Is it safe to discontinue one of the diabetic medications, Jardiance (empagliflozin) and metformin, in a patient with a history of stroke, hypertension, hyperlipidemia, and chronic kidney disease, and an HbA1c level of 5.8%?

Do Not Discontinue Jardiance in This Patient

Keep Jardiance (empagliflozin) and discontinue metformin if the patient insists on stopping one medication. This patient's cardiovascular and renal risk profile makes Jardiance far more valuable than metformin for preventing morbidity and mortality, regardless of the well-controlled A1c of 5.8%.

Why Jardiance Must Be Continued

Cardiovascular Protection in High-Risk Patients

Your patient has established cardiovascular disease (history of stroke) and multiple risk factors (hypertension, hyperlipidemia, CKD). In patients with type 2 diabetes and established cardiovascular disease or kidney disease, an SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended as part of comprehensive cardiovascular risk reduction, independent of glucose-lowering needs 1.

• Empagliflozin reduced cardiovascular death by 38% (HR 0.62,95% CI 0.49-0.77) in patients with established CVD 1
• The cardiovascular benefits of empagliflozin are consistent regardless of baseline glucose-lowering therapy, including metformin use 2
• These benefits extend specifically to patients with CKD, where empagliflozin reduced cardiovascular death by 29% (HR 0.71,95% CI 0.52-0.98) 3

Renal Protection Critical for CKD Patients

With established CKD, this patient faces progressive kidney disease risk that empagliflozin directly addresses:

• Empagliflozin reduced incident or worsening nephropathy by 39% (HR 0.61,95% CI 0.51-0.72) 1
• Doubling of serum creatinine was reduced by 44%, and need for renal replacement therapy by 55% 4
• These renal benefits occur even in patients with stage 2 and 3 CKD (eGFR 30-90 mL/min/1.73 m²) 5, 3
• The renal protective effects persist across all baseline kidney function categories 3

Heart Failure Risk Reduction

Even without documented heart failure, this patient's cardiovascular history places them at risk:

• Empagliflozin reduced heart failure hospitalization by 35% (HR 0.65,95% CI 0.50-0.85) in patients with established CVD 1
• In patients with prevalent kidney disease, heart failure hospitalization was reduced by 39% (HR 0.61,95% CI 0.42-0.87) 3

Why Metformin Can Be Safely Discontinued

Glycemic Control Already Achieved

With an A1c of 5.8%, this patient has achieved excellent glycemic control and is actually below the target where deintensification should be considered:

• Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5% 1
• No trials demonstrate clinical outcome benefits from targeting HbA1c below 6.5%, and treatment to below this target has substantial harms 1
• The ACCORD trial targeting HbA1c <6.5% was discontinued early due to increased mortality 1

Metformin's Role is Primarily Glycemic

Unlike empagliflozin, metformin's benefits are predominantly glucose-lowering without the same magnitude of cardiovascular or renal protection:

• While metformin is generally well-tolerated and low-cost, at HbA1c levels below 7% it provides little additional benefit 1
• The cardiovascular benefits of empagliflozin are independent of and superior to metformin's effects 2
• In patients not using metformin at baseline, empagliflozin showed even greater renal benefit (HR 0.47 vs 0.68 for those on metformin, P-interaction = 0.01) 2

Clinical Algorithm for This Decision

Step 1: Assess cardiovascular/renal risk (this patient has stroke, HTN, HLD, CKD = very high risk)

• If high CV/renal risk → SGLT2 inhibitor is mandatory 1

Step 2: Evaluate current glycemic control (A1c 5.8%)

• If A1c <6.5% → consider deintensification 1

Step 3: Determine which medication to discontinue

• Keep medication with mortality/morbidity benefit (empagliflozin)
• Discontinue medication primarily for glucose control (metformin)

Important Caveats

Monitor for Antipsychotic-Related Metabolic Effects

The patient is on an antipsychotic, which may contribute to metabolic dysregulation:

• Continue monitoring A1c every 3 months after metformin discontinuation 6
• If A1c rises above 7%, consider adding a GLP-1 receptor agonist with cardiovascular benefit rather than restarting metformin 1, 6

Ensure Jardiance Tolerability

Verify the patient tolerates empagliflozin without adverse effects:

• The adverse event profile in patients with impaired kidney function is similar to the overall population 4, 3
• Empagliflozin remains effective even with reduced eGFR, though glucose-lowering potency decreases 5, 3

Document the Rationale

Explain to the patient that Jardiance is being continued not for diabetes control but for stroke prevention, kidney protection, and heart failure risk reduction—benefits that persist even with normal blood sugar 1, 3.