What is the recommended starting dose of Empagliflozin (Empagliflozin) for a patient with Impaired renal function?

Empagliflozin Starting Dose in Impaired Renal Function

The recommended starting dose of empagliflozin for patients with impaired renal function is 10 mg once daily in the morning, but empagliflozin should not be initiated in patients with eGFR less than 45 mL/min/1.73 m².1

Dosing Recommendations Based on Renal Function

• Empagliflozin should not be initiated in patients with an eGFR less than 45 mL/min/1.73 m² 2, 1
• For patients with eGFR ≥45 mL/min/1.73 m², the recommended starting dose is 10 mg once daily in the morning, taken with or without food 1
• If the starting dose is tolerated, it may be increased to 25 mg once daily 1
• Empagliflozin should be discontinued if eGFR falls persistently below 45 mL/min/1.73 m² 1

Renal Function Monitoring

• Assessment of renal function is recommended prior to initiation of empagliflozin and periodically thereafter 1
• More frequent monitoring is needed in patients with eGFR close to 45 mL/min/1.73 m² 3
• Volume status should be assessed and corrected prior to initiation, especially in patients with renal impairment 3, 1

Special Considerations for Different Stages of CKD

• Stage 3b (eGFR 30-44 mL/min/1.73 m²): Empagliflozin use is not recommended 2
• Stage 4-5 (eGFR <30 mL/min/1.73 m²): Empagliflozin use is not recommended 2
• While the glucose-lowering efficacy of empagliflozin decreases with declining eGFR, kidney and cardiovascular benefits have been observed in patients with eGFR as low as 20 mL/min/1.73 m² in clinical trials 2, 4

Safety Considerations in Renal Impairment

• Patients with renal impairment are at increased risk for volume depletion 3, 1
• Risk of genital mycotic infections is increased with empagliflozin (6% vs 1% with placebo) 2, 3
• Potential for euglycemic ketoacidosis exists, especially during acute illness 2, 3
• Consider adjusting doses of concomitant diuretics to prevent excessive volume depletion 3

Combination Products

• For Synjardy (empagliflozin/metformin combination):
  • Should not be used in patients with eGFR <45 mL/min/1.73 m² due to restrictions on both components 3
  • Metformin dose should be reduced to 1000 mg/day for patients with eGFR 30-44 mL/min/1.73 m² 2, 3

Clinical Evidence Supporting Use in Renal Impairment

• The EMPA-REG OUTCOME trial demonstrated that empagliflozin reduced the risk of major adverse cardiovascular events and slowed progression of kidney disease in patients with type 2 diabetes 5
• In the EMPEROR-Reduced trial, empagliflozin showed beneficial effects on heart failure outcomes and slowed the rate of kidney function decline regardless of baseline kidney function, including in patients with eGFR as low as 20 mL/min/1.73 m² 4

Common Pitfalls to Avoid

• Failing to assess renal function before initiating empagliflozin 1
• Not discontinuing empagliflozin when eGFR falls persistently below 45 mL/min/1.73 m² 1
• Overlooking the need to correct volume depletion prior to initiation 3, 1
• Not monitoring for signs of genital mycotic infections, which are more common with empagliflozin 2, 3
• Failing to temporarily discontinue empagliflozin during acute illness or situations predisposing to ketoacidosis 2