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

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

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 the option to increase to 25 mg daily if tolerated. 1

Indications

Jardiance is indicated for:

• Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus
• Reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease 1

The medication has demonstrated significant benefits beyond glycemic control:

• 38% reduction in cardiovascular mortality
• 32% reduction in all-cause mortality
• 35% reduction in hospitalization for heart failure 2

Dosing Guidelines

Initial Dosing

• Start with 10 mg once daily in the morning
• Can be taken with or without food
• May increase to 25 mg daily in patients who tolerate the medication well 1

Renal Dosing Adjustments

• Assess renal function prior to initiation and periodically thereafter
• Do not initiate if eGFR is less than 45 mL/min/1.73 m²
• No dose adjustment needed for eGFR ≥45 mL/min/1.73 m²
• Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 1

Patient Selection Considerations

Empagliflozin is particularly beneficial for patients with:

1. Established cardiovascular disease
2. Heart failure (with reduced or preserved ejection fraction)
3. Chronic kidney disease
4. Need for weight loss (typically 2-3 kg) 2

Clinical Benefits

Cardiovascular Benefits

• 14% reduction in composite outcome of MI, stroke, and cardiovascular death in patients with established cardiovascular disease 2
• 21% reduction in composite of cardiovascular death or hospitalization for worsening heart failure in patients with HFrEF 3
• Benefits observed across the spectrum of heart failure risk, including those with low, high, and very high risk 4

Renal Benefits

• 44% reduction in doubling of serum creatinine
• 55% lower risk of requiring renal replacement therapy
• 39% reduction in progression to macroalbuminuria 5

Monitoring and Safety Considerations

Before Initiating

• Assess volume status and correct volume depletion if present
• Evaluate renal function
• Consider potential drug interactions, especially with diuretics or other antihypertensives 1

Ongoing Monitoring

• Renal function
• Signs of hypotension, particularly in elderly patients, those with renal impairment, or those on diuretics
• Signs of diabetic ketoacidosis, regardless of blood glucose levels
• Genital mycotic infections 2, 1

Key Adverse Effects

• Genital fungal infections (most common)
• Urinary tract infections
• Volume depletion/hypotension
• Risk of euglycemic diabetic ketoacidosis (rare but serious) 2, 1

Important Precautions

• Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 3
• If patient has well-controlled HbA1c or history of hypoglycemia, consider reducing doses of sulfonylureas or insulin (typically by ~20%) when starting empagliflozin 3
• May contribute to intravascular volume contraction; consider reducing diuretic doses if applicable 3
• Contraindicated in patients with:
  • History of serious hypersensitivity to empagliflozin
  • Severe renal impairment (eGFR <30 mL/min/1.73 m²)
  • End-stage renal disease
  • Dialysis 1

Placement in Therapy

Empagliflozin is recommended as a preferred second-line agent after metformin for patients with type 2 diabetes, particularly those with established cardiovascular disease, heart failure, or chronic kidney disease 2. Its cardiovascular and renal benefits appear to be largely independent of its glucose-lowering effects, making it valuable beyond glycemic control alone 6.