What is the estimated glomerular filtration rate (eGFR) cut off for initiating Jardiance (Empagliflozin)?

Jardiance (Empagliflozin) eGFR Cut-off for Initiation

Jardiance (empagliflozin) should not be initiated in patients with an eGFR less than 45 mL/min/1.73 m². 1

Renal Function Requirements for Empagliflozin

Empagliflozin has specific renal function requirements that must be followed for safe and effective use:

• Initial Assessment: Assessment of renal function is required prior to starting Jardiance
• Minimum eGFR for Initiation: 45 mL/min/1.73 m² or higher 1
• No Dose Adjustment: No dose adjustment needed for patients with eGFR ≥45 mL/min/1.73 m² 2
• Discontinuation Threshold: Jardiance should be discontinued if eGFR falls persistently below 45 mL/min/1.73 m² 1

Clinical Considerations

Efficacy Considerations

• The glucose-lowering efficacy of SGLT2 inhibitors diminishes as eGFR declines, particularly below 45 mL/min/1.73 m² 2
• Despite reduced glycemic effects, cardiovascular and renal benefits may persist at lower eGFR levels 2

Continuation After Initiation

• Once initiated, it may be reasonable to continue empagliflozin even if eGFR falls below the initiation threshold, until it reaches a level requiring discontinuation 2
• The EMPA-KIDNEY trial showed benefits in patients with eGFR as low as 20 mL/min/1.73 m², but this was in the context of a clinical trial with close monitoring 3, 4

Monitoring Requirements

• Regular monitoring of renal function is essential after starting empagliflozin 1
• Expect a modest initial decline in eGFR (2-5 mL/min/1.73 m²) within the first 2-4 weeks, which is generally hemodynamic and reversible 5
• This initial "eGFR dip" is not usually an indication to discontinue therapy 2

Special Populations

Patients with Heart Failure

• In patients with heart failure, empagliflozin has shown benefits across a broad range of baseline kidney function, including eGFR as low as 20 mL/min/1.73 m² in clinical trials 6
• The ADA recommends SGLT2 inhibitors for patients with heart failure (with either reduced or preserved ejection fraction) for glycemic management and prevention of heart failure hospitalizations 2

Patients with CKD

• For patients with CKD and eGFR ≥20 mL/min/1.73 m² with urine albumin-to-creatinine ratio ≥200 mg/g, SGLT2 inhibitors are strongly recommended for kidney protection 2
• However, the FDA label for empagliflozin specifically states not to initiate if eGFR <45 mL/min/1.73 m² 1

Common Pitfalls to Avoid

1. Failure to assess baseline renal function: Always check eGFR before initiating Jardiance
2. Misinterpreting the initial eGFR dip: A small initial decline in eGFR is expected and not usually a reason to discontinue therapy
3. Overlooking contraindications: Severe renal impairment, end-stage renal disease, or dialysis are contraindications for empagliflozin 1
4. Not monitoring for adverse effects: Watch for volume depletion, especially in elderly patients or those on diuretics
5. Confusing initiation vs. continuation thresholds: The eGFR threshold for initiation (≥45 mL/min/1.73 m²) is different from what might be acceptable for continuation in some clinical contexts

Remember that while clinical trial data may suggest benefits at lower eGFR levels, the FDA-approved labeling should guide clinical practice in standard care settings.