When to initiate Jardiance (Empagliflozin) for heart failure with reduced ejection fraction?

When to Initiate Jardiance (Empagliflozin) for Heart Failure with Reduced Ejection Fraction

Empagliflozin (Jardiance) should be initiated immediately in all patients with heart failure with reduced ejection fraction (HFrEF), regardless of diabetes status, as it provides early benefits in reducing cardiovascular death and hospitalization that begin within 12 days after initiation. 1

Patient Selection and Timing

• Empagliflozin is indicated for all adults with symptomatic chronic heart failure, regardless of left ventricular ejection fraction (LVEF) 2
• Eligible patients include:
  • LVEF ≤40% (HFrEF) 1
  • NYHA class II-IV symptoms 1
  • eGFR ≥20 mL/min/1.73m² 3

Initiation Algorithm

Outpatient Setting

1. Start immediately upon diagnosis of HFrEF, alongside other core heart failure medications
2. Standard dose: 10 mg orally once daily 2
3. No dose titration required - unlike other HF medications, empagliflozin requires no up-titration 3
4. No adjustment needed for blood pressure, heart rate, or potassium levels 3

Hospitalized Patients

• For stabilized hospitalized HF patients (SBP >100 mmHg, no IV vasodilators or increased IV loop diuretics in 6h, no IV inotropes in 24h), initiate empagliflozin before discharge 3
• Benefits are seen early - within 12 days of initiation 1

Monitoring After Initiation

• Check renal function and electrolytes 1-2 weeks after initiation
• Monitor for:
  • Transient initial drop in eGFR (expected and not concerning) 3
  • Volume depletion/hypotension (rare but possible) 4
  • Genital mycotic infections 4
  • Euglycemic diabetic ketoacidosis (rare) 4

Integration with Other HF Medications

Empagliflozin should be part of comprehensive HFrEF therapy that includes:

1. ACE inhibitor/ARB/ARNI
2. Beta-blocker
3. Mineralocorticoid receptor antagonist (MRA)
4. SGLT2 inhibitor (empagliflozin)
5. Diuretics as needed for congestion

The traditional step-by-step approach of fully up-titrating one medication before starting another is no longer recommended. Instead, initiate all core medications early and adjust doses based on individual tolerance 3.

Benefits of Early Initiation

• Reduced risk of cardiovascular death or hospitalization for heart failure (HR 0.76; 95% CI, 0.67-0.87) 1
• Benefits begin within 12 days of starting treatment 1
• Reduced need for intensification of diuretics (HR 0.67; 95% CI, 0.56-0.78) 1
• Improved NYHA functional class within 28 days 1
• Reduced stressed blood volume during exercise (-198.4 mL compared to placebo) 5
• Consistent benefits across all age groups, including patients ≥75 years 6
• Benefits seen regardless of ischemic or non-ischemic etiology of heart failure 7

Practical Considerations

• Unlike other HF medications, empagliflozin does not require dose adjustment for blood pressure, heart rate, or potassium levels 3
• Empagliflozin appears to facilitate the use of MRAs, with patients less likely to discontinue MRAs or experience severe hyperkalemia 3
• If patient is on insulin or sulfonylureas, consider dose reduction of these medications to prevent hypoglycemia 4
• Discontinue empagliflozin at least 3 days before planned surgery to prevent postoperative ketoacidosis 4

Common Pitfalls to Avoid

1. Delaying initiation - Benefits begin early, so start promptly rather than waiting
2. Withholding due to mild renal dysfunction - Safe with eGFR ≥20 mL/min/1.73m² 3
3. Stopping due to initial eGFR drop - A mild, transient decrease in eGFR is expected and not a reason to discontinue 3
4. Sequential rather than simultaneous initiation of core HF medications - Modern approach favors starting multiple medications early 3
5. Limiting to diabetic patients only - Benefits are independent of diabetes status 2

Empagliflozin's favorable safety profile, lack of need for dose titration, and early onset of benefits make it an essential component of HFrEF therapy that should be initiated promptly upon diagnosis.