Jardiance (Empagliflozin) Use in Dialysis Patients
No, a diabetic patient on hemodialysis Monday, Wednesday, Friday should not take Jardiance (empagliflozin). Empagliflozin is explicitly contraindicated in patients on dialysis and should be discontinued once kidney replacement therapy is initiated.
FDA-Mandated Contraindications
- Empagliflozin is contraindicated in patients on dialysis, as stated in the FDA drug label 1
- The drug is also contraindicated in patients with severe renal impairment and end-stage renal disease (ESRD) 1
- Empagliflozin should be discontinued if eGFR is persistently less than 45 mL/min/1.73 m² 1
Guideline-Based Recommendations
- KDIGO 2020 guidelines explicitly state that SGLT2 inhibitors should be discontinued once kidney replacement therapy is initiated 2
- While SGLT2 inhibitors can be continued even if eGFR falls below 30 mL/min/1.73 m² in patients already taking them, this continuation is only reasonable "unless kidney replacement therapy is initiated" 3
- The American College of Cardiology 2020 consensus pathway lists "on dialysis" as a specific contraindication for empagliflozin 3
Why SGLT2 Inhibitors Don't Work on Dialysis
- SGLT2 inhibitors work by blocking glucose reabsorption in the proximal tubule of functioning kidneys—a mechanism that becomes irrelevant once patients are on dialysis 2
- The drug is not expected to be effective in patients receiving dialysis, as there are no functioning nephrons to exert its glucose-lowering effect 1
- Continuing empagliflozin in dialysis patients exposes them to potential adverse effects without providing therapeutic benefit 2
Alternative Glucose-Lowering Options for Dialysis Patients
For patients on hemodialysis who need glycemic control, consider these alternatives:
- GLP-1 receptor agonists (such as liraglutide or semaglutide) retain glucose-lowering efficacy in dialysis patients and are the preferred alternative 2
- Selected DPP-4 inhibitors (such as sitagliptin with dose adjustment) can be safely used in dialysis patients 2
- Insulin remains the cornerstone of glycemic management in dialysis patients, though doses often need reduction due to decreased insulin clearance 2
Clinical Algorithm for SGLT2 Inhibitor Use by Kidney Function
Pre-dialysis patients:
- Initiate and continue SGLT2 inhibitors for kidney and cardiovascular protection in patients with eGFR ≥20 mL/min/1.73 m² 2
- Continue SGLT2 inhibitors if already taking and tolerating well in patients with eGFR <20 mL/min/1.73 m² (pre-dialysis) 2
Once dialysis starts:
- Discontinue SGLT2 inhibitors immediately when dialysis is initiated, as the mechanism of action requires functioning proximal tubules, which are bypassed by dialysis 2
Critical Safety Considerations
- Empagliflozin carries risks of ketoacidosis, genital mycotic infections, urinary tract infections, and volume depletion 3
- These adverse effects can occur without any therapeutic benefit in dialysis patients 2
- The FDA label specifically warns that removal of empagliflozin by hemodialysis has not been studied 1