Is it safe to start Jardiance (Empagliflozin) in a patient already taking Glipizide, Trulicity (Dulaglutide), and Glargine (Insulin Glargine)?

Adding Jardiance to a Regimen of Glipizide, Trulicity, and Glargine

It is safe to start Jardiance (empagliflozin) in a patient already taking glipizide, Trulicity (dulaglutide), and glargine (insulin glargine), but dose adjustments of existing medications are necessary to prevent hypoglycemia. 1, 2

Safety and Benefits of Adding Jardiance

Adding Jardiance to this medication regimen can provide several benefits:

• Cardiovascular and renal benefits independent of glucose control
• Weight loss effects
• Complementary mechanism of action to existing medications

However, this combination requires careful management due to the increased risk of hypoglycemia when combining an SGLT2 inhibitor with insulin and sulfonylureas.

Required Medication Adjustments

When adding Jardiance to this regimen, make the following adjustments:

1. Reduce glipizide dose by 50% (or discontinue if already on minimal dose) 1
2. Reduce total daily insulin glargine dose by approximately 20% 1, 2
3. Maintain Trulicity (dulaglutide) dose as GLP-1 RAs have a low inherent risk of hypoglycemia 1, 3

Monitoring Requirements

After starting Jardiance:

• Monitor blood glucose closely for the first 3-4 weeks 1
• Check renal function within the first several weeks, particularly in patients with baseline impairment 1
• Monitor for signs of volume depletion (orthostatic lightheadedness) 1
• Assess for genital mycotic infections (more common in women) 1, 2
• Watch for symptoms of diabetic ketoacidosis (nausea, vomiting, abdominal pain, fatigue) 2

Specific Dosing Considerations

• Start Jardiance at the standard dose of 10mg daily 1
• If eGFR is 30-44 ml/min/1.73m², maintain at 10mg daily 1
• If eGFR <30 ml/min/1.73m², Jardiance is not recommended for glycemic control 1

Potential Side Effects to Monitor

1. Hypoglycemia: Most significant risk with this combination therapy 1, 2
2. Genital mycotic infections: Advise patient about personal hygiene measures 1, 2
3. Urinary tract infections: Monitor for symptoms 2
4. Volume depletion: Particularly in elderly or those on diuretics 1
5. Diabetic ketoacidosis: Can occur even with normal blood glucose levels 2

Patient Education Points

Instruct the patient to:

• Monitor blood glucose more frequently during the first month
• Stay hydrated and maintain personal hygiene
• Report symptoms of genital infections promptly
• Seek immediate medical attention for nausea, vomiting, abdominal pain, or unusual fatigue (potential DKA symptoms)
• Be aware of hypoglycemia symptoms and management

Clinical Pearls

• The combination of Jardiance with insulin and sulfonylureas increases hypoglycemia risk, making dose reduction of these agents critical 1
• The diuretic effect of Jardiance may be additive with loop diuretics, requiring careful monitoring 1
• Patients with "brittle" diabetes or complex insulin regimens should have Jardiance initiated in collaboration with their diabetes care provider 1
• The cardiovascular benefits of SGLT2 inhibitors occur independent of their glucose-lowering effects 1

By following these guidelines, Jardiance can be safely added to a regimen of glipizide, Trulicity, and glargine with appropriate monitoring and dose adjustments.