What is the role of Jardiance (empagliflozin) in patients with prior restenosis after Percutaneous Coronary Intervention (PCI) placement?

Role of Empagliflozin (Jardiance) in Patients with Prior Restenosis After PCI

Empagliflozin (Jardiance) may be beneficial as add-on therapy for patients with prior restenosis after PCI, particularly those with diabetes mellitus, due to its cardiometabolic effects that can enhance the effectiveness of myocardial revascularization.

Background on Restenosis After PCI

Restenosis remains a significant clinical challenge following percutaneous coronary intervention (PCI). Understanding the factors contributing to restenosis is essential when considering additional therapeutic options:

• Angiographic restenosis occurs in approximately 17-32% of patients with bare-metal stents (BMS) and at lower rates with drug-eluting stents (DES) 1
• Risk factors for restenosis include:
  • Diabetes mellitus 1
  • Small vessel size 1
  • LAD lesion location 1
  • Shorter time between initial and subsequent PCI 1
  • Stent length 1
  • Higher residual percent diameter stenosis 1

Diabetes and Restenosis Risk

Diabetes significantly increases the risk of restenosis after PCI:

• Patients with diabetes have higher rates of restenosis compared to non-diabetic patients 1
• The progressive nature of atherosclerotic disease, marked endothelial dysfunction, and platelet/coagulation abnormalities in diabetes contribute to less favorable outcomes after revascularization 1
• Diabetes is an independent predictor of adverse outcomes after PCI 1

Empagliflozin's Cardiometabolic Effects Relevant to PCI Patients

Recent evidence suggests empagliflozin may provide benefits beyond glycemic control that are particularly relevant to patients with prior restenosis:

1. Cardiovascular Mortality Reduction:

   • Empagliflozin significantly reduced cardiovascular mortality (38% relative risk reduction) in patients with type 2 diabetes and established cardiovascular disease 2

2. Heart Failure Prevention:

   • Reduced hospitalization for heart failure by 35% 2
   • This benefit was observed across the spectrum of cardiovascular disease and heart failure risk 2

3. Renal Protection:

   • Reduced incident or worsening nephropathy by 39% 2
   • Reduced progression to macroalbuminuria by 38% 2

4. Specific Benefits in PCI Patients:

   • In patients undergoing elective PCI, empagliflozin treatment started one month prior to PCI and continued for 11 months demonstrated:
     • Improved glycemic control (lower fasting glucose and HbA1c) 3
     • Reduced total cholesterol by 5.56% and LDL cholesterol by 3.67% 3
     • Decreased visceral adipose tissue area by 5.83% 3
     • Enhanced effectiveness of myocardial revascularization 3

Practical Approach to Using Empagliflozin in Patients with Prior Restenosis

For patients with prior restenosis after PCI, consider the following algorithm:

1. Identify High-Risk Patients:

   • Patients with diabetes mellitus (primary candidates)
   • Patients with multiple risk factors for restenosis
   • Patients with history of heart failure or at risk for heart failure

2. Timing of Initiation:

   • Consider initiating empagliflozin approximately one month prior to planned elective PCI 3
   • For patients with history of restenosis, consider adding empagliflozin to existing therapy

3. Dosing:

   • Start with empagliflozin 10 mg daily 3
   • May titrate to 25 mg daily based on glycemic control and tolerability

4. Monitoring:

   • Assess glycemic parameters (HbA1c, fasting glucose)
   • Monitor renal function (eGFR)
   • Evaluate lipid profile
   • Regular cardiovascular assessment

Important Considerations and Precautions

1. Patient Selection:

   • Most evidence supports use in patients with type 2 diabetes and established cardiovascular disease 2
   • Benefits may be greatest in patients with history of heart failure or at risk for heart failure 4, 2

2. Potential Adverse Effects:

   • Genital infections
   • Risk of diabetic ketoacidosis
   • Potential volume depletion, especially with concomitant diuretics
   • Possible hepatotoxicity 4

3. Drug Interactions:

   • Caution with nephrotoxic drugs which may aggravate adverse effects 4
   • Diuretic action may interact with other diuretics or antihypertensive drugs 4

Conclusion

While traditional management of restenosis has focused on mechanical interventions (repeat PCI with DES) 1, adding empagliflozin to the treatment regimen of patients with prior restenosis after PCI, particularly those with diabetes, may provide additional cardiovascular and metabolic benefits that could potentially reduce the risk of subsequent adverse events. The evidence is strongest for patients with type 2 diabetes and established cardiovascular disease, where empagliflozin has demonstrated significant reductions in cardiovascular mortality and heart failure hospitalizations.