What is the recommended dose of Tradjenta (linagliptin) and Jardiance (empagliflozin) for an 85-year-old patient with Impaired renal function?

Dosing of Linagliptin and Empagliflozin in an 85-Year-Old Patient with Impaired Renal Function

For an 85-year-old patient with impaired renal function, linagliptin (Tradjenta) can be administered at the standard dose of 5 mg daily regardless of renal function, while empagliflozin (Jardiance) is not recommended if eGFR is below 45 mL/min/1.73 m².

Linagliptin (Tradjenta) Dosing

• Linagliptin requires no dose adjustment in elderly patients with impaired renal function as it is primarily metabolized by the liver 1
• The standard dose of 5 mg once daily can be maintained regardless of the degree of renal impairment 1, 2
• Multiple studies have confirmed that renal impairment has only a minor effect on linagliptin pharmacokinetics, with no clinically relevant increase in drug exposure even in severe renal impairment 3, 4
• Linagliptin is one of the few DPP-4 inhibitors that does not require dose adjustment in any stage of renal impairment, making it particularly suitable for elderly patients 1, 2

Empagliflozin (Jardiance) Dosing

• Empagliflozin is not recommended for initiation in patients with eGFR <45 mL/min/1.73 m² according to FDA labeling 5
• For patients with eGFR ≥45 mL/min/1.73 m², the recommended starting dose is 10 mg once daily 1, 5
• If the patient's eGFR is between 30-44 mL/min/1.73 m², empagliflozin should not be initiated, though it may be continued at 10 mg daily if already established and tolerated 1
• The glucose-lowering efficacy of empagliflozin decreases with declining renal function, though cardiovascular and renal benefits may persist 1

Special Considerations for Elderly Patients

• In patients aged ≥85 years, a more cautious approach to blood pressure management is recommended, which may influence SGLT2 inhibitor use due to their modest antihypertensive effects 1
• Elderly patients, particularly those with renal impairment, are at higher risk for volume depletion and hypotension with SGLT2 inhibitors 1, 5
• Monitoring for adverse effects such as genital mycotic infections, urinary tract infections, and euglycemic ketoacidosis is particularly important in elderly patients on empagliflozin 1
• The risk of hypoglycemia may be increased in elderly patients, especially if they are on insulin or sulfonylureas concurrently with these medications 1

Monitoring Recommendations

• Regular assessment of renal function is essential, particularly when initiating or adjusting doses of empagliflozin 1, 5
• For patients on empagliflozin, monitoring for volume status and symptoms of hypotension is important, especially in the elderly 1, 5
• Blood or urine ketone monitoring may be considered for patients on empagliflozin to detect ketosis early 1
• HbA1c monitoring should be performed at least twice yearly, or more frequently if glycemic targets are not being met 1

Practical Algorithm for Dosing Decision

1. Determine the patient's current eGFR:

   • If eGFR ≥45 mL/min/1.73 m²: Linagliptin 5 mg daily and empagliflozin 10 mg daily can be used 1, 5
   • If eGFR 30-44 mL/min/1.73 m²: Linagliptin 5 mg daily can be used; empagliflozin should not be initiated but may be continued if already established 1
   • If eGFR <30 mL/min/1.73 m²: Only linagliptin 5 mg daily is recommended; empagliflozin should be discontinued 1, 5

2. Consider additional factors:

   • Frailty status: More cautious approach with empagliflozin in frail elderly patients 1
   • Risk of volume depletion: Monitor closely if initiating empagliflozin 1, 5
   • Concomitant medications: Adjust other glucose-lowering medications if needed to prevent hypoglycemia 1

Conclusion

For an 85-year-old patient with impaired renal function, linagliptin can be safely administered at the standard dose of 5 mg daily regardless of renal function level. Empagliflozin should only be used if eGFR is ≥45 mL/min/1.73 m², starting at 10 mg daily. Close monitoring of renal function, volume status, and potential adverse effects is essential, particularly in this elderly population.