are not on dialysis. Age alone is not a contraindication, and the cardiovascular and kidney protective benefits extend to elderly patients.

Evidence Supporting Use in Elderly Patients

The FDA label explicitly addresses geriatric use and confirms safety and efficacy in older adults 1. In heart failure studies, EMPEROR-Reduced included 503 patients (27%) aged ≥75 years, and EMPEROR-Preserved included 1,281 patients (43%) aged ≥75 years, with similar safety and efficacy profiles compared to younger patients 1.

Key guideline recommendations strongly support SGLT2 inhibitor use regardless of age:

  • The 2022 KDIGO guideline recommends treating patients with type 2 diabetes, CKD, and eGFR ≥20 mL/min/1.73 m² with an SGLT2 inhibitor (Strong Recommendation, 1A evidence) 2, 3
  • The 2022 ADA Standards recommend SGLT2 inhibitors to reduce CKD progression and cardiovascular events in patients with eGFR ≥20 mL/min/1.73 m² 4
  • The 2025 ADA Standards reinforce that SGLT2 inhibitors can be initiated if eGFR is above 20 mL/min/1.73 m² 5

Specific Considerations for Elderly Patients

Increased Monitoring Requirements

While empagliflozin is safe in elderly patients, those aged ≥75 years have higher rates of certain adverse events that require closer monitoring 1:

  • Volume depletion: Increased from 2.1% (placebo) to 4.4% (empagliflozin 25 mg) in patients ≥75 years
  • Urinary tract infections: Increased from 10.5% (placebo) to 15.1-15.7% (empagliflozin) in patients ≥75 years

Practical Initiation Strategy

Start with empagliflozin 10 mg once daily 2, 1. The 10 mg dose provides substantial kidney and cardiovascular protection while potentially reducing adverse event risk in this vulnerable population.

Before initiating, assess:

  • Current eGFR (must be ≥20 mL/min/1.73 m²)
  • Volume status and concurrent diuretic use
  • Risk factors for genital mycotic infections
  • Concurrent insulin or sulfonylurea use (may need dose reduction to prevent hypoglycemia)

Key contraindications to verify:

  • Not on dialysis (absolute contraindication) 1
  • eGFR not <20 mL/min/1.73 m² for initiation 2, 6

Expected Benefits in This Population

The cardiovascular and kidney benefits are particularly important in elderly patients with diabetes and CKD:

  • Mortality reduction: All-cause mortality reduced by 31% in DAPA-CKD trial 7
  • Kidney protection: 44% reduction in composite renal outcomes including sustained eGFR decline, end-stage kidney disease, or renal death 7
  • Cardiovascular protection: 29% reduction in cardiovascular death or heart failure hospitalization 7

Monitoring After Initiation

Expect an initial eGFR dip of 3-5 mL/min/1.73 m² within the first 4 weeks 6, 8. This is a hemodynamic effect, not kidney injury, and is not a reason to discontinue therapy 2, 6. The eGFR typically stabilizes and may improve over subsequent months 9, 8.

Follow-up schedule:

  • Reassess volume status, blood pressure, and eGFR at 2-4 weeks
  • Monitor for genital mycotic infections (higher risk in elderly)
  • Check for hypoglycemia if on insulin or sulfonylureas
  • Continue regular monitoring every 3-6 months 3

Common Pitfalls to Avoid

  1. Don't withhold based on age alone - The evidence shows similar efficacy and acceptable safety in patients ≥75 years 1
  2. Don't stop for the initial eGFR dip - This is expected and reversible 6, 8
  3. Don't wait for "optimal" glycemic control - SGLT2 inhibitors should be initiated for kidney and cardiovascular protection independent of HbA1c 2, 5, 3
  4. Don't discontinue if eGFR falls below 20 after initiation - Once started, empagliflozin can be continued even if eGFR declines below 20 mL/min/1.73 m² until dialysis is initiated 2, 6

Special Situations

If the patient has heart failure: The indication is even stronger, with robust evidence from EMPEROR trials showing benefit regardless of diabetes status 7.

If eGFR is 20-30 mL/min/1.73 m²: Initiation is still recommended, though glucose-lowering efficacy is diminished at this level 10, 1. The primary benefit is kidney and cardiovascular protection, not glycemic control.

Sick day management: Educate patients to temporarily withhold empagliflozin during acute illness, excessive exercise, or procedures requiring fasting to reduce ketoacidosis risk 2, 6.

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.