Should Jardiance (Empagliflozin) be stopped at discharge in a patient who presented with Diabetic Ketoacidosis (DKA) on admission?

Should Jardiance Be Stopped at Discharge After DKA?

Yes, Jardiance (empagliflozin) should be permanently discontinued at discharge in a patient who presented with DKA on admission, and the patient should be transitioned to alternative glucose-lowering agents that do not carry DKA risk.

Rationale for Permanent Discontinuation

The occurrence of DKA while on an SGLT2 inhibitor represents a serious adverse event that fundamentally changes the risk-benefit calculation for this medication class in that specific patient 1, 2.

Key Evidence Supporting Discontinuation

• FDA labeling explicitly warns that ketoacidosis is a serious life-threatening condition requiring urgent hospitalization, with fatal cases reported in patients taking SGLT2 inhibitors 1.

• KDIGO guidelines recommend withholding SGLT2 inhibitors during critical medical illness when patients are at greater risk for ketosis 3.

• The patient has demonstrated susceptibility to SGLT2 inhibitor-associated DKA, which may recur even 8-11 days after the last dose due to prolonged glucosuria and ketonuria 4.

Clinical Decision Algorithm

Step 1: Assess DKA Characteristics

• Determine if DKA was euglycemic (glucose <250 mg/dL) or hyperglycemic 1, 2
• Identify precipitating factors: insulin dose reduction, acute illness, reduced caloric intake, surgery, alcohol use 1, 2
• Review timing of last empagliflozin dose relative to DKA onset 4

Step 2: Evaluate Patient Risk Profile

High-risk features that mandate permanent discontinuation:

• Insulin-deficient diabetes (Type 1 or advanced Type 2 requiring insulin) 2, 5
• History of pancreatic disorders or pancreatic surgery 1
• Low-carbohydrate or ketogenic diet 5
• Recurrent DKA episodes 4
• Alcohol abuse 1

Step 3: Alternative Medication Selection at Discharge

For patients requiring cardio-renal protection:

• First-line alternative: GLP-1 receptor agonists with proven cardiovascular benefits (dulaglutide, liraglutide, semaglutide) 3
• These provide cardiovascular and kidney benefits without DKA risk 3
• Start with low dose and titrate slowly to minimize GI side effects 3

For patients with heart failure or CKD:

• Consider nonsteroidal mineralocorticoid receptor antagonists if eGFR ≥25 mL/min/1.73 m² and normal potassium 3
• Optimize RAS inhibitor therapy 3

For glycemic control:

• Intensify insulin therapy with basal-bolus regimen 3
• Add metformin if eGFR ≥30 mL/min/1.73 m² 3
• Consider DPP-4 inhibitors as add-on therapy 3

Critical Pitfalls to Avoid

Pitfall 1: Attempting to Restart SGLT2 Inhibitor

Do not restart empagliflozin even after DKA resolution, as the patient has proven susceptibility to this life-threatening complication 1, 2. The risk of recurrence outweighs potential benefits.

Pitfall 2: Inadequate Patient Education

• Counsel patient that empagliflozin is permanently contraindicated due to their DKA episode 1
• Ensure patient understands to inform all future healthcare providers about this adverse event 2
• Document prominently in medical record as drug allergy/adverse reaction 2

Pitfall 3: Premature Discharge Planning

• Ensure complete DKA resolution before discharge: glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH >7.3, anion gap ≤12 mEq/L 3
• Transition to subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound ketoacidosis 3, 6
• Monitor for persistent ketonuria/glucosuria which may persist 8-11 days after last SGLT2 inhibitor dose 4

Pitfall 4: Failing to Address Precipitating Factors

• Identify and treat underlying triggers: infection, myocardial infarction, stroke 6
• Optimize insulin dosing to prevent future DKA from insulin deficiency 3
• Provide sick day protocol education for future acute illnesses 3, 2

Discharge Medication Reconciliation

Medications to STOP:

• Empagliflozin (Jardiance) - permanently discontinued 1
• Document as adverse drug reaction in medical record 2

Medications to START/OPTIMIZE:

• Basal-bolus insulin regimen (0.5-0.8 units/kg/day total daily dose) 3
• GLP-1 RA for cardio-renal protection (if not contraindicated) 3
• Metformin if eGFR permits 3

Medications to CONTINUE:

• RAS inhibitors for kidney protection 3
• Other cardiovascular medications as indicated 3

Follow-up Requirements

• Within 1 week: Endocrinology follow-up to optimize insulin regimen and assess glycemic control 6
• Within 2-4 weeks: Primary care follow-up for medication reconciliation and cardiovascular risk assessment 6
• Ongoing monitoring: HbA1c every 3 months, annual kidney function assessment 3

Special Considerations

If patient has CKD with eGFR 20-45 mL/min/1.73 m²:

• The cardio-renal benefits of SGLT2 inhibitors are substantial in this population 3
• However, prior DKA is an absolute contraindication regardless of potential benefits 1, 2
• Prioritize GLP-1 RA therapy instead for kidney protection 3

If patient has heart failure:

• SGLT2 inhibitors provide significant mortality benefit in heart failure 3
• Despite this, prior DKA mandates permanent discontinuation 1, 2
• Optimize guideline-directed medical therapy for heart failure with other agents 3