When adding Jardiance (empagliflozin) to a regimen of glipizide and metformin, which medications need to be stopped or adjusted?

From the Guidelines

When adding Jardiance to a regimen of glipizide and metformin, the glipizide should be stopped or its dose reduced to prevent hypoglycemia, while metformin can typically be continued at the same dose. This is based on the recommendation from the KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease, which suggests that for patients in whom additional glucose-lowering may increase risk for hypoglycemia, it may be necessary to stop or reduce the dose of an antihyperglycemic drug other than metformin to facilitate addition of an SGLT2i 1.

Key Considerations

• Glipizide is a sulfonylurea that increases insulin secretion, and when combined with Jardiance, which works by increasing glucose excretion through the kidneys, the risk of low blood sugar increases.
• Metformin works through a different mechanism (decreasing hepatic glucose production and improving insulin sensitivity) and generally does not increase hypoglycemia risk when combined with Jardiance, so it can usually be maintained at the current dose.
• Patients should be advised to monitor their blood glucose levels more frequently during the first few weeks after adding Jardiance, particularly before meals and at bedtime, and educated about hypoglycemia symptoms and appropriate management.

Adjustments and Monitoring

• Consider reducing the glipizide dose by 25-50% when initiating Jardiance, with subsequent adjustments based on blood glucose monitoring.
• Patients should be closely monitored for signs of hypoglycemia, such as shakiness, sweating, and confusion, and know how to manage these symptoms appropriately.

From the FDA Drug Label

Empagliflozin pharmacokinetics were similar with and without coadministration of metformin, glimepiride, pioglitazone, sitagliptin, linagliptin, warfarin, verapamil, ramipril, and simvastatin in healthy volunteers and with or without coadministration of hydrochlorothiazide and torsemide in patients with type 2 diabetes Empagliflozin had no clinically relevant effect on the pharmacokinetics of metformin, glimepiride, pioglitazone, sitagliptin, linagliptin, warfarin, digoxin, ramipril, simvastatin, hydrochlorothiazide, torsemide, and oral contraceptives when coadministered in healthy volunteers

No medications need to be stopped when adding Jardiance (empagliflozin) to a regimen of glipizide and metformin, as there are no known significant interactions between these medications that would require stopping or adjusting any of the old DM meds, according to the provided drug label 2.

From the Research

Medication Adjustments when Adding Jardiance to Glipizide and Metformin

When adding Jardiance (empagliflozin) to a regimen of glipizide and metformin, the following considerations should be taken into account:

• The primary concern is the potential for increased risk of hypoglycemia when combining empagliflozin with glipizide, a sulfonylurea known to cause hypoglycemia 3.
• Studies have shown that empagliflozin can be safely added to metformin therapy, with significant improvements in HbA1c levels and weight reduction 4, 5.
• However, there is limited evidence to suggest that glipizide needs to be stopped or adjusted when adding empagliflozin to the regimen.
• One study found that adding empagliflozin to metformin and glimepiride (a sulfonylurea similar to glipizide) resulted in improved glycemic control without exacerbating toxicity 4.
• Another study compared the efficacy and safety of initial combinations of empagliflozin and metformin with empagliflozin and metformin monotherapy, but did not specifically address the addition of empagliflozin to a regimen of glipizide and metformin 5.

Key Considerations

• Monitor patients for signs of hypoglycemia when adding empagliflozin to a regimen of glipizide and metformin 3.
• Adjust the dose of glipizide as needed to minimize the risk of hypoglycemia.
• Consider the potential benefits of adding empagliflozin to the regimen, including improved glycemic control and weight reduction 4, 5.
• Be aware of the potential adverse effects of empagliflozin, including genital infections, kidney failure, and diabetic ketoacidosis 6.