What is the recommended dosage and monitoring for Jardiance (Empagliflozin) in a patient with Chronic Kidney Disease (CKD) stage 3b/2a and impaired renal function?

Jardiance (Empagliflozin) Dosing and Monitoring in CKD Stage 3b/2a

For patients with CKD stage 3b/2a (eGFR 30-59 mL/min/1.73m²), Jardiance (empagliflozin) should be initiated at 10 mg once daily only if eGFR is ≥45 mL/min/1.73m², and should be discontinued if eGFR persistently falls below 45 mL/min/1.73m².

Dosing Recommendations

Initial Assessment and Dosing

• Assess renal function prior to initiating Jardiance 1
• For patients with eGFR ≥45 mL/min/1.73m² (CKD stage 3a or better):
  • Start with 10 mg once daily, taken in the morning with or without food 1
  • May increase to 25 mg once daily if well tolerated and additional glycemic control is needed 1
• For patients with eGFR <45 mL/min/1.73m² (CKD stage 3b or worse):
  • Do not initiate Jardiance 1

Ongoing Management

• If a patient's eGFR falls persistently below 45 mL/min/1.73m², Jardiance should be discontinued 1
• Once initiated, it is reasonable to continue Jardiance even if eGFR falls below 20 mL/min/1.73m², unless not tolerated or kidney replacement therapy is initiated 2
• Withhold Jardiance during times of prolonged fasting, surgery, or critical medical illness when patients may be at greater risk for ketosis 2

Monitoring Protocol

Renal Function Monitoring

• Assess renal function before initiating Jardiance 1
• After initiation:
  • Monitor eGFR periodically (every 3-6 months is reasonable based on clinical practice guidelines) 2
  • The initial reversible decrease in eGFR upon starting Jardiance is generally not an indication to discontinue therapy 2
  • No alteration in the frequency of CKD monitoring is necessary specifically due to Jardiance use 2

Additional Monitoring

• Monitor for signs and symptoms of hypotension, especially in patients with renal impairment, elderly patients, those with low systolic blood pressure, and patients on diuretics 1
• Assess for volume contraction before initiating and correct volume status if indicated 1
• Monitor for ketoacidosis regardless of blood glucose levels, as ketoacidosis associated with SGLT2 inhibitors may occur even with blood glucose levels below 250 mg/dL 1

Clinical Benefits in CKD

• SGLT2 inhibitors like Jardiance have demonstrated significant benefits in slowing CKD progression and reducing cardiovascular events 2, 3
• In the EMPA-REG OUTCOME trial, empagliflozin was associated with:
  • 44% reduction in doubling of serum creatinine 3
  • 55% reduction in initiation of renal replacement therapy 3
  • Slower progression of kidney disease compared to placebo 4

Important Considerations and Precautions

Volume Status

• Jardiance causes intravascular volume contraction which may lead to symptomatic hypotension 1
• Correct volume depletion prior to initiation, particularly in patients with renal impairment 1

Potential Adverse Effects

• Hypotension, especially in patients with renal impairment 1
• Ketoacidosis (rare but serious) 1
• Genital mycotic infections
• Urinary tract infections

Common Pitfalls to Avoid

1. Failing to assess baseline renal function before initiating therapy
2. Discontinuing Jardiance prematurely due to the initial, expected, reversible decrease in eGFR
3. Not monitoring for volume depletion in vulnerable patients
4. Initiating Jardiance in patients with eGFR <45 mL/min/1.73m²
5. Continuing Jardiance despite persistent decline in eGFR below 45 mL/min/1.73m²

Comprehensive Management Approach

For optimal management of patients with CKD stage 3b/2a and type 2 diabetes:

1. For patients with eGFR ≥45 mL/min/1.73m²:

   • Consider Jardiance 10 mg daily as part of comprehensive diabetes management
   • Monitor renal function regularly

2. For patients with eGFR <45 mL/min/1.73m²:

   • Do not initiate Jardiance
   • Consider alternative glucose-lowering medications appropriate for renal impairment

3. For all patients with CKD:

   • Optimize RAS inhibition (ACEi or ARB) unless contraindicated 2
   • Consider adding a nonsteroidal MRA for patients with T2D, eGFR >25 mL/min/1.73m², normal potassium, and albuminuria despite RAS inhibition 2
   • Consider GLP-1 receptor agonists if glycemic targets are not achieved 2

By following these evidence-based recommendations, you can optimize the use of Jardiance in patients with CKD stage 3b/2a while minimizing risks and maximizing benefits for renal and cardiovascular outcomes.