What are the recommendations for reintroducing Jardiance (empagliflozin) in patients with heart failure who developed a groin rash less than 10 percent of their body surface area?

Reintroducing Empagliflozin (Jardiance) After Groin Rash in Heart Failure Patients

Empagliflozin can be safely reintroduced in heart failure patients who developed a limited groin rash (less than 10% body surface area), with careful monitoring and potentially using a desensitization approach.

Assessment of Rash and Risk Factors

• Evaluate the severity and characteristics of the previous rash to confirm it was limited to <10% body surface area and not associated with systemic symptoms 1
• Determine if the rash was a simple irritant contact dermatitis or a more concerning hypersensitivity reaction 1
• Review concurrent medications that might have contributed to the rash 2

Reintroduction Protocol

• Consider a gradual reintroduction approach similar to beta-blocker reintroduction protocols in heart failure patients 2
• Start with a lower dose (5mg if available) and gradually titrate up to the target dose of 10mg daily while monitoring for recurrence of rash 2
• Monitor the patient closely during the first 1-2 weeks after reintroduction, which is when most adverse reactions typically recur 2

Rationale for Reintroduction

• Empagliflozin provides significant benefits for heart failure patients that justify careful reintroduction attempts:
  • Reduces the risk of cardiovascular death or hospitalization for heart failure by 25% (HR 0.75; 95% CI, 0.65 to 0.86) 3
  • Improves clinical stability with benefits seen as early as 12 days after initiation 4
  • Reduces total number of heart failure hospitalizations by 30% (HR 0.70; 95% CI, 0.58 to 0.85) 3
  • Provides beneficial cardiac remodeling by reducing left ventricular volumes 5

Special Considerations

• For patients with heart failure with reduced ejection fraction (HFrEF), the benefits of SGLT2 inhibitors are particularly strong and reintroduction should be strongly considered 2
• Empagliflozin has shown benefits in patients hospitalized for acute heart failure, with clinical improvement regardless of baseline renal function 6
• The EMPULSE trial demonstrated that empagliflozin initiated during hospitalization for acute heart failure improved outcomes compared to placebo 2

Monitoring After Reintroduction

• Monitor for recurrence of rash, particularly in the groin area 1
• Regular monitoring of renal function and electrolytes is recommended, as with standard SGLT2 inhibitor therapy 2
• Assess for signs of clinical improvement in heart failure symptoms 4

Alternative Approaches If Reintroduction Fails

• If rash recurs, consider switching to another SGLT2 inhibitor (dapagliflozin) which may have a different side effect profile but similar benefits in heart failure 2
• If SGLT2 inhibitors cannot be used, optimize other guideline-directed medical therapies including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists 2

Practical Management Tips

• Provide patient education on proper hygiene and keeping the groin area dry to prevent recurrence 1
• Consider topical treatments (mild corticosteroids) to have on hand if mild rash recurs 1
• The benefits of empagliflozin on heart failure outcomes are consistent regardless of diabetes status, so reintroduction is important even in non-diabetic heart failure patients 3