How many days after Coronary Artery Bypass Grafting (CABG) can we initiate Jardiance (Empagliflozin) in a hemodynamically stable patient?

Timing of Jardiance Initiation After Coronary Artery Bypass Grafting

Jardiance (empagliflozin) should be initiated no earlier than 72 hours after CABG in hemodynamically stable patients to minimize the risk of complications while maximizing potential benefits.

Rationale for Timing

• Current guidelines do not specifically address the timing of SGLT2 inhibitor initiation after CABG, but several principles can guide clinical decision-making 1
• Hemodynamic stability is a prerequisite before initiating any new medication after CABG, as patients need to recover from the surgical stress and stabilize their fluid balance 2
• Recent research suggests that empagliflozin can be safely discontinued 72 hours before CABG and then restarted postoperatively in stable patients 3

Evidence Supporting This Recommendation

• In the POST-CABGDM trial, empagliflozin was discontinued 72 hours before surgery in diabetic patients undergoing on-pump CABG, suggesting this timeframe is appropriate for medication clearance and could guide reinitiation timing 3
• The EMPOAF trial protocol indicates empagliflozin can be started at least 3 days before CABG and continued until discharge, suggesting a similar timeframe for postoperative initiation 4
• Studies have shown that empagliflozin use before CABG was associated with reduced incidence of postoperative acute kidney injury without increased safety events 3

Considerations for Medication Management After CABG

• Beta-blockers should be reinstituted as soon as possible after CABG in all patients without contraindications 1
• ACE inhibitors and ARBs should be reinstituted postoperatively once the patient is stable 1
• Statins should be continued or initiated for all CABG patients without contraindications 1
• Antiplatelet therapy with aspirin should be initiated within 6 hours postoperatively if not started preoperatively 1

Potential Benefits of Empagliflozin After CABG

• Empagliflozin may provide cardiometabolic benefits in patients with coronary artery disease and diabetes 5
• It may reduce the risk of postoperative acute kidney injury in diabetic patients undergoing CABG 3
• SGLT2 inhibitors may have mechanisms that could potentially prevent postoperative atrial fibrillation, though this requires further study 4

Precautions and Monitoring

• Monitor for hemodynamic stability before initiating empagliflozin, as SGLT2 inhibitors can cause volume depletion 3
• Watch for signs of acute kidney injury, urinary tract infections, and ketoacidosis, which are potential adverse effects of empagliflozin 3
• Ensure adequate hydration status before initiating therapy 2
• Start with the lowest effective dose (10mg) to minimize potential adverse effects 2

Common Pitfalls to Avoid

• Initiating empagliflozin too early after CABG before hemodynamic stability is established could potentially exacerbate fluid shifts and hypotension 2
• Aggressive antihypertensive therapy immediately after CABG is strongly discouraged to avoid hemodynamic collapse 2
• Failing to monitor renal function before and after initiating empagliflozin, as renal function may be affected by both CABG and the medication 3

By waiting at least 72 hours after CABG to initiate Jardiance in hemodynamically stable patients, clinicians can balance the potential benefits of the medication while minimizing risks during the critical postoperative recovery period.