What are the considerations for using Jardiance (Empagliflozin) in patients with cardiomyopathy and type 2 diabetes?

Empagliflozin (Jardiance) for Patients with Cardiomyopathy and Type 2 Diabetes

Empagliflozin (Jardiance) is strongly recommended for patients with cardiomyopathy and type 2 diabetes as it reduces cardiovascular death, heart failure hospitalizations, and improves quality of life regardless of ejection fraction. 1

Recommendations Based on Heart Failure Status

For Patients with Heart Failure with Reduced Ejection Fraction (HFrEF, LVEF ≤40%)

• Empagliflozin has a Class I recommendation (highest level) to reduce the risk of cardiovascular death and heart failure hospitalization, regardless of diabetes status 2, 1
• Empagliflozin should be used at a dose of 10 mg once daily, taken in the morning with or without food 3
• Empagliflozin is recommended even when patients are already on optimal heart failure therapy including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists 2, 1

For Patients with Heart Failure with Preserved Ejection Fraction (HFpEF, LVEF >40%)

• Empagliflozin has a Class IIa recommendation to decrease heart failure hospitalizations and improve quality of life, regardless of diabetes status 2, 1
• The benefits in HFpEF are particularly important as treatment options for this condition have historically been limited 4

Mechanisms of Benefit in Cardiomyopathy

• Empagliflozin provides cardioprotection through multiple mechanisms beyond glucose control:
  • Reduction of myocardial oxidative stress 5
  • Attenuation of cardiac fibrosis through inhibition of the TGF-β/Smad pathway 5
  • Improvement in mitochondrial function 6
  • Diuretic effects that help reduce cardiac preload 7
  • Anti-inflammatory effects that may reduce cardiomyocyte injury 6

Monitoring and Safety Considerations

Renal Function Monitoring

• Assess renal function before initiating empagliflozin 3
• Do not initiate if eGFR is below 45 mL/min/1.73 m² 3
• Discontinue if eGFR falls persistently below 45 mL/min/1.73 m² 3
• Consider temporary discontinuation in settings of reduced oral intake or fluid losses 3

Potential Adverse Effects to Monitor

• Genital mycotic infections (most common adverse effect) 2, 3
• Volume depletion and hypotension, especially when combined with diuretics 2, 3
• Diabetic ketoacidosis (rare but serious) - assess patients who present with signs of metabolic acidosis regardless of blood glucose level 3
• Urinary tract infections and potential urosepsis 3

Medication Adjustments

• If HbA1c is well-controlled at baseline, consider:
  • Reducing total daily insulin dose by approximately 20% when starting therapy 2
  • Weaning or stopping sulfonylureas or glinides to prevent hypoglycemia 2
• Consider stopping or reducing diuretic doses if there are signs of volume contraction 2

Special Considerations

• Discontinue empagliflozin at least 3 days before planned surgery to prevent postoperative ketoacidosis 2
• Use with caution in patients with prior amputation, severe peripheral neuropathy, or active diabetic foot ulcers 2
• Empagliflozin may be particularly beneficial in patients with both cardiomyopathy and diabetic kidney disease 2, 1

Clinical Pearls

• The cardiovascular benefits of empagliflozin appear early (within months) and are not solely attributable to its glucose-lowering effects 7
• The FDA has approved empagliflozin for heart failure treatment regardless of diabetes status, expanding its use beyond just diabetic patients 8
• The recommended dose for heart failure is 10 mg once daily, which is the same starting dose used for diabetes management 3, 4
• Empagliflozin's benefits in heart failure appear to be a class effect of SGLT2 inhibitors, though empagliflozin specifically has robust evidence for cardiovascular mortality reduction 2, 1

By addressing both diabetes and cardiomyopathy simultaneously, empagliflozin represents an important therapeutic option that can significantly improve outcomes in this high-risk patient population.