What are the considerations for switching from glipizide (Glibenclamide) to Jardiance (Empagliflozin) in patients with type 2 diabetes?

Switching from Glipizide to Empagliflozin (Jardiance) in Type 2 Diabetes

Patients with type 2 diabetes should switch from glipizide to empagliflozin if they have established cardiovascular disease, heart failure, or chronic kidney disease, as empagliflozin offers superior cardiovascular and renal protection compared to sulfonylureas. 1, 2

Benefits of Switching to Empagliflozin

Cardiovascular Benefits

• Empagliflozin reduces major adverse cardiovascular events (MACE) by 14% and cardiovascular death by 38% in patients with established cardiovascular disease 2
• Reduces hospitalization for heart failure by 35% in patients with type 2 diabetes and cardiovascular disease 2
• Provides cardiovascular protection independent of its glucose-lowering effect 1

Renal Benefits

• Prevents progression of chronic kidney disease 1
• Beneficial for patients with eGFR 30-60 mL/min/1.73m² or albuminuria 1

Metabolic Benefits

• Modest weight loss (2.6-3.8 kg) versus weight gain with sulfonylureas 3, 4
• Lower risk of hypoglycemia (2% with empagliflozin vs 24% with sulfonylureas) 4
• Similar A1C-lowering efficacy to sulfonylureas (approximately 0.7-0.8% reduction) 1, 4

Algorithm for Decision-Making

1. Strongly consider switching if patient has:

   • Established atherosclerotic cardiovascular disease
   • Heart failure (especially with reduced ejection fraction)
   • Chronic kidney disease (eGFR 30-60 mL/min/1.73m² or albuminuria)
   • History of hypoglycemia with glipizide
   • Obesity or need for weight loss

2. Consider continuing glipizide if:

   • Cost is a major barrier (sulfonylureas are significantly less expensive) 1
   • Patient has excellent glycemic control without hypoglycemia
   • eGFR < 30 mL/min/1.73m² (empagliflozin has reduced efficacy) 5

Implementation Considerations

Dosing

• Start with empagliflozin 10mg daily, can increase to 25mg daily if needed 6
• Both doses provide similar improvements in glycemic control 3

Monitoring

• Monitor renal function before initiating empagliflozin 2
• Assess for volume depletion, especially if patient is on diuretics 5
• Monitor for genital infections, which are more common with SGLT2 inhibitors 3

Transition Strategy

• Consider overlapping medications briefly to avoid hyperglycemia during transition
• Monitor blood glucose more frequently during transition period
• Adjust other diabetes medications if needed to prevent hypoglycemia 2

Potential Adverse Effects of Empagliflozin

• Genital mycotic infections
• Urinary tract infections
• Volume depletion (especially in elderly or those on diuretics)
• Rare risk of diabetic ketoacidosis
• Potential hepatotoxicity 5

Common Pitfalls to Avoid

1. Avoid initiating empagliflozin in patients with:

   • eGFR < 30 mL/min/1.73m² (reduced efficacy)
   • Active urinary tract infection or history of recurrent genital infections
   • Foot ulcers or high risk for amputation (careful shared decision-making needed) 1

2. Avoid abrupt discontinuation of glipizide without monitoring for hyperglycemia

3. Don't overlook patient education about:

   • Genital hygiene to prevent infections
   • Signs of volume depletion
   • Sick day management to prevent ketoacidosis

By following this approach, clinicians can optimize the benefits of switching from glipizide to empagliflozin in appropriate patients with type 2 diabetes, particularly those with or at high risk for cardiovascular or renal complications.