Safety of Starting Jardiance (Empagliflozin) Post-CABG
Starting Jardiance (empagliflozin) after coronary artery bypass grafting (CABG) is generally safe once the patient is hemodynamically stable, and may even provide cardiovascular and renal benefits in patients with type 2 diabetes.
Timing of Initiation
- Specific guidelines for SGLT2 inhibitor initiation after CABG are limited, but can be guided by principles similar to other cardiovascular medications 1
- Medications should generally be reinstituted postoperatively once the patient is stable 2
- Similar to ACE inhibitors and ARBs, SGLT2 inhibitors should not be initiated in the immediate postoperative period if systolic blood pressure is low (≤100 mmHg) or if the patient develops hypotension 2
- In clinical trials, empagliflozin has been safely initiated as early as 3 months before CABG (discontinued 72 hours before surgery) and restarted post-surgery 3
Benefits in Post-CABG Patients
In the EMPA-REG OUTCOME trial subanalysis of patients with prior CABG, empagliflozin demonstrated significant benefits compared to placebo 4:
- 48% reduction in cardiovascular mortality (HR 0.52; 95% CI 0.32-0.84)
- 43% reduction in all-cause mortality (HR 0.57; 95% CI 0.39-0.83)
- 50% reduction in hospitalization for heart failure (HR 0.50; 95% CI 0.32-0.77)
- 35% reduction in incident or worsening nephropathy (HR 0.65; 95% CI 0.50-0.84)
A recent randomized clinical trial (POST-CABGDM) showed that empagliflozin use before on-pump CABG in patients with T2DM was associated with a 43% reduction in postoperative acute kidney injury (22.5% vs 39.1%, RR 0.57 [95% CI 0.34-0.96]) 3
Medication Management Principles After CABG
- Current guidelines recommend that after CABG 2:
- Beta-blockers should be reinstituted as soon as possible
- ACE inhibitors/ARBs should be reinstituted once the patient is stable
- Statins should be continued without interruption
- Aspirin should be initiated within 6 hours postoperatively if not started preoperatively
Precautions and Monitoring
Monitor for potential side effects of SGLT2 inhibitors 2:
- Hypotension, especially in the early postoperative period
- Volume depletion
- Urinary tract infections
- Ketoacidosis (rare but serious)
In the POST-CABGDM trial, no significant differences in safety events were observed between empagliflozin and control groups 3
Special Considerations
For patients with diabetes, continuous intravenous insulin to maintain blood glucose ≤180 mg/dL in the early postoperative period is indicated to reduce adverse events, including deep sternal wound infection 2
SGLT2 inhibitors are recommended by the European Society of Cardiology (ESC) to lower the risk of heart failure hospitalization in patients with diabetes 2
Ongoing trials are investigating empagliflozin's potential to prevent post-operative atrial fibrillation in CABG patients, which affects approximately one-third of cardiac surgery patients 5
Conclusion
Starting Jardiance after CABG appears to be safe once the patient is hemodynamically stable, with evidence suggesting significant cardiovascular and renal benefits in patients with type 2 diabetes. The timing should follow similar principles to other cardiovascular medications, with careful monitoring for potential side effects, particularly in the early postoperative period.