Restarting Jardiance After Renal Function Recovery
Yes, you should restart Jardiance (empagliflozin) now that the GFR has recovered to 61 mL/min/1.73 m², and you can transition off or reduce the basal insulin accordingly. The current GFR is well above the FDA-mandated threshold for both initiation and continuation of empagliflozin, and the patient will benefit from the cardiovascular and renal protective effects of this medication 1.
FDA-Approved Thresholds for Empagliflozin
- Empagliflozin can be initiated when eGFR is ≥45 mL/min/1.73 m² according to FDA labeling 1
- No dose adjustment is needed when eGFR is ≥45 mL/min/1.73 m² 1
- With a current GFR of 61 mL/min/1.73 m², this patient is safely above the initiation threshold 1
Guideline-Based Recommendations for Restarting
- The ADA/KDIGO consensus strongly recommends SGLT2 inhibitors with proven kidney or cardiovascular benefit for patients with type 2 diabetes, CKD, and eGFR ≥20 mL/min/1.73 m² 2
- Once initiated, SGLT2 inhibitors can be continued even if eGFR falls below initiation thresholds, as trial protocols (CREDENCE, DAPA-CKD, EMPA-KIDNEY) specified continuation when eGFR declined 2
- The reversible decline in eGFR associated with SGLT2i initiation (typically 3-5 mL/min/1.73 m²) generally does not require drug discontinuation 2
Practical Restart Protocol
- Restart empagliflozin at 10 mg once daily in the morning, with or without food 1
- Consider increasing to 25 mg once daily if additional glycemic control is needed after tolerating the 10 mg dose 1
- Recheck eGFR within 1-2 weeks after restarting to monitor for the expected hemodynamic dip 3
- An initial eGFR decrease of 3-5 mL/min/1.73 m² within the first 1-4 weeks is expected and reversible 3
Managing the Transition from Basal Insulin
- Reduce basal insulin dose by 20-30% when restarting empagliflozin to minimize hypoglycemia risk 2
- Monitor blood glucose closely during the first 1-2 weeks of the transition 2
- Maintain at least low-dose insulin if the patient is insulin-requiring to mitigate the risk of euglycemic diabetic ketoacidosis, which is higher in patients taking SGLT2 inhibitors 2
- Further insulin dose reductions can be made based on glycemic response over subsequent weeks 2
Critical Safety Monitoring
- Assess volume status before restarting empagliflozin, particularly if the patient is on diuretics, has low systolic blood pressure, or is elderly 2, 1
- Consider proactive dose reduction of concurrent diuretics if the patient is at high risk for volume depletion 2
- Educate the patient on sick day rules: hold empagliflozin during acute illness, fever, vomiting, diarrhea, or reduced oral intake 3
- Monitor for signs of genital mycotic infections (6% incidence vs 1% with placebo) and counsel on genital hygiene 2
- Withhold empagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis 3, 4
Long-Term Benefits at This eGFR Level
- Empagliflozin reduces the risk of kidney disease progression (composite of sustained eGFR decline ≥40%, end-stage kidney disease, or renal death) by 28% in the EMPA-KIDNEY trial 5
- Cardiovascular benefits include reduced risk of cardiovascular death and heart failure hospitalization, which are consistent across eGFR ranges ≥20 mL/min/1.73 m² 6, 5, 7
- The glucose-lowering efficacy is preserved at eGFR 61 mL/min/1.73 m², though it decreases progressively below 45 mL/min/1.73 m² 8, 9
Common Pitfall to Avoid
- Do not permanently discontinue empagliflozin solely due to transient eGFR fluctuations unless eGFR persistently falls below 45 mL/min/1.73 m² per FDA labeling, or below 20 mL/min/1.73 m² per current guideline recommendations 2, 1
- The initial eGFR dip is hemodynamic and reversible, not indicative of true kidney injury 2
- In fact, SGLT2 inhibitors protect against acute kidney injury in the long term 2