Can a 62-year-old male patient with uncontrolled diabetes (HbA1c of 10), chronic obstructive pulmonary disease (COPD), and currently on Novomix (insulin aspart) 34 units at night, Venlafaxine (Effexor) and Mirtazapine (Remeron), be started on Empagliflozin (Jardiance)?

Can Empagliflozin Be Started in This Patient?

Yes, empagliflozin can and should be started in this 62-year-old male patient with uncontrolled diabetes (HbA1c 10%), provided his renal function is adequate (eGFR ≥45 mL/min/1.73 m²). The presence of COPD, venlafaxine, and mirtazapine are not contraindications to empagliflozin use. 1

Key Considerations Before Initiating

Renal Function Assessment (Critical)

• Check eGFR before starting empagliflozin - this is mandatory 1
• Empagliflozin should NOT be initiated if eGFR <45 mL/min/1.73 m² 1
• If eGFR ≥45 mL/min/1.73 m², no dose adjustment is needed 1
• The cardiovascular benefits of SGLT2 inhibitors extend down to eGFR of 30 mL/min/1.73 m², though glucose-lowering efficacy diminishes with declining renal function 2, 3

Volume Status Assessment

• Assess for volume depletion before initiating - empagliflozin causes intravascular volume contraction 1
• Correct any volume depletion prior to starting therapy 1
• Monitor for signs of hypotension after initiation, particularly since elderly patients are at higher risk 4
• The patient's concurrent use of no diuretics (based on provided information) is favorable, though COPD patients may have reduced fluid intake during exacerbations 1

Dosing Strategy

Start with empagliflozin 10 mg once daily in the morning, with or without food 1

• This is the recommended starting dose for cardiovascular benefit 2
• No up-titration is required for cardiovascular risk reduction 2
• The dose may be increased to 25 mg for additional glucose-lowering if needed, but 10 mg provides equivalent cardiovascular protection 2

Drug Interactions and Concurrent Medications

Insulin Adjustment Required

• The patient is on Novomix (insulin aspart) 34 units at night - this dose will likely need reduction 1
• Empagliflozin increases hypoglycemia risk when combined with insulin 1
• Monitor blood glucose closely after starting empagliflozin and reduce insulin dose as needed 1
• Typical HbA1c reduction with empagliflozin ranges from 0.59-0.82% 5

Psychiatric Medications (No Interaction)

• Venlafaxine and mirtazapine have no known significant interactions with empagliflozin
• These medications do not contraindicate SGLT2 inhibitor use

COPD (No Contraindication)

• COPD is not a contraindication to empagliflozin use 1
• However, COPD patients may be at higher risk for volume depletion during acute exacerbations with reduced oral intake 4

Critical Safety Warnings for This Patient

Diabetic Ketoacidosis Risk

This patient has multiple risk factors for euglycemic DKA:

• Insulin-dependent diabetes (on basal insulin) 4
• Potential for reduced caloric intake during COPD exacerbations 4
• Risk during acute illness or infection 4

Prevention strategies:

• Educate patient to discontinue empagliflozin during acute illness, infection, or COPD exacerbations 4
• Never reduce insulin doses excessively - maintain adequate basal insulin 4
• Check ketones if patient develops nausea, vomiting, abdominal pain, or fatigue, even with normal blood glucose 1
• Consider discontinuing 3-4 days before any planned surgery 4

Genital Mycotic Infections

• Increased risk of genital mycotic infections with empagliflozin 2, 1
• These are typically straightforward to manage 3
• Educate patient about hygiene and early recognition 1

Urinary Tract Infections

• Monitor for signs of serious UTI (fever, back pain, dysuria, urgency) 1
• Instruct patient to report symptoms promptly 1

Expected Benefits in This Patient

Glycemic Control

• Expected HbA1c reduction of 0.5-0.8% from baseline of 10% 5
• Weight loss of 2-3 kg expected 2, 5
• Systolic blood pressure reduction of 3-5 mmHg 5

Cardiovascular Protection

Even without established cardiovascular disease, empagliflozin provides:

• 14% reduction in major adverse cardiovascular events 3, 5
• 38% reduction in cardiovascular death 3, 5
• 32% reduction in all-cause mortality 3, 5
• 36% reduction in heart failure hospitalization 5

Renal Protection

• Slows progression of diabetic kidney disease 2
• Reduces risk of worsening nephropathy 2

Monitoring Plan

Initial monitoring (first 2-4 weeks):

• Blood glucose monitoring 4 times daily to adjust insulin doses 1
• Blood pressure monitoring for hypotension 1
• Assess for volume depletion symptoms (dizziness, weakness) 1

Ongoing monitoring:

• Renal function (eGFR) periodically - discontinue if persistently <45 mL/min/1.73 m² 1
• HbA1c every 3 months until stable 1
• Monitor for genital infections and UTI symptoms 1

Common Pitfalls to Avoid

• Do not start if renal function unknown - always check eGFR first 1
• Do not reduce insulin too aggressively - this increases DKA risk 4
• Do not continue during acute illness - instruct patient to hold during COPD exacerbations 4
• Do not ignore volume status - correct dehydration before initiating 1
• Do not assume glucose-lowering is the primary benefit - cardiovascular and renal protection occur independent of HbA1c reduction 6