Protocol for Starting a Patient on Jardiance (Empagliflozin)
The recommended protocol for starting Jardiance (empagliflozin) is to begin with 10 mg once daily in the morning, taken with or without food, with the option to increase to 25 mg daily if tolerated and if additional glycemic control is needed. 1
Initial Assessment and Patient Selection
- Assess renal function prior to initiation with estimated glomerular filtration rate (eGFR); do not initiate Jardiance if eGFR is below 45 mL/min/1.73 m² 1
- Evaluate volume status before starting therapy, particularly in patients with renal impairment, elderly patients, those with low systolic blood pressure, or patients on diuretics 1
- Consider Jardiance as a second-line agent after metformin for patients with type 2 diabetes, especially those with established cardiovascular disease or at high cardiovascular risk 2
- Assess baseline blood pressure, as SGLT2 inhibitors can cause intravascular volume contraction and hypotension 1
Dosing Protocol
- Start with 10 mg once daily in the morning, with or without food 1
- No dose titration is required initially; the medication can be started at the full therapeutic dose 3
- After initial period, dose may be increased to 25 mg once daily if additional glycemic control is needed and the 10 mg dose is well tolerated 1
- Morning administration is standard, though studies show no significant pharmacokinetic or pharmacodynamic differences between morning and evening dosing 4
Monitoring and Follow-up
- Monitor renal function periodically after initiation 1
- Expect a transient initial eGFR decrease of 3-5 mL/min/1.73 m² in the first 4 weeks, which is generally not a reason to discontinue therapy 5
- Monitor for signs and symptoms of hypotension, especially in at-risk patients 1
- Check for genital mycotic infections and urinary tract infections, which occur more frequently with SGLT2 inhibitors 2, 3
- Monitor for ketoacidosis, regardless of blood glucose levels, especially during illness, reduced oral intake, or fluid losses 3, 1
Special Considerations
- For patients on insulin or sulfonylureas, consider reducing doses of these medications by approximately 20% when starting Jardiance to reduce hypoglycemia risk 2
- Consider reducing diuretic doses in patients taking concurrent diuretics due to potential volume depletion 2, 3
- Discontinue Jardiance at least 3 days before scheduled surgery to reduce risk of ketoacidosis 2, 3
- In patients with heart failure with reduced ejection fraction (HFrEF), Jardiance 10 mg daily is recommended regardless of diabetes status 3
Contraindications and Precautions
- Do not use in patients with severe renal impairment (eGFR <30 mL/min/1.73 m²), end-stage renal disease, or on dialysis 1
- Avoid in patients with history of serious hypersensitivity reaction to empagliflozin 1
- Use caution in patients with conditions that may reduce eGFR 2
- Temporarily discontinue during acute illness, vomiting, or dehydration to prevent acute kidney injury 2, 1
Patient Education
- Educate patients about potential side effects, including genital mycotic infections, urinary tract infections, and volume depletion symptoms 3, 1
- Instruct patients to temporarily stop Jardiance during acute illness or when unable to maintain adequate fluid intake (sick day management) 2
- Advise patients about the signs and symptoms of ketoacidosis and when to seek medical attention 3, 1
- Inform patients about expected benefits beyond glycemic control, including potential cardiovascular and renal benefits 2, 3
By following this protocol, healthcare providers can safely initiate Jardiance therapy in appropriate patients with type 2 diabetes while minimizing potential adverse effects.