Can I use Jardiance (empagliflozin) in a patient with impaired renal function and Hemoglobin A1c (HbA1c) of 7%?

Empagliflozin Use in Patients with Impaired Renal Function and HbA1c of 7%

Empagliflozin (Jardiance) can be used in patients with eGFR of 55 mL/min/1.73m² and HbA1c of 7%, but should be limited to 10 mg daily due to reduced glucose-lowering efficacy at this level of renal function. 1

Efficacy and Benefits in Moderate Renal Impairment

• Empagliflozin provides cardiovascular and renal benefits even at eGFR levels as low as 20-30 mL/min/1.73m², despite diminished glucose-lowering effects 1, 2
• At eGFR 55 mL/min/1.73m², empagliflozin can still reduce the risk of cardiovascular death, hospitalization for heart failure, and slow the progression of kidney disease 2, 3
• Empagliflozin's blood pressure-lowering effects are maintained or even enhanced in patients with lower eGFR, with mean systolic blood pressure reductions of -5.5 mmHg in patients with eGFR 30-59 mL/min/1.73m² 4

Dosing Considerations

• For patients with eGFR 30-44 mL/min/1.73m², empagliflozin should be limited to 10 mg daily 1
• For eGFR <45 mL/min/1.73m², empagliflozin has limited glucose-lowering efficacy but can still be used for cardiovascular and renal benefits 1
• According to the 2022 ADA/KDIGO consensus report, empagliflozin use is not recommended with eGFR <45 mL/min/1.73m² for glycemic control purposes, but can be continued for cardiovascular and kidney benefits 1

Benefits Beyond Glycemic Control

• SGLT2 inhibitors like empagliflozin have demonstrated benefits in reducing:
  • Major adverse cardiovascular events (MACE) 1
  • Hospitalization for heart failure 1, 2
  • Progression of kidney disease 1, 5, 3
• These benefits appear to be independent of baseline diabetes status and glycemic control 6, 2
• In the EMPEROR-Reduced trial, empagliflozin improved cardiovascular and renal outcomes regardless of baseline diabetes status and across the continuum of HbA1c levels 6

Monitoring and Safety Considerations

• Monitor for potential side effects including:
  • Volume depletion (particularly important in patients with renal impairment) 1
  • Genital mycotic infections (occurs in approximately 6% of patients on SGLT2 inhibitors) 1
  • Euglycemic ketoacidosis (rare but serious; risk is higher in insulin-dependent patients) 1
• Consider pausing empagliflozin during periods of acute illness, surgery, or other stressors 1
• Regular monitoring of renal function is recommended, though empagliflozin has been shown to slow the decline in eGFR over time 2, 5

Mechanism in Renal Impairment

• While glucose-lowering efficacy diminishes with declining renal function, cardiovascular and renal benefits are preserved 1, 4
• Empagliflozin reduces intraglomerular pressure, which may contribute to long-term preservation of kidney function 5
• In the EMPA-KIDNEY trial, empagliflozin reduced the risk of kidney disease progression or cardiovascular death across a broad range of baseline kidney function, including patients with eGFR as low as 20 mL/min/1.73m² 3

Conclusion

Empagliflozin can be safely used in this patient with eGFR of 55 mL/min/1.73m² and HbA1c of 7%, with the primary benefits extending beyond glycemic control to include cardiovascular and renal protection. The recommended dose is 10 mg daily, with regular monitoring of renal function and awareness of potential side effects.