Is it safe to give Jardiance (empagliflozin) to a patient with congestive heart failure (CHF) who is on intravenous (IV) Lasix (furosemide) and midodrine?

From the Guidelines

Empagliflozin (Jardiance) can be safely administered to patients with congestive heart failure who are on IV furosemide (Lasix) and midodrine, but careful monitoring is essential. In fact, empagliflozin has demonstrated cardiovascular benefits in heart failure patients, including those with reduced ejection fraction, by reducing hospitalizations and cardiovascular mortality, as shown in the EMPA-REG OUTCOME trial 1. When combining these medications, monitor fluid status closely as both empagliflozin and furosemide have diuretic effects that could potentially lead to volume depletion or hypotension, especially during initial therapy. Blood pressure should be monitored regularly since midodrine is a vasopressor that increases blood pressure, while empagliflozin may cause modest blood pressure reduction. Renal function and electrolytes should be assessed before starting empagliflozin and periodically thereafter, as the combination with furosemide increases the risk of acute kidney injury and electrolyte imbalances.

The benefits of empagliflozin in heart failure patients have been consistently demonstrated in several trials, including the DAPA-HF trial 1 and the EMPEROR-Reduced trial 1. These trials have shown that empagliflozin reduces the risk of worsening heart failure and cardiovascular death in patients with heart failure, regardless of the presence or absence of type 2 diabetes. The typical starting dose for empagliflozin in heart failure is 10 mg once daily, which can be taken regardless of meals. Patients should be educated about potential symptoms of volume depletion (dizziness, lightheadedness) and instructed to maintain adequate hydration while avoiding excessive fluid intake that could exacerbate heart failure.

Key considerations when administering empagliflozin to patients with congestive heart failure on IV furosemide and midodrine include:

• Monitoring fluid status and blood pressure closely
• Assessing renal function and electrolytes before starting empagliflozin and periodically thereafter
• Educating patients about potential symptoms of volume depletion and the importance of maintaining adequate hydration
• Starting with a dose of 10 mg once daily and adjusting as needed. The most recent and highest quality study, the EMPEROR-Reduced trial 1, supports the use of empagliflozin in patients with heart failure, demonstrating a 21% reduction in the primary outcome of cardiovascular death or hospitalization for worsening heart failure.

From the FDA Drug Label

JARDIANCE causes intravascular volume contraction [see Warnings and Precautions (5. 1)] and can cause renal impairment [see Adverse Reactions (6. 1)]. There have been postmarketing reports of acute kidney injury, some requiring hospitalization and dialysis, in patients receiving SGLT2 inhibitors, including JARDIANCE; some reports involved patients younger than 65 years of age Before initiating JARDIANCE, consider factors that may predispose patients to acute kidney injury including hypovolemia, chronic renal insufficiency, congestive heart failure and concomitant medications (diuretics, ACE inhibitors, ARBs, NSAIDs)

The use of Jardiance in a patient with congestive heart failure (CHF) who is on intravenous (IV) Lasix (furosemide) and midodrine may increase the risk of acute kidney injury due to the potential for intravascular volume contraction and renal impairment.

• Key considerations:
  • Concomitant diuretic use: The patient is already on IV Lasix, which can increase the risk of hypovolemia and renal impairment.
  • CHF: The patient's underlying condition may predispose them to acute kidney injury.
  • Midodrine: Although not directly mentioned in the label, midodrine can increase blood pressure, which may affect renal function. It is not recommended to initiate Jardiance in this patient without careful consideration of the potential risks and close monitoring of renal function 2.

From the Research

Safety of Jardiance with IV Lasix and Midodrine in CHF Patients

• The use of Jardiance (empagliflozin) in patients with congestive heart failure (CHF) who are on intravenous (IV) Lasix (furosemide) and midodrine has been studied in various clinical trials 3, 4, 5, 6.
• Empagliflozin has been shown to reduce the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure and a reduced ejection fraction, with or without diabetes 4, 6.
• The EMPEROR-Reduced trial demonstrated that empagliflozin reduced the combined risk of death, hospitalization for heart failure, or an emergent/urgent heart failure visit requiring intravenous treatment 4.
• Additionally, the EMPACT-MI trial showed that empagliflozin reduced the risk of first and recurrent heart failure hospitalizations after myocardial infarction 5.
• However, the safety of empagliflozin in patients with CHF who are on IV Lasix and midodrine specifically has not been directly studied.
• A review of renal dysfunction in acute heart failure suggests that high furosemide doses can worsen renal function, but aggressive fluid removal may be beneficial in patients with fluid overload 7.
• The use of empagliflozin in patients with CHF who are on IV Lasix and midodrine may require careful monitoring of renal function and electrolyte levels, as well as adjustment of diuretic doses as needed 3, 4, 7.

Key Considerations

• Empagliflozin may reduce the risk of heart failure events in patients with CHF, but its safety and efficacy in patients on IV Lasix and midodrine require careful consideration 4, 5, 6.
• Monitoring of renal function, electrolyte levels, and diuretic doses is crucial when using empagliflozin in patients with CHF who are on IV Lasix and midodrine 3, 4, 7.
• Further studies are needed to fully understand the safety and efficacy of empagliflozin in this patient population 3, 4, 5, 6.