Should a patient with end-stage renal disease (ESRD) and impaired urinary output, who is taking Jardiance (empagliflozin) for renal and cardiac protection, continue this medication?

Jardiance (Empagliflozin) Should Be Discontinued in End-Stage Renal Disease with No Urinary Output

Jardiance (empagliflozin) should be discontinued immediately in this end-stage renal disease patient who is no longer urinating and approaching hospice care, as it will provide no benefit and may cause harm.

Mechanism of Action and Limitations in ESRD

Jardiance works by inhibiting sodium-glucose cotransporter 2 (SGLT2) in the kidneys, which prevents glucose reabsorption and increases glucose excretion through urine. This mechanism requires:

1. Functioning kidneys with adequate filtration
2. Active urinary output

Why Jardiance Won't Work in This Patient:

• No urinary output: The patient is no longer urinating, making the medication's mechanism of action impossible 1, 2
• FDA contraindication: Jardiance is contraindicated in "severe renal impairment, end-stage renal disease, or dialysis" 2
• Minimum eGFR requirement: Jardiance should not be initiated if eGFR is below 45 mL/min/1.73 m² and should be discontinued if eGFR falls persistently below this threshold 2

Potential Risks of Continuing Jardiance

Continuing Jardiance in this situation poses several risks:

• Volume depletion: Can worsen hypotension in an already compromised patient 2
• Acute kidney injury: May further damage already failing kidneys 2
• Electrolyte imbalances: Particularly concerning in end-stage renal disease
• Drug interactions: May interact with other medications the patient is taking for end-of-life care 2

Explaining to the Family

When discussing with the family:

1. Explain the mechanism: "Jardiance works by helping the kidneys filter out sugar through urine. Since your loved one is no longer urinating, the medication cannot work."

2. Address misconceptions: "Jardiance does not directly improve heart or kidney function in ways that would benefit someone at this stage of kidney disease."

3. Focus on comfort: "At this stage, our priority is your loved one's comfort and quality of life. Continuing medications that no longer help may cause unnecessary side effects."

4. Discuss alternatives: "We will focus on medications that can provide comfort and manage symptoms effectively at this stage."

Evidence-Based Rationale

The 2023 American Diabetes Association guidelines clearly indicate that SGLT2 inhibitors like Jardiance require functioning kidneys to be effective 1. The EMPA-KIDNEY trial and other studies showing benefits of empagliflozin in chronic kidney disease specifically excluded patients with end-stage renal disease and those without urinary output 3, 4.

The FDA label explicitly contraindicates Jardiance in "severe renal impairment, end-stage renal disease, or dialysis" 2. This is because the medication cannot work without kidney function and urinary output, and may potentially cause harm.

Conclusion for End-of-Life Care

For a patient approaching hospice care with end-stage renal disease and no urinary output, the focus should shift to:

• Comfort measures
• Symptom management
• Discontinuation of medications that no longer provide benefit
• Medications that improve quality of life in the end-stage setting

Jardiance should be discontinued as part of appropriate medication optimization for end-of-life care.