Do you hold Jardiance (Empagliflozin) prior to catheterization?

Management of Jardiance (Empagliflozin) Before Cardiac Catheterization

For patients taking Jardiance (empagliflozin), it is recommended to withhold the medication for 48 hours before cardiac catheterization only if the patient has pre-existing renal impairment; otherwise, it can be continued and only stopped after the procedure if renal function deteriorates.

Patient Assessment and Risk Stratification

Normal Renal Function Patients

• Continue Jardiance up to the day of catheterization
• Monitor renal function after the procedure
• If renal function deteriorates post-procedure, withhold Jardiance for 48 hours 1
• Resume only after confirming renal function has returned to baseline

Impaired Renal Function Patients

• Stop Jardiance 48 hours before the procedure 1
• Monitor renal function closely after catheterization
• Resume only when renal function stabilizes and returns to baseline

Rationale for Recommendations

The European Society of Cardiology guidelines indicate that there is no convincing evidence supporting the routine practice of stopping SGLT2 inhibitors like Jardiance before cardiac catheterization in patients with normal renal function 1. This represents a shift from older approaches that recommended routine discontinuation.

The primary concern with SGLT2 inhibitors during catheterization is the potential increased risk of contrast-induced acute kidney injury (CI-AKI), which is one of the most common causes of acute kidney injury in hospitalized patients 2.

Best Practices for Preventing Contrast-Induced Nephropathy

In addition to appropriate management of Jardiance, the following measures should be implemented to reduce the risk of contrast-induced nephropathy during catheterization:

1. Hydration: Administer adequate preprocedural hydration with isotonic saline (1 mL/kg/h 12 hours before and continued for 24 hours after the procedure) 2

2. Contrast Volume: Minimize contrast media volume (<350 mL or <4 mL/kg) 2

3. Access Route: Use radial artery access when feasible to reduce the risk of AKI 2

4. Statin Therapy: Administer high-intensity statins before the procedure 2

5. Contrast Type: Use low- or iso-osmolar contrast media 2

High-Risk Patients Requiring Special Attention

• Heart Failure: Patients with severe heart failure require special attention due to increased risk of lactic acidosis 1

• Multiple Comorbidities: Patients with multiple risk factors (renal impairment, heart failure, diabetes) require more careful management 1

• Contrast Volume Consideration: Research shows that a contrast volume to estimated GFR ratio (V/eGFR) ≥2.6 significantly increases the risk of contrast-induced AKI 3

Common Pitfalls to Avoid

• Failing to assess baseline renal function before catheterization
• Not monitoring renal function after the procedure
• Prematurely restarting Jardiance after contrast exposure in patients with deteriorated renal function
• Overlooking the need for adequate hydration before and after the procedure

Timing of Catheterization After Contrast Exposure

For patients who have recently undergone contrast procedures and now need cardiac catheterization, evidence suggests that:

• A time interval of ≤7 days between catheterization and cardiac surgery is associated with increased risk of AKI 4
• For patients who received high doses of contrast media (>240 mg/kg), postponing cardiac surgery beyond 7 days may reduce the risk of AKI 4

By following these guidelines, clinicians can minimize the risk of contrast-induced nephropathy while ensuring appropriate management of Jardiance in patients undergoing cardiac catheterization.