When is Jardiance (Empagliflozin) indicated in patients with systolic congestive heart failure (CHF)?

Jardiance (Empagliflozin) in Systolic Heart Failure

Jardiance (empagliflozin) is indicated for all adult patients with symptomatic chronic heart failure, regardless of left ventricular ejection fraction, to reduce the risk of cardiovascular death and hospitalization for heart failure. 1, 2

Indications Based on Ejection Fraction

• Heart Failure with Reduced Ejection Fraction (HFrEF):

  • Recommended for patients with LVEF ≤40% 3
  • Should be added to standard guideline-directed medical therapy including:
    • ACE inhibitors (or ARBs/ARNI)
    • Beta-blockers
    • Mineralocorticoid receptor antagonists (MRAs)
    • Diuretics (as needed for congestion) 4, 1

• Heart Failure with Mildly Reduced or Preserved Ejection Fraction:

  • Also indicated for patients with LVEF >40% 1, 5
  • Benefits observed across the entire spectrum of ejection fractions

Dosing and Administration

• Standard dose: 10 mg once daily in the morning, with or without food 6
• Renal considerations:
  • Not recommended for initiation if eGFR <25 mL/min/1.73 m² 1
  • For heart failure indication, can be used with eGFR ≥20 mL/min/1.73 m² 1
  • Should be discontinued if eGFR persistently falls below recommended thresholds

Clinical Benefits

• Primary outcome reduction: 21-25% reduction in the composite of cardiovascular death or hospitalization for heart failure 3, 1
• Additional benefits:
  • Slows decline in renal function
  • Reduces total number of heart failure hospitalizations
  • Improves New York Heart Association (NYHA) functional class
  • Benefits appear early (within 12-28 days of initiation) 7
  • Effects consistent regardless of diabetes status 3, 5

Patient Selection Considerations

• Optimal candidates:

  • Symptomatic heart failure (NYHA class II-IV)
  • Patients already on optimal guideline-directed medical therapy
  • Patients with or without diabetes 3, 5

• Precautions:

  • Assess volume status before initiation
  • Monitor for hypotension, especially in patients on diuretics
  • Watch for genital mycotic infections and urinary tract infections
  • Rare risk of euglycemic diabetic ketoacidosis 6

Practical Implementation

1. Assess baseline renal function before initiation
2. Start at 10 mg once daily regardless of diabetes status
3. Monitor for volume depletion especially during first few weeks
4. Continue indefinitely as part of comprehensive heart failure management
5. Hold medication at least 3 days before major surgery or procedures requiring fasting

Common Pitfalls to Avoid

• Not considering empagliflozin in non-diabetic patients - benefits are independent of diabetes status
• Failing to monitor renal function - baseline and periodic assessment is essential
• Stopping medication prematurely - benefits continue long-term and medication should be continued indefinitely
• Overlooking volume status - correct volume depletion before initiation

Empagliflozin represents a significant advancement in heart failure management, with consistent benefits across the spectrum of ejection fractions and regardless of diabetes status, making it an essential component of modern heart failure therapy.