Should Empagliflozin (Jardiance) and Metformin be included in the take-home medication?

Empagliflozin and Metformin for Take-Home Medication

Recommendation

Yes, Empagliflozin (Jardiance) and Metformin should be included in the take-home medication as they provide complementary benefits for glycemic control, cardiovascular risk reduction, and renal protection in patients with type 2 diabetes. 1, 2

Benefits of This Combination

• Metformin remains the first-line pharmacotherapy for type 2 diabetes due to its effectiveness, safety, low cost, and potential to reduce cardiovascular events and mortality 1
• Empagliflozin has demonstrated significant cardiovascular benefits, including reduction in the composite of cardiovascular death, myocardial infarction, or stroke (HR 0.80 [95% CI 0.67–0.95]), as well as lower risk of hospitalizations for heart failure (HR 0.61 [95% CI 0.47–0.80]) 1
• The combination of empagliflozin and metformin provides complementary mechanisms of action, resulting in more effective glycemic control than either agent alone 2, 3
• Initial combination therapy with empagliflozin and metformin has shown reductions in HbA1c of 1.9-2.1% compared to 1.2-1.8% with metformin alone and 1.4% with empagliflozin alone 3
• The combination has been shown to reduce body weight by 2.8-3.8 kg, which is significantly greater than metformin alone (0.5-1.3 kg) 3

Dosing and Administration

• For patients with normal renal function, standard dosing of metformin (up to 2000 mg daily) and empagliflozin (10-25 mg daily) can be used 2
• For patients with renal impairment:
  • If eGFR is 30-44 mL/min/1.73 m², metformin dose should be reduced to 1000 mg/day 1
  • Empagliflozin can be used at 10 mg daily in patients with eGFR 30-44 mL/min/1.73 m² 1
  • Both medications are contraindicated if eGFR is <30 mL/min/1.73 m² 1

Safety Considerations

• The combination of empagliflozin and metformin has been well-tolerated in clinical trials with adverse event rates similar to individual components (56.7-66.3%) 3
• Hypoglycemia risk is minimal with this combination, with no severe hypoglycemic events requiring assistance reported in clinical trials 3
• Common side effects of empagliflozin include genital mycotic infections (occurring in approximately 6% of patients) 1
• Patients should be monitored for potential side effects of SGLT2 inhibitors, including:
  • Genital mycotic infections 1
  • Volume depletion, especially in patients on multiple medications affecting fluid status 1
  • Risk of euglycemic diabetic ketoacidosis, particularly during periods of acute illness 1
• Metformin's main side effects are gastrointestinal intolerance (bloating, abdominal discomfort, diarrhea), which can be mitigated by gradual dose titration 1

Special Considerations

• For patients with established cardiovascular disease or high cardiovascular risk, this combination is particularly beneficial due to the cardiovascular protective effects of empagliflozin 1
• The combination has shown favorable effects on blood pressure, with empagliflozin reducing systolic blood pressure by 2.6-4.8 mmHg compared to placebo 2
• Fixed-dose combination tablets of empagliflozin/metformin are available and may improve medication adherence by reducing pill burden 4
• Long-term use of metformin may be associated with vitamin B12 deficiency, so periodic testing of vitamin B12 levels should be considered 1

Conclusion

The combination of empagliflozin and metformin provides complementary mechanisms for glycemic control with additional benefits of weight reduction, blood pressure lowering, and cardiovascular protection. This combination is well-tolerated with a low risk of hypoglycemia, making it an excellent choice for take-home medication in patients with type 2 diabetes, particularly those with or at risk for cardiovascular disease 1, 2, 3.