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

Jardiance (Empagliflozin) for Type 2 Diabetes: Recommended Use and Dosing

Start empagliflozin at 10 mg orally once daily in the morning, with or without food, for all patients with type 2 diabetes—this dose provides full cardiovascular and renal protection without need for titration. 1

Standard Dosing Protocol

• Initial dose: 10 mg once daily is the FDA-approved starting dose and the dose proven to reduce cardiovascular death in the EMPA-REG OUTCOME trial 1
• The 10 mg dose provides complete cardiovascular risk reduction benefits—no dose titration is needed for cardiovascular or renal protection because there is no graded dose-response relationship for these outcomes 2, 3
• May increase to 25 mg once daily only if additional glucose lowering is needed after tolerating the 10 mg dose, but this higher dose offers no additional cardiovascular benefit 2, 1

Primary Indications

Empagliflozin has three FDA-approved indications: 1

• Glycemic control: As adjunct to diet and exercise to improve blood sugar control in adults with type 2 diabetes 1
• Cardiovascular death reduction: To reduce risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease 1
• Heart failure hospitalization prevention: Reduces hospitalization for heart failure by 35% compared to placebo 2

The cardiovascular benefits are particularly robust—empagliflozin reduced cardiovascular death by 38% and all-cause mortality by 32% in the EMPA-REG OUTCOME trial 2, 4

Renal Function Requirements and Restrictions

Critical renal thresholds to remember: 1

• Do not initiate if eGFR <45 mL/min/1.73 m² 1
• No dose adjustment needed if eGFR ≥45 mL/min/1.73 m² 1
• Discontinue permanently if eGFR falls persistently below 45 mL/min/1.73 m² 1
• Absolute contraindications: severe renal impairment, end-stage renal disease, or dialysis 1

Assess renal function before starting empagliflozin and monitor periodically during treatment 1. The glucose-lowering efficacy decreases substantially with declining renal function, though cardiovascular benefits may persist 4

Concomitant Medication Adjustments

When initiating empagliflozin, make these dose reductions to prevent hypoglycemia: 2, 3

• Reduce total daily insulin dose by approximately 20% if patient is on insulin 2, 3
• Wean or stop sulfonylureas or glinides if HbA1c is well-controlled at baseline or if patient has history of frequent hypoglycemic events 2
• Consider reducing or stopping diuretics if patient has volume depletion risk, as empagliflozin causes intravascular volume contraction 2, 1

Surgical and Procedural Management

Discontinue empagliflozin at least 3 days before any planned surgery to prevent postoperative ketoacidosis 2, 3. Resume only when the patient is clinically stable and has resumed oral intake 5

Volume Status Assessment

Before initiating empagliflozin, correct volume depletion if present 1. This is particularly important in: 1

• Patients with renal impairment
• Elderly patients
• Patients with low systolic blood pressure
• Patients already on diuretics

Monitor for signs and symptoms of hypotension after starting therapy, especially in these high-risk groups 1

Key Safety Monitoring

Monitor for these serious adverse effects: 1

• Ketoacidosis: Can occur even with blood glucose <250 mg/dL—assess any patient with signs of metabolic acidosis regardless of glucose level 1
• Genital mycotic infections: Most common adverse effect (>5% incidence), particularly in women 2, 1
• Urinary tract infections: Monitor and treat promptly; evaluate for urosepsis if severe 1
• Acute kidney injury: Consider temporarily discontinuing in settings of reduced oral intake or fluid losses 1

Common Pitfalls to Avoid

• Never start empagliflozin in patients with eGFR <45 mL/min/1.73 m²—this is both ineffective for glycemic control and contraindicated 3, 1
• Do not forget to reduce insulin or sulfonylurea doses when starting empagliflozin, as this significantly increases hypoglycemia risk 2, 3
• Do not continue empagliflozin through surgical procedures—the risk of ketoacidosis is substantial 2, 3
• Do not use for type 1 diabetes or diabetic ketoacidosis treatment—empagliflozin is not indicated for these conditions 1

Cardiovascular Disease Considerations

For patients with established cardiovascular disease, empagliflozin is particularly valuable because it: 2

• Reduces major adverse cardiovascular events by 14% 2
• Reduces cardiovascular death by 38% 2
• Reduces hospitalization for heart failure by 35% 2
• Provides renoprotection with 44% reduction in doubling of serum creatinine 6

These benefits appear within months of starting therapy and are independent of glucose-lowering effects 7, 4