How to initiate empagliflozin (Empagliflozin) therapy?

Initiating Empagliflozin Therapy

The recommended starting dose of empagliflozin is 10 mg once daily, taken in the morning with or without food, after assessing renal function to ensure eGFR is ≥45 mL/min/1.73 m². 1

Patient Selection and Pre-Initiation Assessment

• Assess renal function before starting empagliflozin; do not initiate if eGFR is below 45 mL/min/1.73 m² 1, 2
• Evaluate volume status, especially in patients with renal impairment, the elderly, those with low systolic blood pressure, or patients on diuretics 3
• Consider reducing doses of concurrent diuretics to prevent volume depletion 3
• Review current medications, particularly insulin secretagogues or insulin, which may need dose reduction to avoid hypoglycemia 2
• Ensure patient is not pregnant or breastfeeding, as empagliflozin is contraindicated in these populations 2, 1

Dosing Protocol

• Start with empagliflozin 10 mg once daily, taken in the morning 1, 2
• No dose titration is required for cardiovascular or renal risk reduction benefits 2
• The dose may be increased to 25 mg once daily for additional glycemic control if needed 1
• Empagliflozin can be taken with or without food 1
• Morning versus evening administration shows no significant differences in pharmacokinetics or pharmacodynamics 4, 5

Renal Function Considerations

• For eGFR ≥45 mL/min/1.73 m²: Standard dosing of 10 mg daily 2, 1
• For eGFR 30-44 mL/min/1.73 m²: Not recommended for glycemic control, but may be used at 10 mg daily for cardiovascular benefits 2, 6
• For eGFR <30 mL/min/1.73 m²: Do not use empagliflozin 2, 1
• Monitor renal function periodically during therapy, with more frequent monitoring for patients with eGFR close to 45 mL/min/1.73 m² 3
• Discontinue empagliflozin if eGFR falls persistently below 45 mL/min/1.73 m² 1

Monitoring and Follow-up

• Monitor for signs of volume depletion, especially in elderly patients or those on diuretics 1, 3
• Assess for genital mycotic infections, which occur in approximately 6% of patients (higher risk in women) 2, 3
• Watch for symptoms of ketoacidosis, regardless of blood glucose levels, particularly during acute illness 2, 3
• Consider pausing empagliflozin during periods of acute illness, fasting, or reduced oral intake 2
• Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 2
• If starting in a patient with well-controlled HbA1c, consider reducing doses of sulfonylureas, glinides, or insulin (by approximately 20%) to prevent hypoglycemia 2

Special Considerations

• For patients with heart failure, empagliflozin has demonstrated significant cardiovascular benefits regardless of diabetes status 7, 2
• In-hospital initiation of empagliflozin may be considered for stabilized heart failure patients 2
• For patients with established cardiovascular disease, empagliflozin reduces the risk of major adverse cardiovascular events and hospitalization for heart failure 8, 2
• Elderly patients (≥75 years) have increased risk of volume depletion and urinary tract infections; monitor more closely 1
• For patients on Synjardy (empagliflozin/metformin combination), do not use if eGFR <45 mL/min/1.73 m² due to restrictions on both components 3

Common Pitfalls to Avoid

• Failing to assess renal function before initiation 1, 2
• Not adjusting doses of concurrent medications, particularly diuretics and insulin 2
• Continuing empagliflozin during acute illness or perioperative periods 2
• Overlooking patient education about symptoms of ketoacidosis and genital mycotic infections 2, 3
• Initiating in patients with severe renal impairment (eGFR <30 mL/min/1.73 m²) 1, 2
• Not considering cardiovascular benefits independent of glycemic control when selecting patients 9, 7