Should Jardiance (empagliflozin) be held in the setting of elevated lactic acid levels (lactic acidosis)?

Management of Jardiance (Empagliflozin) in the Setting of Elevated Lactic Acid

Jardiance (empagliflozin) should be temporarily discontinued in patients with elevated lactic acid levels until the acidosis resolves and contributing factors are addressed. 1

Rationale for Holding Jardiance

SGLT2 inhibitors like Jardiance can complicate metabolic acidosis through several mechanisms:

1. Risk of euglycemic diabetic ketoacidosis (euDKA): SGLT2 inhibitors can precipitate ketoacidosis even with normal blood glucose levels, particularly during acute illness 2

2. Potential synergistic effects: When combined with other factors that contribute to acidosis (such as metformin, which is commonly co-prescribed), the risk of severe metabolic acidosis increases 3

3. Volume depletion concerns: The diuretic effect of Jardiance can exacerbate dehydration in patients with acidosis, potentially worsening kidney function and acid clearance 1, 4

Clinical Decision Algorithm

When to Hold Jardiance:

• Elevated lactic acid levels (>2 mmol/L) 1
• Signs of acute illness, especially with:
  • Dehydration
  • Decreased oral intake
  • Vomiting or diarrhea
  • Hypoxia or hypoperfusion
  • Acute kidney injury
  • Sepsis

When to Resume Jardiance:

• After resolution of lactic acidosis
• When adequate hydration is restored
• When underlying precipitating factors are addressed
• When kidney function has stabilized

Monitoring During Lactic Acidosis

• Serial lactate measurements every 4-6 hours 5
• Arterial blood gases to assess pH and bicarbonate levels
• Renal function tests
• Fluid status assessment
• Evaluation for other causes of lactic acidosis

Management of Lactic Acidosis

1. Address underlying cause: Identify and treat the primary cause of lactic acidosis 5

2. Fluid management: Provide appropriate hydration while avoiding fluid overload 5

3. Medication review: Temporarily discontinue medications that may contribute to lactic acidosis, including:

   • Metformin (if present) 1, 6
   • SGLT2 inhibitors like Jardiance 1

4. Consider renal replacement therapy: For severe cases with significant acidosis and acute kidney injury 6

Special Considerations

• Diabetic management during Jardiance discontinuation: Alternative glucose-lowering strategies may be needed, typically with insulin 1

• Monitoring for euglycemic DKA: Check for ketones even if blood glucose is not significantly elevated 2

• Caution with combined therapy: The combination of SGLT2 inhibitors with metformin requires particularly careful monitoring of acid-base status, especially in elderly patients or those with compromised renal function 3

• Cardiovascular benefits: While Jardiance offers cardiovascular benefits in patients with diabetes, these benefits do not outweigh the risks during acute lactic acidosis 4

By temporarily discontinuing Jardiance during episodes of lactic acidosis, you can reduce the risk of worsening acidosis and allow for more effective treatment of the underlying condition.