What is the recommended use and dosage of Jardiance (empagliflozin) for patients with type 2 diabetes?

Jardiance (Empagliflozin) for Type 2 Diabetes

Recommended Dosing

Start empagliflozin at 10 mg orally once daily in the morning, with or without food, as this dose provides optimal cardiovascular and renal protection without need for titration. 1, 2, 3

• The 10 mg daily dose is the evidence-based starting point that demonstrated cardiovascular mortality reduction in the EMPA-REG OUTCOME trial. 1, 2
• No dose titration is required for cardiovascular or renal risk reduction, as there is no graded dose-response relationship for these critical outcomes. 1, 2
• The dose may be increased to 25 mg daily if additional glucose lowering is needed to reach glycemic targets, but this provides no additional cardiovascular benefit. 1, 2, 3

Primary Indications

Empagliflozin has three FDA-approved indications: 3

• Improve glycemic control in adults with type 2 diabetes as adjunct to diet and exercise 1, 3
• Reduce cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 1, 3
• The drug is NOT indicated for type 1 diabetes or diabetic ketoacidosis treatment 3

Cardiovascular Benefits

Empagliflozin reduced cardiovascular death by 38% and the composite outcome of MI, stroke, or cardiovascular death by 14% in patients with type 2 diabetes and established cardiovascular disease. 1

• Hospitalization for heart failure was reduced by 35% in the EMPA-REG OUTCOME trial. 1
• These benefits appeared within months of treatment initiation, suggesting mechanisms beyond glucose control. 4
• The cardiovascular protection was consistent in patients with and without baseline heart failure. 1, 5

Renal Considerations and Contraindications

Do not initiate empagliflozin if eGFR is <45 mL/min/1.73 m², and discontinue if eGFR persistently falls below this threshold. 1, 2, 3

• Assess renal function before starting therapy and periodically thereafter. 3
• The drug is contraindicated in severe renal impairment, end-stage renal disease, or patients on dialysis. 1, 2, 3
• Despite renal limitations for glycemic control, empagliflozin showed renoprotective effects including 44% reduction in doubling of serum creatinine and slower progression of kidney disease. 1, 6

Critical Safety Measures Before Initiation

Assess and correct volume depletion before starting empagliflozin, particularly in elderly patients, those with low blood pressure, or patients on diuretics. 1, 3

• Consider reducing or stopping diuretic therapy when initiating empagliflozin to minimize hypotension risk. 1
• If the patient is on insulin or sulfonylureas, reduce insulin dose by approximately 20% or discontinue sulfonylureas/glinides to prevent hypoglycemia. 1, 2
• For patients with well-controlled HbA1c at baseline or history of frequent hypoglycemia, proactively adjust these medications. 1

Perioperative Management

Discontinue empagliflozin at least 3 days before any planned surgery or procedure with prolonged fasting to prevent postoperative ketoacidosis. 1, 2, 3

• Resume only when the patient is clinically stable and has resumed oral intake. 1

Monitoring for Adverse Effects

Watch for these specific complications: 1, 3

• Genital mycotic infections (most common adverse effect, especially in women) 1
• Euglycemic diabetic ketoacidosis (rare but serious; assess for ketoacidosis even if blood glucose <250 mg/dL in patients with metabolic acidosis symptoms) 3
• Urinary tract infections 1
• Volume depletion and hypotension (monitor signs/symptoms, especially early in therapy) 3

Special Populations at Higher Risk

Use with extreme caution or avoid in patients with: 1

• Prior amputation history
• Severe peripheral neuropathy
• Severe peripheral vascular disease
• Active diabetic foot ulcers or soft tissue infections

Common Pitfalls to Avoid

• Do NOT start empagliflozin in patients with eGFR <45 mL/min/1.73 m² for glycemic control, though cardiovascular benefits may still apply in established CVD. 1, 2, 3
• Do NOT fail to reduce insulin or sulfonylurea doses when initiating therapy, as this substantially increases hypoglycemia risk. 1, 2
• Do NOT continue empagliflozin through surgical procedures without a 3-day washout period. 1, 2
• Do NOT assume higher doses provide better cardiovascular protection—the 10 mg dose is sufficient for all non-glycemic benefits. 1, 2