What is the best management for a patient on Jardiance (Empagliflozin) 25mg with persistent hyperglycemia?

Management of Persistent Hyperglycemia in a Patient on Jardiance 25 mg

Discontinue Jardiance and transition to insulin therapy immediately, as SGLT2 inhibitors are not recommended for routine inpatient use and insulin is the preferred treatment for managing hyperglycemia in hospitalized patients.

Immediate Action: Discontinue Jardiance

• Stop empagliflozin immediately as SGLT2 inhibitors are not recommended for routine use in the hospital setting due to risks of euglycemic diabetic ketoacidosis, genitourinary infections, and limited efficacy in acute hyperglycemic management 1.
• The patient is already on the maximum dose (25 mg) per FDA labeling, so dose escalation is not an option 2.
• SGLT2 inhibitors have only moderate glucose-lowering action, reducing HbA1c by approximately 0.5% compared to placebo, which is insufficient for persistent hyperglycemia 3.

Initiate Insulin Therapy

For Severe Hyperglycemia (>250 mg/dL):

• Start continuous intravenous insulin infusion at 0.1 units/kg/hour for critically ill patients or those with severe hyperglycemia 4.
• Target a gradual glucose reduction of 50-75 mg/dL per hour 4.
• Once glucose reaches 200-250 mg/dL, reduce the insulin infusion rate and add dextrose-containing fluids 4.

For Moderate Hyperglycemia (140-250 mg/dL):

• Implement a basal-bolus insulin regimen for noncritically ill patients with good oral intake 1.
• Use basal insulin plus correction insulin for patients with poor oral intake or those taking nothing by mouth 1.
• Target premeal glucose <140 mg/dL and random glucose <180 mg/dL 1.

Alternative: DPP-4 Inhibitor Plus Basal Insulin (For Mild-Moderate Hyperglycemia Only)

• If the patient has mild hyperglycemia (<180 mg/dL) and is noncritically ill, consider sitagliptin or linagliptin plus basal insulin as an alternative to basal-bolus insulin 1.
• This approach is effective for patients with HbA1c values that are not severely elevated and reduces hypoglycemia risk by 86% compared to basal-bolus therapy 1.
• However, treatment failure increases with higher HbA1c values (odds ratio 1.3 per one unit HbA1c increase) 1.

Critical Pitfalls to Avoid

• Never use sliding scale insulin alone as the sole regimen—this is strongly discouraged and associated with poor glycemic control 1, 4.
• Do not continue SGLT2 inhibitors in the hospital given the lack of evidence for benefit and increased risk of complications 1.
• Assess renal function before any medication decisions, as empagliflozin should be discontinued if eGFR falls persistently below 45 mL/min/1.73 m² 2.

Monitoring Requirements

• Perform point-of-care glucose monitoring every 1-2 hours initially when using intravenous insulin 4.
• Monitor serum electrolytes (particularly potassium), renal function, and volume status every 2-4 hours initially 4.
• Implement a hypoglycemia management protocol and document all episodes 1.

Transition Planning

• Transition to subcutaneous insulin using a basal-bolus regimen once the patient is stable 4.
• Administer basal insulin 2-4 hours before discontinuing intravenous insulin infusion 4.
• Consider obtaining an HbA1c if not available from the previous 3 months to guide long-term management 1.
• Consult with a specialized diabetes or glucose management team when possible 1.

Discharge Considerations

• Develop a structured discharge plan including diabetes education, medication reconciliation, and scheduled follow-up 4.
• If oral medications are to be resumed, restart them 1-2 days before discharge 1.
• Provide clear diabetes management instructions at discharge 1.