What is the initial dose of Synjardy (empagliflozin and metformin) for patients with type 2 diabetes?

Initial Dosing of Synjardy (Empagliflozin and Metformin) for Type 2 Diabetes

The initial dose of Synjardy should be individualized based on the patient's current regimen, with a typical starting dose of empagliflozin 5 mg/metformin 500 mg twice daily, titrated gradually to minimize gastrointestinal side effects. 1

Dosing Algorithm

For Patients Not Currently on Metformin or Empagliflozin:

• Start with Synjardy containing empagliflozin 5 mg/metformin 500 mg twice daily 1, 2
• Titrate dose gradually by increasing metformin by 500 mg increments every 7 days to minimize gastrointestinal side effects 1, 3
• Maximum recommended daily dose is empagliflozin 25 mg/metformin 2000 mg 2, 4

For Patients Already on Metformin:

• Switch to Synjardy containing empagliflozin 5 mg plus a similar total daily dose of metformin the patient is already receiving 1, 2
• Maximum daily dose should not exceed empagliflozin 25 mg and metformin 2000 mg 1

For Patients Already on Empagliflozin:

• Start with Synjardy containing the same dose of empagliflozin the patient is already receiving plus metformin 500 mg twice daily 1, 2
• Titrate metformin component as needed 1

Important Considerations

Renal Function Assessment:

• Assess eGFR before initiating therapy 3
• Synjardy is contraindicated in patients with eGFR <30 ml/min/1.73 m² 3
• For patients with eGFR 30-44 ml/min/1.73 m², reduce metformin component to maximum 1000 mg daily 3, 1
• For patients with eGFR 45-59 ml/min/1.73 m², consider dose reduction in those at high risk for complications 3, 1
• Monitor renal function at least annually in patients with normal function and every 3-6 months in patients with eGFR <60 ml/min/1.73 m² 3, 1

Monitoring and Safety:

• Monitor for vitamin B12 deficiency with long-term use, especially in patients with anemia or peripheral neuropathy 3, 1
• Advise patients to temporarily discontinue Synjardy during acute illness, before procedures, or during hospitalizations that may compromise renal function 1
• Patients should be instructed to stop taking medication if they experience nausea, vomiting, or dehydration 3

Efficacy Considerations:

• Combination therapy with empagliflozin and metformin has shown greater HbA1c reductions (-1.9 to -2.1%) compared to either agent alone (empagliflozin: -1.4%, metformin: -1.2 to -1.8%) 2
• Adding empagliflozin to metformin therapy has demonstrated significant weight reduction benefits compared to metformin alone (-2.8 to -3.8 kg vs -0.5 to -1.3 kg) 2

Special Populations

Elderly Patients:

• Start at the lower end of the dosing range due to potential decreased renal function 1
• More frequent monitoring of renal function is recommended 3

Patients with Hepatic Impairment:

• Use caution as hepatic impairment has been associated with some cases of lactic acidosis with metformin 3

Common Pitfalls to Avoid

• Failure to assess renal function before initiating therapy 3
• Starting with too high a dose of metformin component, leading to gastrointestinal intolerance 3, 1
• Not monitoring renal function regularly, especially in at-risk patients 3, 1
• Overlooking the need for vitamin B12 monitoring with long-term use 3, 1
• Continuing medication during acute illness that may compromise renal function 1