When to add Jardiance (empagliflozin) to a patient with type 2 diabetes mellitus (DM II) not responding to metformin?

When to Add Jardiance to Type 2 Diabetes Not Responding to Metformin

Jardiance (empagliflozin) should be added to metformin when a patient with type 2 diabetes has inadequate glycemic control (HbA1c ≥7%) despite maximum tolerated metformin therapy, especially in patients with established cardiovascular disease, heart failure, or chronic kidney disease. 1

Patient Selection for Jardiance Addition

Primary Indications for Adding Jardiance:

• Inadequate glycemic control (HbA1c ≥7%) on maximum tolerated metformin dose 2
• Presence of any of the following:
  • Established cardiovascular disease (ASCVD)
  • Heart failure (particularly HFrEF)
  • Chronic kidney disease (diabetic nephropathy with albuminuria)
  • Multiple cardiovascular risk factors

Clinical Decision Algorithm:

1. Assess glycemic control:

   • If HbA1c ≥7% despite maximum tolerated metformin (typically 2000mg/day), consider adding Jardiance

2. Evaluate cardiovascular and renal status:

   • If patient has established ASCVD, heart failure, or diabetic kidney disease, prioritize Jardiance addition regardless of HbA1c level 1
   • For patients with multiple CV risk factors (hypertension, dyslipidemia, obesity), Jardiance provides additional benefit beyond glucose control

3. Check renal function:

   • Confirm eGFR ≥30 mL/min/1.73m² (Jardiance is not recommended for glycemic control if eGFR <45 mL/min/1.73m²) 1
   • For patients with eGFR 30-44 mL/min/1.73m², Jardiance 10mg daily can be used for cardiovascular and renal benefits, though glucose-lowering efficacy will be reduced 1

Dosing and Administration

• Start with Jardiance 10 mg once daily (lowest effective dose) 1
• No dose titration is required for cardiovascular or renal risk reduction 1
• Monitor response to therapy and adjust other antihyperglycemic agents if necessary

Special Considerations

Cardiovascular Benefits:

• Empagliflozin is specifically recommended to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease 1
• Reduces risk of hospitalization for heart failure 1

Renal Benefits:

• Reduces progression of diabetic kidney disease 1
• Consider in patients with albuminuria for renoprotective effects

Weight Management:

• Provides additional benefit of weight reduction (approximately 2-2.5 kg) 2

Blood Pressure:

• Modest reduction in systolic and diastolic blood pressure 2

Precautions and Contraindications

Do not start Jardiance if:

• Patient is pregnant or breastfeeding
• eGFR <30 mL/min/1.73m² 1
• History of serious hypersensitivity to empagliflozin

Use with caution in:

• Patients at risk for volume depletion (consider reducing diuretic dose)
• Patients with history of genital mycotic infections
• Patients at risk for diabetic ketoacidosis
• Discontinue at least 3 days before planned surgery 1

Monitoring After Initiation

• Monitor renal function
• Watch for signs of genital mycotic infections
• Monitor for euglycemic diabetic ketoacidosis
• Assess for volume depletion, particularly in elderly patients

Clinical Pearls

• Unlike many other diabetes medications, SGLT2 inhibitors like Jardiance work independently of insulin and can be used at any stage of type 2 diabetes 3
• Consider Jardiance early in the treatment algorithm for patients with cardiovascular disease, as it has demonstrated mortality benefit 1
• The cardiovascular and renal benefits of Jardiance appear to be independent of its glucose-lowering effects 1
• If a patient has both cardiovascular disease and heart failure, Jardiance would be preferred over a GLP-1 receptor agonist 1

By following this approach, you can optimize the timing of Jardiance addition to maximize both glycemic control and cardiorenal protection in patients with type 2 diabetes not responding adequately to metformin.