Can I add Jardiance (Empagliflozin) to a regimen of Linagliptin (Tradjenta) and Amaryl (Glimepiride) in an 82-year-old patient with Diabetes Mellitus (DM) and Chronic Kidney Disease (CKD)?

Adding Jardiance to Linagliptin and Amaryl in an 82-year-old with DM and CKD

Yes, adding Jardiance (empagliflozin) to the current regimen of Linagliptin and Amaryl is strongly recommended for this 82-year-old patient with diabetes and CKD, as it offers significant cardiovascular and kidney protection benefits. 1

Rationale for Adding Empagliflozin

SGLT2 inhibitors like empagliflozin have demonstrated substantial benefits in patients with CKD:

• KDIGO 2024 guidelines specifically recommend treating patients with type 2 diabetes, CKD, and an eGFR ≥20 ml/min per 1.73 m² with an SGLT2 inhibitor (strong recommendation, 1A evidence) 1
• Empagliflozin has shown a 28% reduction in the risk of kidney disease progression or cardiovascular death in patients with CKD (EMPA-KIDNEY trial) 2
• The benefits of empagliflozin are consistent across different primary kidney diseases and eGFR ranges 3

Medication Compatibility and Dosing

Current Medications Assessment:

• Linagliptin (Tradjenta): No dose adjustment required in CKD, making it an appropriate DPP-4 inhibitor choice 1
• Glimepiride (Amaryl): Requires caution in elderly and CKD patients due to hypoglycemia risk; consider dose reduction 1

Adding Empagliflozin:

• Start with 10 mg daily if eGFR ≥30 ml/min/1.73 m² 1
• If eGFR is between 20-30 ml/min/1.73 m², empagliflozin can still be initiated at 10 mg daily for kidney and cardiovascular benefits, though glucose-lowering effect will be reduced 2, 3
• Not recommended if eGFR <20 ml/min/1.73 m² 1

Safety Considerations

Hypoglycemia Risk:

• The combination of empagliflozin with glimepiride increases hypoglycemia risk 1
• Important action: Consider reducing glimepiride dose by 25-50% when adding empagliflozin, especially in this elderly patient 1

Other Safety Considerations:

1. Monitor for genital mycotic infections
2. Advise on proper hydration to prevent volume depletion
3. Temporarily withhold during acute illness, surgery, or prolonged fasting to reduce DKA risk 1
4. Monitor kidney function within 2-4 weeks after initiation 1

Monitoring Plan

1. Check serum creatinine, eGFR, and potassium within 2-4 weeks of starting empagliflozin
2. Monitor for signs of hypoglycemia, especially in the first few weeks
3. Assess for volume depletion symptoms (dizziness, orthostatic hypotension)
4. Continue empagliflozin even if eGFR falls below initial threshold, unless not tolerated or kidney replacement therapy is initiated 1

Common Pitfalls to Avoid

1. Failing to reduce sulfonylurea dose: In elderly patients with CKD, the risk of hypoglycemia is substantial when adding an SGLT2 inhibitor to a sulfonylurea
2. Not monitoring kidney function: While empagliflozin is kidney-protective, initial transient eGFR decline may occur
3. Overlooking sick day management: Provide clear instructions to hold empagliflozin during acute illness
4. Inadequate hydration: Ensure patient maintains adequate fluid intake to prevent volume depletion

In summary, adding empagliflozin to this patient's regimen offers significant kidney and cardiovascular benefits that outweigh the risks, provided appropriate monitoring and dose adjustments of glimepiride are implemented.