Synjardy (Empagliflozin/Metformin) Dosing and Management for Type 2 Diabetes
The recommended initial dosage of Synjardy for type 2 diabetes is empagliflozin 5 mg/metformin 500 mg twice daily, with gradual titration to minimize gastrointestinal side effects, up to a maximum daily dose of empagliflozin 25 mg and metformin 2000 mg. 1
Initial Dosing Strategy
- For patients not currently on metformin or empagliflozin, start with Synjardy containing empagliflozin 5 mg/metformin 500 mg twice daily 1
- For patients already on metformin, maintain a similar total daily dose of metformin while adding empagliflozin 5 mg twice daily, not exceeding empagliflozin 25 mg and metformin 2000 mg daily 1
- Twice-daily dosing of empagliflozin has been shown to be therapeutically equivalent to once-daily dosing when used with metformin, supporting the twice-daily administration schedule of Synjardy 2
Renal Function Considerations
- Assess eGFR before initiating therapy and periodically during treatment 1
- Synjardy is contraindicated in patients with eGFR <30 ml/min/1.73 m² 1, 3
- For patients with eGFR 30-44 ml/min/1.73 m², reduce metformin component to a maximum of 1000 mg daily 1, 3
- For patients with eGFR 45-59 ml/min/1.73 m², consider dose reduction in those at high risk for complications 1, 3
- Monitor renal function at least every 3-6 months in patients with eGFR <60 ml/min/1.73 m² 3
Efficacy and Benefits
- Initial combination therapy with empagliflozin and metformin has demonstrated significant HbA1c reductions of 1.9-2.1% after 24 weeks, which is greater than either component as monotherapy 4
- Empagliflozin added to metformin provides superior glycemic control compared to sulfonylureas (like glimepiride) with significantly fewer hypoglycemic events (2% vs 24%) 5
- Empagliflozin combined with metformin leads to significant weight reduction (2.0-3.8 kg) compared to metformin alone or sulfonylurea combinations 5, 4
Safety Monitoring and Precautions
- Temporarily discontinue Synjardy during acute illness, before procedures, or during hospitalizations that may compromise renal function 1
- Monitor for vitamin B12 deficiency with long-term use, especially in patients with anemia or peripheral neuropathy 1, 3
- Instruct patients to stop taking medication if they experience nausea, vomiting, or dehydration to prevent lactic acidosis 1
- Discontinue Synjardy at least 3 days before planned surgery to prevent postoperative ketoacidosis 6
Special Populations
- For elderly patients, start at the lower end of the dosing range due to potentially decreased renal function 1
- Use caution in patients with hepatic impairment due to increased risk of lactic acidosis from the metformin component 1
- If HbA1c is well-controlled at baseline or there is a known history of frequent hypoglycemic events, consider reducing or stopping sulfonylureas or insulin doses when starting Synjardy 6
Common Adverse Effects to Monitor
- Genital fungal infections 6
- Urinary tract infections 6
- Gastrointestinal side effects (primarily from metformin component) 1
- Euglycemic diabetic ketoacidosis (rare but serious) 6
Cardiovascular and Renal Benefits
- Empagliflozin has demonstrated cardiovascular benefits, including reduced risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 6
- The empagliflozin component of Synjardy may provide renal protection, with reduced risk of renal endpoints in patients with type 2 diabetes 6