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

Empagliflozin (Jardiance) Use and Dosage in Type 2 Diabetes

Jardiance (empagliflozin) is recommended at a starting dose of 10 mg once daily in the morning for patients with type 2 diabetes, with potential titration to 25 mg daily if needed for glycemic control, and should be prioritized in patients with established cardiovascular disease, heart failure, or diabetic kidney disease due to its proven mortality benefits. 1

Indications and Dosing

• Starting dose: 10 mg once daily in the morning, taken with or without food
• Dose titration: May increase to 25 mg daily if tolerated and additional glycemic control is needed 1
• Administration timing: Morning administration is recommended
• Renal function requirements:
  • Must have eGFR ≥45 mL/min/1.73 m² to initiate therapy
  • Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 1

Primary Indications

1. Glycemic control: As an adjunct to diet and exercise in adults with type 2 diabetes
2. Cardiovascular protection: To reduce risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 1
3. Heart failure management: Beneficial in patients with heart failure regardless of ejection fraction or diabetes status 2, 3

Patient Selection Algorithm

1. First-line consideration: Patients with type 2 diabetes and established cardiovascular disease, heart failure, or diabetic kidney disease
2. Second-line consideration: Patients with type 2 diabetes requiring additional glycemic control
3. Special populations:
   • Particularly beneficial in patients with heart failure (with reduced or preserved ejection fraction)
   • Effective in patients with diabetic kidney disease with albuminuria (UACR >300 mg/g) 2

Contraindications

• History of serious hypersensitivity to empagliflozin
• Severe renal impairment (eGFR <45 mL/min/1.73 m²)
• End-stage renal disease or dialysis 1
• Type 1 diabetes (not indicated) 1
• Pregnancy or breastfeeding 2

Clinical Benefits Beyond Glycemic Control

• Cardiovascular outcomes:

  • 38% reduction in cardiovascular death 4
  • 35% reduction in hospitalization for heart failure 2
  • 32% reduction in all-cause mortality 4

• Heart failure benefits:

  • 21% reduction in composite of cardiovascular death or hospitalization for worsening heart failure in patients with heart failure with reduced ejection fraction (HFrEF) 2
  • Benefits consistent regardless of diabetes status 2, 3

• Renal protection:

  • Slows decline in renal function 3
  • Benefits seen in patients with chronic kidney disease 5

Monitoring and Management

1. Before initiation:

   • Assess renal function
   • Evaluate volume status and correct volume depletion if present 1

2. After initiation:

   • Monitor renal function periodically
   • Check for signs of hypotension, especially in patients with renal impairment, elderly, those with low systolic blood pressure, or on diuretics 1
   • Monitor for genital mycotic infections 3
   • Watch for signs of diabetic ketoacidosis, even with blood glucose <250 mg/dL 1

3. Medication adjustments:

   • If patient is on insulin or sulfonylureas, consider reducing doses by ~20% when starting empagliflozin to prevent hypoglycemia 2
   • Consider reducing diuretic dose if patient is at risk for volume depletion 2

Common Adverse Effects

• Genital mycotic infections (more common in women)
• Urinary tract infections
• Volume depletion and hypotension
• Diabetic ketoacidosis (rare but serious)
• Lower limb ulcerations and soft tissue infections 2

Special Considerations

• Perioperative management: Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 2
• Cardiovascular risk: Initiate early in patients with established cardiovascular disease for mortality benefit 3
• Heart failure patients: Consider regardless of diabetes status due to consistent benefits across HFrEF and HFpEF 2, 3
• Renal function: Benefits observed even in patients with reduced renal function (eGFR ≥30 mL/min/1.73 m²), though glycemic effects are reduced 5

Clinical Pearls

• Benefits on cardiovascular outcomes appear to be a class effect of SGLT2 inhibitors and are largely independent of glucose-lowering effects 2
• Early initiation during hospitalization for heart failure improves post-discharge medication adherence 3
• Modest weight reduction (approximately 2 kg) and blood pressure reduction (systolic ~4 mmHg) are additional benefits 6
• Unlike some other SGLT2 inhibitors, empagliflozin has not been associated with increased risk of amputation or bone fractures 7

Empagliflozin represents a valuable treatment option for type 2 diabetes management with proven cardiovascular and renal benefits, making it particularly suitable for patients with established cardiovascular disease or at high risk for cardiovascular complications.