What is the appropriate dosing for Jardiance (empagliflozin) and Lantus (insulin glargine) in a patient with type 2 diabetes and impaired renal function?

Jardiance and Lantus Dosing with Impaired Renal Function

Direct Answer

For Jardiance (empagliflozin): Do not initiate if eGFR is below 45 mL/min/1.73 m², and discontinue if eGFR falls persistently below 45 mL/min/1.73 m² 1. For Lantus (insulin glargine): No dose adjustment is required based on renal function alone; titrate to glycemic targets with close monitoring for hypoglycemia risk, which increases with declining kidney function.

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Empagliflozin (Jardiance) Dosing Algorithm by GFR

eGFR ≥45 mL/min/1.73 m²

• Initiate at 10 mg orally once daily 1, 2
• No dose adjustment required 2, 3
• May increase to 25 mg daily if additional glycemic control is needed, though cardiovascular and renal benefits do not increase with higher dosing 3, 1
• Take in the morning, with or without food 1

eGFR 30 to <45 mL/min/1.73 m²

• Do not initiate empagliflozin 1
• If already on therapy when eGFR declines to this range, discontinue empagliflozin 1
• Glucose-lowering efficacy is significantly reduced at this level of renal function 1, 4
• Consider switching to GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide), which require no renal dose adjustment 2

eGFR <30 mL/min/1.73 m²

• Empagliflozin is contraindicated 2, 1
• Mechanism of action (SGLT2 inhibition) is ineffective at this level of kidney function 1
• Use GLP-1 receptor agonists or insulin for glycemic control 2

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Important Caveats for Empagliflozin Use

Pre-Initiation Assessment

• Assess renal function (eGFR) before starting empagliflozin 1, 2
• Recheck eGFR within 1-2 weeks after initiation to monitor for expected transient decline 5
• An initial eGFR dip of 3-5 mL/min/1.73 m² is expected and reversible 5

Concomitant Medication Adjustments

• Reduce insulin dose by approximately 20% when initiating empagliflozin to prevent hypoglycemia 2, 3
• Consider reducing or stopping sulfonylureas or glinides 2, 3
• If patient is on diuretics, assess volume status and consider reducing diuretic dose to prevent intravascular volume contraction 2, 5

Surgical and Sick Day Management

• Discontinue empagliflozin at least 3 days before planned surgery to prevent postoperative ketoacidosis 2, 3, 5
• Hold empagliflozin during acute illness, especially with fever, vomiting, diarrhea, or reduced oral intake 5
• Monitor for euglycemic diabetic ketoacidosis (DKA), which can occur even with normal blood glucose 2, 5
• Do not completely stop insulin during sick days, as this increases DKA risk 5

Monitoring for Adverse Effects

• Genital mycotic infections are the most common adverse effect 2, 6
• Urinary tract infections occur more frequently than placebo 2
• Monitor for signs of volume depletion, especially in elderly patients or those on diuretics 2, 5

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Lantus (Insulin Glargine) Dosing with Renal Impairment

General Principles

• Insulin remains effective at all levels of renal function and requires no contraindication based on GFR
• Insulin clearance decreases with declining kidney function, increasing hypoglycemia risk
• More frequent glucose monitoring is essential as renal impairment progresses

Dosing Strategy

• Start conservatively and titrate slowly in patients with eGFR <45 mL/min/1.73 m²
• Reduce total daily insulin dose by 20-25% when initiating empagliflozin (if eGFR permits) 2, 3
• Increase frequency of blood glucose monitoring to detect hypoglycemia early
• Consider reducing basal insulin dose by 10-20% if eGFR <30 mL/min/1.73 m² due to decreased insulin clearance

Hypoglycemia Prevention

• Educate patient on hypoglycemia symptoms and treatment
• Ensure patient has access to rapid-acting carbohydrates
• Consider continuous glucose monitoring if available
• Adjust doses based on individualized glycemic targets, which may be less stringent in patients with advanced CKD 2

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Comprehensive Treatment Algorithm

Step 1: Assess Renal Function

• Measure eGFR and urine albumin-to-creatinine ratio (UACR) 2
• Confirm persistence of abnormalities over at least 3 months before diagnosing CKD 2

Step 2: Determine Empagliflozin Eligibility

• If eGFR ≥45 mL/min/1.73 m²: Initiate empagliflozin 10 mg daily 1, 2
• If eGFR 30-44 mL/min/1.73 m²: Do not initiate; use GLP-1 RA instead 1, 2
• If eGFR <30 mL/min/1.73 m²: Empagliflozin contraindicated; use GLP-1 RA or insulin 1, 2

Step 3: Optimize Insulin Dosing

• If starting empagliflozin, reduce Lantus dose by 20% 2, 3
• If empagliflozin not appropriate, continue Lantus with cautious titration
• Monitor glucose 2-3 times daily initially, then adjust frequency based on stability

Step 4: Add Cardio-Renal Protective Agents

• SGLT2 inhibitor (if eGFR ≥20 mL/min/1.73 m²) is first-line for cardio-renal protection 2
• GLP-1 receptor agonist if SGLT2i not tolerated or contraindicated 2
• Continue ACE inhibitor or ARB at maximum tolerated dose 2
• Add statin therapy (moderate to high intensity) 2

Step 5: Ongoing Monitoring

• Recheck eGFR within 1-2 weeks of starting empagliflozin 5
• Monitor eGFR every 3-6 months thereafter 2
• If eGFR falls persistently below 45 mL/min/1.73 m², discontinue empagliflozin 1
• Adjust insulin doses based on glucose patterns and renal function changes

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Common Pitfalls to Avoid

With Empagliflozin

• Failing to discontinue before surgery increases ketoacidosis risk 2, 3
• Not reducing insulin/sulfonylurea doses when starting empagliflozin causes hypoglycemia 2, 3
• Continuing empagliflozin when eGFR falls below 45 mL/min/1.73 m² provides minimal benefit and potential harm 1
• Not educating patients about sick day rules increases DKA risk 5

With Insulin in CKD

• Over-aggressive insulin dosing in advanced CKD causes severe hypoglycemia
• Ignoring decreased insulin clearance as kidney function declines
• Not increasing glucose monitoring frequency when renal function worsens
• Failing to adjust glycemic targets in patients with limited life expectancy or high hypoglycemia risk 2