Can Diltiazem (calcium channel blocker) and Jardiance (Empagliflozin, SGLT2 inhibitor) be used together in patients with type 2 diabetes and hypertension?

Diltiazem and Jardiance Can Be Safely Used Together in Patients with Type 2 Diabetes and Hypertension

Diltiazem (calcium channel blocker) and Jardiance (empagliflozin, SGLT2 inhibitor) can be safely used together in patients with type 2 diabetes and hypertension, and this combination may provide complementary cardiovascular benefits.

Rationale for Combination Therapy

Cardiovascular Benefits

• Empagliflozin (Jardiance) has demonstrated significant cardiovascular benefits in patients with type 2 diabetes, including:

  • Reduction in cardiovascular mortality by 38%
  • Reduction in all-cause mortality by 32%
  • Reduction in hospitalization for heart failure 1
  • Reduction in major adverse cardiovascular events (MACE) 2

• Diltiazem has been shown to:

  • Effectively reduce both systolic and diastolic blood pressure in diabetic patients
  • Increase forearm blood flow by 32%
  • Not negatively affect diabetes control 3

Complementary Mechanisms

• Diltiazem works by blocking calcium channels, leading to vasodilation and decreased peripheral resistance
• Empagliflozin works by inhibiting SGLT2 in the kidneys, promoting glucose excretion and providing cardiovascular benefits through multiple mechanisms

Safety Considerations

Potential Concerns

• Blood Pressure Effects: Both medications can lower blood pressure, but studies have not shown problematic additive hypotensive effects
• Renal Function:
  • SGLT2 inhibitors may cause a modest initial decrease in eGFR that is typically hemodynamically mediated and reversible 2
  • Monitor renal function in the first several weeks of therapy, particularly in patients with impaired baseline renal function

Metabolic Effects

• Diltiazem has been shown to have neutral effects on glycemic control in diabetic patients 3
• Unlike beta-blockers and thiazide diuretics, calcium channel blockers like diltiazem do not have significant negative metabolic effects 2
• Empagliflozin improves glycemic control and has beneficial effects on weight and blood pressure 1

Monitoring Recommendations

When using this combination:

1. Blood Pressure Monitoring:

   • Check blood pressure at baseline and regularly during follow-up
   • Target blood pressure should be <130/80 mmHg in patients with diabetes 2

2. Volume Status:

   • Monitor for signs of volume depletion, especially when initiating empagliflozin
   • Patients should be advised about potential diuretic effects of SGLT2 inhibitors 2

3. Renal Function:

   • Check baseline renal function
   • Monitor eGFR within the first few weeks of initiating empagliflozin
   • Adjust dosing according to renal function guidelines

4. Glycemic Control:

   • Monitor blood glucose and HbA1c
   • Adjust other diabetes medications if needed to prevent hypoglycemia

Special Considerations

• In patients also taking insulin or sulfonylureas, consider reducing doses of these medications by 20-50% when adding empagliflozin to reduce hypoglycemia risk 2
• Patients should be advised about the risk of genital mycotic infections with empagliflozin 1
• The combination may be particularly beneficial in patients with:
  • Diabetes with established cardiovascular disease
  • Hypertension requiring multiple agents
  • Heart failure or risk factors for heart failure

Conclusion

The combination of diltiazem and empagliflozin represents a rational approach for patients with both type 2 diabetes and hypertension, particularly those with or at risk for cardiovascular disease. The complementary mechanisms and favorable safety profiles make this combination appropriate for many patients, with proper monitoring and dose adjustments as needed.