What dose of Jardiance (empagliflozin) should be started in a patient with hyperglycemia, currently on metformin 1000mg twice daily (bid), with an A1C of 11.6?

Jardiance (Empagliflozin) Dosing for Patient with A1C 11.6% on Metformin

For a patient with an A1C of 11.6% who is currently on metformin 1000mg twice daily, Jardiance should be initiated at the lowest available dose of 10 mg once daily taken in the morning, with or without food.

Rationale for Starting Dose

According to the American College of Cardiology expert consensus guidelines, SGLT2 inhibitors with demonstrated cardiovascular benefit (like empagliflozin) should be initiated at the lowest available dose 1. The FDA-approved prescribing information for Jardiance specifically states that the recommended starting dose is 10 mg once daily in the morning, taken with or without food 2.

Dosing Considerations

• Starting dose: 10 mg once daily in the morning
• Timing: Can be taken with or without food
• Potential for dose increase: In patients tolerating the initial 10 mg dose, it may be increased to 25 mg once daily 2
• No dose titration needed for CV benefit: For cardiovascular risk reduction, no further up-titration is needed beyond the starting dose 1

Important Clinical Considerations

Pre-initiation Assessment

• Assess renal function before starting Jardiance
• Do not initiate if eGFR is below 45 mL/min/1.73 m² 2
• Assess for volume depletion and correct prior to initiation 2

Monitoring

• Monitor for signs and symptoms of hypotension after initiating therapy, especially in patients with risk factors 2
• Regular monitoring of renal function is recommended 3
• Assess for genital mycotic infections, which are a common side effect 1

Special Precautions

• Be alert for potential ketoacidosis, even when blood glucose levels are less than 250 mg/dL 2
• Instruct the patient to temporarily stop taking Jardiance during periods of reduced oral intake or fluid losses 3

Expected Benefits

• Glycemic control: Initial combinations of empagliflozin and metformin have shown HbA1c reductions of 1.9-2.1% in patients with baseline A1C of 8.6-8.9% 4
• Weight reduction: Empagliflozin therapy is associated with weight loss (2.8-3.8 kg over 24 weeks) 4
• Cardiovascular benefits: Empagliflozin has demonstrated cardiovascular benefits in patients with type 2 diabetes 1
• Blood pressure reduction: SGLT2 inhibitors provide nonglycemic benefits including blood pressure reduction 1

Common Pitfalls to Avoid

1. Failing to assess renal function: Always check eGFR before initiating Jardiance and discontinue if eGFR falls persistently below 45 mL/min/1.73 m² 2

2. Not preparing patients for side effects: Inform patients about potential genital mycotic infections, which occur more frequently with SGLT2 inhibitors 1

3. Missing early signs of volume depletion: Correct volume depletion before starting Jardiance and monitor for hypotension, especially in elderly patients or those on diuretics 2

4. Overlooking ketoacidosis risk: Be vigilant for signs of ketoacidosis regardless of blood glucose levels 2

Given the patient's significantly elevated A1C of 11.6%, adding Jardiance 10 mg daily to the existing metformin regimen is an appropriate step to improve glycemic control while providing potential cardiovascular and weight benefits.