When to Add Jardiance (Empagliflozin) to Treatment Regimen for Type 2 Diabetes
Jardiance (empagliflozin) should be added to treatment regimens for patients with type 2 diabetes who have established cardiovascular disease or are at high/very high cardiovascular risk, as it has demonstrated significant reductions in cardiovascular events and mortality. 1, 2
Primary Indications for Adding Empagliflozin
- Empagliflozin is recommended for patients with type 2 diabetes and established cardiovascular disease to reduce cardiovascular events (Class I recommendation) 1, 2
- Empagliflozin specifically reduces the risk of death in patients with type 2 diabetes and cardiovascular disease (Class I recommendation) 1, 2
- For patients with type 2 diabetes and heart failure with reduced ejection fraction (LVEF ≤40%), empagliflozin is recommended to reduce cardiovascular death and heart failure hospitalization 2
- For patients with type 2 diabetes and heart failure with preserved ejection fraction (LVEF >40%), empagliflozin is recommended to decrease heart failure hospitalizations and improve quality of life 2
- Empagliflozin should be considered for patients with type 2 diabetes and diabetic kidney disease to reduce disease progression 2
Timing in Treatment Algorithm
- Empagliflozin can be used as part of combination therapy when metformin alone is insufficient for glycemic control 1
- Assessment of response to current therapy should occur within approximately 3 months; if HbA1c target is not achieved, therapy should be intensified, potentially with empagliflozin 1
- For patients with type 2 diabetes who have not achieved glycemic targets on current therapy and have established cardiovascular disease, empagliflozin should be prioritized as an add-on agent 1, 2
Dosing and Administration Considerations
- Empagliflozin is administered as a once-daily oral medication 3, 4
- Available in 10 mg and 25 mg tablets 3
- Can be taken with or without food 3
- When initiating empagliflozin in patients on insulin or insulin secretagogues, consider reducing insulin dose by approximately 20% if HbA1c is well-controlled to prevent hypoglycemia 2
- Consider reducing diuretic doses if signs of volume contraction occur 2
Contraindications and Cautions
- Not recommended for patients with severe renal impairment (eGFR <30 mL/min/1.73 m²), end-stage renal disease, or those on dialysis 3
- Should be discontinued at least 3 days before planned surgery to prevent postoperative ketoacidosis 2
- Monitor for genital mycotic infections, which are common adverse effects 2, 3
- Be vigilant for euglycemic diabetic ketoacidosis, particularly during periods of acute illness or reduced food intake 3
- Not recommended in women of childbearing potential without appropriate contraception 5
Clinical Benefits Beyond Glycemic Control
- Moderate glucose-lowering effect: approximately 0.5% reduction in HbA1c compared to placebo in patients with baseline HbA1c of about 8% 6
- Modest reductions in body weight (2.1-2.5 kg) 7
- Reduction in systolic blood pressure (2.9-5.2 mmHg) 7
- Improved vascular insulin sensitivity and muscle perfusion 8
- Enhanced insulin's vascular actions, which may contribute to improved cardiorenal outcomes 8
Monitoring After Initiation
- Assess HbA1c response within approximately 3 months of therapy initiation 1
- Monitor renal function regularly, particularly in patients on multiple medications that can affect kidney function 3
- Assess for volume depletion and hypotension, especially when combined with diuretics 2, 3
- Monitor for genital mycotic infections and urinary tract infections, which increase with worsening renal function 3
By following these evidence-based recommendations, clinicians can appropriately incorporate empagliflozin into treatment regimens for patients with type 2 diabetes, particularly those with or at high risk for cardiovascular disease, to improve both glycemic control and cardiovascular outcomes.