What is the recommended use and dosage of Jardiance (empagliflozin) in patients with type 2 diabetes?

Jardiance (Empagliflozin) for Type 2 Diabetes: Recommended Use and Dosage

Jardiance (empagliflozin) is recommended at a starting dose of 10 mg once daily in the morning for patients with type 2 diabetes, with the option to increase to 25 mg daily if needed for glycemic control, and should be considered first-line therapy particularly in patients with established cardiovascular disease, heart failure, or chronic kidney disease. 1

Indications and Benefits

Empagliflozin is FDA-approved for:

• Improving glycemic control in adults with type 2 diabetes as an adjunct to diet and exercise
• Reducing the risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 1

Beyond glycemic control, empagliflozin offers significant cardiovascular and renal benefits:

• 38% relative risk reduction in cardiovascular death 2
• 35% reduction in hospitalization for heart failure 3
• Benefits in heart failure patients regardless of ejection fraction 3, 4
• Modest reductions in body weight and blood pressure 5

Dosing Algorithm

1. Initial Dosing:

   • Start with 10 mg once daily in the morning, with or without food 1
   • No dose titration is needed for cardiovascular or renal risk reduction 3

2. Dose Adjustment:

   • May increase to 25 mg daily in patients tolerating the medication who need additional glycemic control 1
   • HbA1c reduction is approximately 0.7-1.0% 4

3. Renal Function Considerations:

   • Assess renal function before initiation and periodically thereafter 1
   • Do not initiate if eGFR <45 mL/min/1.73 m² 1
   • Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 1

Patient Selection

Empagliflozin is particularly beneficial for patients with:

• Type 2 diabetes with established cardiovascular disease 3, 1
• Heart failure (with reduced or preserved ejection fraction) 3, 4
• High risk for heart failure 6
• Diabetic kidney disease 3

Contraindications

• History of serious hypersensitivity to empagliflozin 1
• Severe renal impairment (eGFR <45 mL/min/1.73 m²) 1
• End-stage renal disease or dialysis 1
• Type 1 diabetes (not indicated) 1
• Pregnancy or breastfeeding 3

Monitoring and Precautions

• Volume Status: Correct volume depletion before initiating; monitor for hypotension especially in elderly, those with renal impairment, low systolic blood pressure, or on diuretics 1
• Renal Function: Check within 2-4 weeks after initiation 4
• Ketoacidosis: Monitor for signs regardless of blood glucose levels 1
• Surgical Procedures: Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 3
• Hypoglycemia Risk: If patient is on insulin or sulfonylureas, consider reducing doses of these medications when adding empagliflozin 3

Common Adverse Effects

• Genital mycotic infections (especially in women) 3, 7
• Urinary tract infections (mild increase in risk) 7
• Volume depletion (low risk in most patients) 7

Clinical Pearls

• Benefits of empagliflozin extend beyond glycemic control and appear consistent across the spectrum of heart failure risk 6
• Cardiovascular benefits are seen regardless of baseline HbA1c and are evident within months of initiation 7, 2
• The cardiovascular and renal benefits appear to be a class effect of SGLT2 inhibitors 3
• Consider empagliflozin preferentially in patients at high cardiovascular risk who require additional antidiabetic medication 5
• Unlike some other SGLT2 inhibitors, empagliflozin has not been associated with increased risk of amputation or bone fractures 5

By following these recommendations, clinicians can optimize the use of empagliflozin to improve both glycemic control and cardiovascular outcomes in patients with type 2 diabetes.