What are the management guidelines for an outpatient with impaired renal function taking Jardiance (empagliflozin) and experiencing abdominal pain?

Management of Abdominal Pain in an Outpatient with Impaired Renal Function Taking Jardiance (Empagliflozin)

For an outpatient with impaired renal function experiencing abdominal pain while on Jardiance (empagliflozin), temporarily discontinue the medication immediately and ensure adequate hydration until symptoms resolve or for up to 3 days, whichever comes first. 1

Assessment and Initial Management

Immediate Steps

1. Temporarily discontinue Jardiance (empagliflozin) 1, 2

   • Empagliflozin should be stopped when patients experience significant symptoms like abdominal pain, especially with impaired renal function
   • This is consistent with sick day medication guidance for SGLT2 inhibitors

2. Assess hydration status and encourage fluid intake 1

   • Ensure patient can maintain adequate fluid intake
   • If unable to maintain hydration, consider urgent medical evaluation
   • Monitor for signs of volume depletion (lightheadedness, dizziness, decreased urine output)

3. Monitor renal function 1

   • Check eGFR and electrolytes promptly
   • Compare with baseline values to assess for acute kidney injury

When to Seek Immediate Medical Attention

Patient should contact healthcare provider immediately if: 1

• Unable to maintain fluid intake
• Symptoms persist beyond 72 hours
• Vomiting occurs more than 4 times in 12 hours
• Develops reduced level of consciousness or confusion
• Experiences significant drop in blood pressure
• Develops moderate or high ketones (if testing available)

Medication Considerations in Renal Impairment

SGLT2 Inhibitor Management

1. Empagliflozin and renal function 1, 2

   • For patients with eGFR <45 mL/min/1.73m², empagliflozin is not recommended for glycemic control
   • However, it can be used for cardiovascular and renal protection with eGFR as low as 20-30 mL/min/1.73m²
   • Acute kidney injury has been reported with empagliflozin use, especially during acute illness 2

2. Monitoring after restarting 3

   • Check renal function within 1 week of restarting medication
   • Expect a mild initial decrease in eGFR, which is generally not concerning

Potential Causes of Abdominal Pain with Empagliflozin

1. Direct medication effects

   • Gastrointestinal disturbances are known side effects
   • Volume depletion can cause abdominal symptoms

2. Serious complications to rule out

   • Diabetic ketoacidosis (can occur even with normal blood glucose) 2
   • Acute kidney injury 2
   • Urinary tract infection or genital infections 2

Resuming Medications

1. When to restart empagliflozin 1

   • Resume at usual dose within 24-48 hours of eating and drinking normally
   • If symptoms persist beyond 72 hours, consult healthcare provider before restarting

2. Special considerations

   • If renal function has worsened, reassess appropriateness of continuing empagliflozin
   • Consider dose adjustments for other medications that may be affected by changes in renal function 1

Common Pitfalls to Avoid

1. Failing to recognize diabetic ketoacidosis

   • SGLT2 inhibitors can cause euglycemic ketoacidosis (ketoacidosis without significantly elevated blood glucose)
   • Check ketones if available, even if blood glucose is not elevated 2

2. Overlooking drug interactions

   • SGLT2 inhibitors interact with nephrotoxic drugs, which can worsen adverse effects 4
   • The diuretic action can lead to volume depletion, especially with concurrent diuretics 4

3. Continuing medication during acute illness

   • SGLT2 inhibitors should be temporarily discontinued during acute illness with potential volume depletion 1
   • Failure to stop during illness increases risk of complications

4. Ignoring the need for medication review

   • Patients with CKD often have complex medication regimens requiring periodic comprehensive review 1
   • Consider all medications that may need dose adjustment based on renal function 1

By following these guidelines, you can effectively manage abdominal pain in an outpatient with impaired renal function who is taking empagliflozin, while minimizing risks and optimizing outcomes.