What are the risks of using Jardiance (Empagliflozin) in an 80-year-old patient with potential Impaired renal function?

Risks of Using Jardiance (Empagliflozin) in an 80-Year-Old Patient

In an 80-year-old patient, Jardiance (empagliflozin) carries significant risks of volume depletion, urinary tract infections, and reduced efficacy due to age-related renal impairment, requiring careful monitoring and potentially lower dosing. 1

Key Risks in Elderly Patients

Volume Depletion and Hypotension

• The risk of volume depletion-related adverse reactions significantly increases in patients ≥75 years old:
  • 4.4% with Jardiance 25 mg vs. 2.1% with placebo 1
  • May lead to orthostatic hypotension, dizziness, and falls
  • Particularly concerning in elderly who may have impaired baroreceptor responses 2

Urinary Tract Infections

• Higher incidence in patients ≥75 years:
  • 15.7% with Jardiance 10 mg and 15.1% with Jardiance 25 mg vs. 10.5% with placebo 1
  • Elderly patients are more susceptible to complications from UTIs

Reduced Efficacy with Renal Impairment

• Jardiance has diminished glycemic efficacy in elderly patients with renal impairment 1
• The glucose-lowering benefit decreases with worsening renal function 1
• Not recommended in severe renal impairment (eGFR <30 mL/min/1.73m²) 1

Polypharmacy Concerns

• Elderly patients often take multiple medications, increasing risk of drug interactions 2
• 29-45% of nursing home residents are prescribed at least one potentially inappropriate medication 2
• Prescription of potentially inappropriate medications is particularly frequent in individuals with renal impairment 2

Monitoring Recommendations

Renal Function Assessment

• Monitor eGFR every 3-6 months in those at risk for decline in kidney function 2
• Assess renal function before starting and periodically during treatment 1

Hydration Status

• Monitor for signs of dehydration and hypotension, particularly during initial treatment period
• Consider temporary discontinuation during acute illness that may compromise renal function 2

Medication Review

• Review all current medications before prescribing Jardiance to avoid harmful interactions 2
• Consider simplification of complex treatment plans to reduce polypharmacy burden 2

Benefits to Consider Against Risks

Despite these risks, Jardiance has shown:

• Cardiovascular protection in the EMPA-REG OUTCOME trial 3
• Renal protection with slower progression of kidney disease 4
• Consistent efficacy and safety across age groups, including patients ≥75 years, in heart failure with reduced ejection fraction 5
• Significant reduction in progression of kidney disease in patients with chronic kidney disease 6

Practical Recommendations

1. Start with the lower dose (10 mg) if Jardiance is deemed appropriate 1
2. Ensure adequate hydration and monitor blood pressure regularly
3. Assess renal function before initiation and periodically during treatment
4. Educate the patient about symptoms of UTIs and volume depletion
5. Consider alternative glucose-lowering agents with lower risk of hypoglycemia if renal function is significantly impaired 2
6. Temporarily discontinue during acute illness, procedures, or hospitalizations 2

Contraindications

• Severe renal impairment (eGFR <30 mL/min/1.73m²) 1
• End-stage renal disease or dialysis 1
• Patients at high risk for volume depletion who cannot be adequately monitored 1

Remember that elderly patients often present with atypical symptoms of hyperglycemia and adverse drug reactions, making careful monitoring essential when using Jardiance in this population 2.