What is the recommended use and dosage of Jardiance (empagliflozin) for patients with type 2 diabetes?

Jardiance (Empagliflozin) for Type 2 Diabetes

Recommended Dosing

Start empagliflozin at 10 mg orally once daily in the morning, with or without food, for all patients with type 2 diabetes. 1

• The 10 mg dose provides optimal cardiovascular and renal benefits without need for titration 2, 3
• You may increase to 25 mg once daily if additional glucose lowering is needed, but this does not provide additional cardiovascular or renal protection 2, 3, 1
• No dose titration is required for cardiovascular or renal risk reduction because there is no graded dose-response relationship for these outcomes 2, 3

Primary Indications

Empagliflozin has three FDA-approved indications 1:

1. Glycemic control: As adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes 1
2. Cardiovascular death reduction: To reduce risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 2, 1
3. Heart failure hospitalization: Reduces hospitalization for heart failure by 35% compared to placebo 2, 4

Renal Function Requirements

Do not initiate empagliflozin if eGFR is below 45 mL/min/1.73 m² 1

• Assess renal function before starting therapy and periodically thereafter 1
• No dose adjustment needed if eGFR ≥45 mL/min/1.73 m² 1
• Discontinue if eGFR falls persistently below 45 mL/min/1.73 m² 1
• Contraindicated in severe renal impairment, end-stage renal disease, or dialysis 2, 1

Concomitant Medication Adjustments

When initiating empagliflozin, make these adjustments to prevent hypoglycemia 2, 3:

• Insulin: Reduce total daily dose by approximately 20% 2, 3
• Sulfonylureas or glinides: Consider weaning or stopping, especially if HbA1c is well-controlled at baseline or patient has history of frequent hypoglycemia 2, 3
• Diuretics: Consider stopping or reducing dose if volume contraction is a concern 2

Volume Status Management

Correct volume depletion before initiating empagliflozin 1

Assess volume status carefully in 2, 1:

• Patients with renal impairment
• Elderly patients
• Patients with low systolic blood pressure
• Patients on diuretics

Monitor for signs of hypotension after starting therapy 1

Surgical Considerations

Discontinue empagliflozin at least 3 days before planned surgery or procedures with prolonged fasting 2, 5, 3

• This prevents postoperative ketoacidosis 2, 3
• Resume only when patient is clinically stable and has resumed oral intake 5

Key Safety Warnings

Ketoacidosis

Monitor for diabetic ketoacidosis, which can occur even with blood glucose <250 mg/dL 1. If signs of metabolic acidosis occur, assess for ketoacidosis regardless of glucose level, discontinue empagliflozin immediately, and treat promptly 1.

Acute Kidney Injury

Consider temporarily discontinuing in settings of reduced oral intake or fluid losses 1. If acute kidney injury occurs, discontinue and treat promptly 1.

Genital Mycotic Infections

The most common adverse reactions (≥5% incidence) are urinary tract infections and female genital mycotic infections 1. Monitor and treat as appropriate 1.

Cardiovascular Benefits

Empagliflozin demonstrated significant cardiovascular benefits in the EMPA-REG OUTCOME trial 2, 4:

• 14% reduction in composite outcome of MI, stroke, and cardiovascular death 2
• 38% reduction in cardiovascular death 2, 4
• 35% reduction in hospitalization for heart failure 2, 4
• 32% reduction in all-cause mortality 4

These benefits were consistent across the spectrum of heart failure risk, including patients without baseline heart failure 6.

Renal Protection

Empagliflozin reduces progression of kidney disease 7:

• 39% reduction in incident or worsening nephropathy 7
• 44% reduction in doubling of serum creatinine 7
• 55% lower risk of renal-replacement therapy initiation 7

Common Pitfalls to Avoid

• Do not initiate in patients with eGFR <45 mL/min/1.73 m² 2, 3, 1
• Do not forget to reduce insulin or sulfonylurea doses when starting therapy 2, 3
• Do not continue through surgical procedures without 3-day washout period 2, 3
• Do not use for type 1 diabetes or diabetic ketoacidosis treatment 1
• Do not assume higher doses provide better cardiovascular protection—they do not 2, 3