What is the recommended use and dosage of Jardiance (empagliflozin) in patients with type 2 diabetes?

Jardiance (Empagliflozin) in Type 2 Diabetes: Recommended Use and Dosage

Jardiance (empagliflozin) is recommended at a starting dose of 10 mg once daily in the morning (with or without food) for patients with type 2 diabetes, with possible increase to 25 mg daily if tolerated, and should not be initiated in patients with eGFR less than 45 mL/min/1.73 m². 1

Indications and Benefits

Empagliflozin is FDA-approved for:

• Improving glycemic control in adults with type 2 diabetes as an adjunct to diet and exercise
• Reducing the risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 1

Beyond glycemic control, empagliflozin offers several important clinical benefits:

• Cardiovascular protection: In the EMPA-REG OUTCOME trial, empagliflozin reduced:

  • Cardiovascular death by 38% (absolute rate 3.7% vs 5.9%, HR 0.62) 2
  • Hospitalization for heart failure by 35% 2
  • Overall mortality by 32% 2

• Renal protection: Empagliflozin slows progression of kidney disease and reduces clinically relevant renal events in patients with type 2 diabetes at high cardiovascular risk 3

Dosing Guidelines

• Starting dose: 10 mg once daily in the morning, with or without food 1
• Dose titration: May increase to 25 mg daily if tolerated 1
• Renal function considerations:
  • Assess renal function before starting therapy
  • Do not initiate if eGFR <45 mL/min/1.73 m²
  • Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 1

Patient Selection and Considerations

Empagliflozin is particularly beneficial for patients with:

• Type 2 diabetes with established cardiovascular disease 2
• Heart failure with reduced ejection fraction (HFrEF) 2
• Heart failure with preserved ejection fraction (HFpEF) 2
• Diabetic kidney disease 3

Contraindications

• History of serious hypersensitivity to empagliflozin
• Severe renal impairment (eGFR <45 mL/min/1.73 m²)
• End-stage renal disease or dialysis 1

Important Safety Considerations

1. Volume depletion: Correct volume status before initiation, especially in:

   • Elderly patients
   • Patients with renal impairment
   • Patients with low systolic blood pressure
   • Patients on diuretics 1

2. Ketoacidosis risk: Monitor for signs of ketoacidosis regardless of blood glucose levels 1

3. Surgery: Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 2

4. Medication adjustments: If HbA1c is well-controlled at baseline or patient has history of hypoglycemia:

   • Consider weaning/stopping sulfonylureas or glinides
   • Consider reducing total daily insulin dose by ~20% when starting therapy 2

5. Common adverse effects:

   • Genital fungal infections
   • Urinary tract infections
   • Euglycemic diabetic ketoacidosis 2

Clinical Pearls

• Unlike canagliflozin, empagliflozin has not been associated with increased risk of amputation or bone fractures 4
• Benefits on heart failure outcomes appear consistent regardless of baseline heart failure risk 5
• The cardiovascular and renal benefits appear to be a class effect of SGLT2 inhibitors and are largely independent of glucose-lowering effects 2
• Empagliflozin's diuretic effect likely contributes to its rapid impact on mortality and heart failure outcomes 6

By following these guidelines for appropriate patient selection, dosing, and monitoring, empagliflozin can be a valuable treatment option for type 2 diabetes management, particularly in patients with or at high risk for cardiovascular disease.