What A1c (glycated hemoglobin) level is too high to initiate Jardiance (empagliflozin)?

From the Guidelines

There is no specific A1c level that is too high to initiate Jardiance (empagliflozin). Jardiance can be prescribed for patients with type 2 diabetes regardless of how elevated their A1c is, and in fact, patients with higher A1c levels may benefit significantly from its glucose-lowering effects. The standard starting dose is 10 mg once daily, taken in the morning, with or without food, which can be increased to 25 mg daily if needed and tolerated. Before initiating Jardiance, healthcare providers should assess kidney function, as it is not recommended for patients with an eGFR below 30 mL/min/1.73m², as noted in general guidelines for SGLT2 inhibitors 1. Patients should be informed about potential side effects including genital mycotic infections, urinary tract infections, and the rare but serious risk of diabetic ketoacidosis. Jardiance works by inhibiting sodium-glucose cotransporter-2 (SGLT2) in the kidneys, which increases urinary glucose excretion and reduces blood glucose levels independently of insulin action. This mechanism makes it effective across a wide range of A1c values and particularly beneficial for patients with cardiovascular disease or chronic kidney disease, as it has demonstrated cardiovascular and renal protective effects.

Key considerations for initiating Jardiance include:

• Assessing kidney function before starting the medication, as it is contraindicated in patients with severe renal impairment (eGFR below 30 mL/min/1.73m²) 1.
• Monitoring for potential side effects, including but not limited to, genital mycotic infections and urinary tract infections.
• Recognizing the benefits of Jardiance in patients with higher A1c levels, as it can provide significant glucose-lowering effects, and its use is supported by guidelines for the management of type 2 diabetes, which emphasize individualized treatment goals and the consideration of factors such as disease duration, baseline glycemia, and previous therapy 1.

Given the most recent and highest quality evidence, the decision to initiate Jardiance should be based on individual patient factors and not solely on the A1c level, as the medication's benefits can extend to patients across a wide range of glycemic control levels, particularly those with cardiovascular or renal comorbidities, as highlighted in more recent clinical guidelines and recommendations 1.

From the Research

A1c Levels and Jardiance Initiation

• The provided studies do not directly address the specific A1c level that is too high to initiate Jardiance (empagliflozin) 2.
• However, the studies suggest that the decision to initiate Jardiance should be based on individual patient factors, such as cardiovascular risk and glycemic control 2, 3.
• One study found that empagliflozin had a moderate glucose-lowering effect, with an average reduction in HbA1c of 0.5% compared to placebo 2.
• Another study suggested that insulin initiation at lower levels of A1c improves goal attainment and independently increases glycemic response 4.
• The American Diabetes Association and the European Association for the Study of Diabetes recommend individualizing the treatment approach to glucose control, considering factors such as age, health behaviors, comorbidities, and life expectancy 3.

Glycemic Control and Treatment Intensification

• Clinical inertia should be prevented with timely intensification of therapy when HbA1c levels are greater than 7% (or rising above a patient's individual target) according to national guidelines 3.
• Increased personalization in the intensification of type 2 diabetes treatment is necessary to improve HbA1c targets while addressing risk of hypoglycemia, concern about weight gain, and overall health goals 3.
• Healthcare providers are encouraged to address glycemic control with a variety of strategies, including prandial insulin, while developing evidence-based treatment plans on the basis of algorithms discussed in the literature 3.

Predictors of Glycemic Control

• Higher pre-treatment HbA1c, younger age, female sex, shorter diabetes duration, higher serum creatinine, and being an ex-smoker predicted time until A1c > or =8.0% or glucose-lowering therapy was intensified 5.
• Pre-insulin A1c was responsible for nearly all the explained variance in A1c change, with each one percentage point of pre-insulin A1c reducing the probability of attaining <7% by 26% 4.