Managing Constipation in Patients Taking Jardiance (Empagliflozin)
Constipation associated with empagliflozin should be managed with standard constipation protocols, starting with increased fluid intake, dietary fiber, and exercise, followed by osmotic laxatives like polyethylene glycol as first-line pharmacologic therapy, then escalating to stimulant laxatives if needed. 1, 2
Understanding the Context
Empagliflozin is an SGLT2 inhibitor that causes osmotic diuresis and increases urinary glucose excretion, which can lead to dehydration—a known risk factor for constipation. 3, 4 In clinical trials, constipation was reported in approximately 9% of patients taking empagliflozin. 4 The dehydration risk is particularly concerning in elderly patients and those with reduced oral intake. 3
Initial Management Approach
Non-Pharmacologic Interventions (First-Line)
Increase fluid intake aggressively to counteract the osmotic diuresis caused by empagliflozin, as dehydration is a modifiable risk factor for constipation and a known complication of SGLT2 inhibitors. 1, 3, 2
Increase dietary fiber only if the patient has adequate fluid intake and physical activity, as fiber without sufficient hydration can worsen constipation. 1, 2
Encourage exercise and physical activity when appropriate, as insufficient physical activity is a modifiable risk factor for chronic constipation. 1, 2
Pharmacologic Management (Stepwise Escalation)
First-Line Pharmacologic Therapy
Start with osmotic laxatives, specifically polyethylene glycol (PEG) 17g (one heaping tablespoon) mixed with 8 oz water twice daily, as this is the recommended first-line pharmacologic treatment for primary constipation. 1, 2
Goal: Achieve one non-forced bowel movement every 1-2 days. 1
Second-Line Therapy (If First-Line Fails)
Add stimulant laxatives: Bisacodyl 10-15 mg daily, titrating up to three times daily as needed to achieve the bowel movement goal. 1
Alternative stimulant option: Senna with or without docusate (stool softener), 2-3 tablets twice to three times daily. 1
Third-Line Options (For Refractory Cases)
Magnesium-based laxatives can be effective but require caution:
- Magnesium hydroxide 30-60 mL daily to twice daily, OR
- Magnesium citrate 8 oz daily
- Critical caveat: Avoid in patients with renal impairment due to hypermagnesemia risk. 1
Lactulose 30-60 mL two to four times daily can be added if other measures fail. 1
Prokinetic agents: Consider metoclopramide 10-20 mg orally four times daily for severe or refractory constipation. 1
Assessment Before Escalating Therapy
Before adding more aggressive treatments, systematically evaluate for:
Rule out fecal impaction, especially if diarrhea accompanies constipation (suggesting overflow around impaction). 1
Rule out bowel obstruction through physical examination and consider abdominal x-ray if clinically indicated. 1
Review and discontinue non-essential constipating medications (anticholinergics, calcium channel blockers, iron supplements, etc.). 1
Treat underlying metabolic causes: hypercalcemia, hypokalemia, hypothyroidism, or poorly controlled diabetes mellitus. 1
Critical Pitfalls to Avoid
Do not rely on stool softeners alone (like docusate) without stimulant laxatives, as they are ineffective as monotherapy. 5
Ensure adequate hydration is addressed first, as empagliflozin-induced dehydration can be severe enough to cause cardiac arrest in vulnerable patients with reduced oral intake. 3
Monitor elderly patients and those with neurological deficits closely, as they are at highest risk for severe dehydration complications with SGLT2 inhibitors. 3
Avoid bulk laxatives (like psyllium) if the patient is not adequately hydrated, as they can worsen constipation. 1
When to Refer
Refer to gastroenterology if constipation persists despite second-line therapy for specialized testing such as anorectal manometry and balloon expulsion test to evaluate for defecatory disorders. 2
Consider discontinuing empagliflozin if constipation is severe, refractory to treatment, or if the patient cannot maintain adequate hydration due to the medication's diuretic effects. 3