What is the rationale for holding Jardiance (Empagliflozin) for 3 days before a 10-minute Transesophageal Echocardiogram (TEE)?

Rationale for Holding Jardiance Before TEE

Jardiance (empagliflozin) should be held for 3 days before a transesophageal echocardiogram (TEE) due to its diuretic effect which could increase the risk of dehydration and hemodynamic instability during the procedure.

Mechanism of Action and Concerns

Empagliflozin is an SGLT2 inhibitor that works by:

• Inhibiting glucose reabsorption in renal tubules, promoting glucosuria 1
• Causing osmotic diuresis and volume depletion 2
• Reducing blood pressure through its diuretic effect 3

These effects create specific concerns for TEE procedures:

1. Volume Status and Hemodynamic Stability

   • TEE is an invasive procedure that may cause hemodynamic changes
   • Empagliflozin's diuretic effect can lead to volume depletion 2
   • The medication reduces blood volume by approximately 208 mL after 14 days of therapy 2

2. Procedural Considerations

   • TEE procedures typically last only 10 minutes but require sedation
   • Patients may have restricted oral intake before the procedure
   • Combined with empagliflozin's diuretic effect, this could exacerbate dehydration

Clinical Guidelines and Recommendations

While there are no specific guidelines addressing empagliflozin and TEE directly, periprocedural management principles apply:

1. Periprocedural Medication Management

   • The American College of Chest Physicians recommends careful management of medications before TEE procedures to minimize complications 4
   • Medications that affect volume status require special consideration

2. TEE-Specific Considerations

   • TEE is considered a procedure with low-to-moderate bleeding risk 4
   • Guidelines recommend holding medications that may affect hemodynamic stability before procedures 5
   • Emergency use of TEE in patients with hemodynamic instability is reasonable if expertise is available 5

Timing Considerations

The 3-day holding period for empagliflozin before TEE is based on:

1. Pharmacokinetic Properties

   • Empagliflozin has a half-life of approximately 12 hours 6
   • Complete washout requires approximately 5 half-lives (60 hours or 2.5 days)
   • The 3-day window provides adequate time for drug elimination

2. Volume Repletion

   • Allows time for restoration of normal fluid balance
   • Reduces risk of procedure-related hypotension
   • Minimizes risk of hemodynamic instability during sedation

Special Considerations

1. Diabetes Management

   • Patients should monitor blood glucose levels more frequently during the holding period
   • Alternative diabetes medications may be needed temporarily
   • Blood glucose should be checked immediately before the procedure

2. Resumption After Procedure

   • Empagliflozin can typically be resumed 24 hours after the TEE procedure
   • Ensure adequate oral intake has been established before resumption
   • Monitor for signs of dehydration upon restarting

Potential Risks of Not Holding Empagliflozin

1. Procedural Complications

   • Increased risk of hypotension during sedation
   • Potential for hemodynamic instability during the procedure
   • Dehydration may complicate recovery

2. Patient Comfort and Safety

   • Volume depletion may exacerbate post-procedural symptoms
   • Increased risk of orthostatic hypotension after the procedure
   • Potential for electrolyte disturbances

By holding empagliflozin for 3 days before a TEE, clinicians can minimize the risk of procedure-related complications while ensuring optimal conditions for this brief but important diagnostic test.