What precautions should be taken when using Jardiance (Empagliflozin) and Acarbose in patients with diabetes at risk for acute kidney injury (AKI)?

Precautions for Jardiance and Acarbose in Patients at Risk for AKI

Both Jardiance (empagliflozin) and acarbose can be used in diabetic patients at risk for AKI, but Jardiance requires temporary discontinuation during acute illness or volume depletion, while acarbose should be avoided only when eGFR is persistently below 25 mL/min/1.73 m².

Jardiance (Empagliflozin) Precautions

Volume Status Assessment and Monitoring

• Before initiating Jardiance, assess and correct volume status in high-risk patients including those with renal impairment, elderly patients, those with low systolic blood pressure, and patients on diuretics 1.
• Monitor for signs and symptoms of volume depletion throughout therapy, as Jardiance causes intravascular volume contraction that can precipitate AKI 1.

Temporary Discontinuation Scenarios

• Temporarily discontinue Jardiance in any setting of reduced oral intake (acute illness, fasting) or fluid losses (gastrointestinal illness, excessive heat exposure) 1.
• Consider discontinuation in clinical situations predisposing to ketoacidosis, which can complicate AKI management 1.
• Monitor patients for signs and symptoms of acute kidney injury during these periods 1.

Renal Function Monitoring Requirements

• Evaluate renal function prior to initiation and monitor periodically thereafter 1.
• Implement more frequent renal function monitoring in patients with eGFR below 60 mL/min/1.73 m² 1.
• Use is not recommended when eGFR is persistently less than 45 mL/min/1.73 m² and is contraindicated below 30 mL/min/1.73 m² 1.

Concomitant Medication Considerations

• Exercise particular caution when combining Jardiance with diuretics, ACE inhibitors, ARBs, or NSAIDs, as these combinations increase AKI risk 1, 2.
• Diuretics carry the highest risk (HR 1.64), followed by ACE inhibitors (HR 1.39) when administered in settings predisposing to AKI 2.
• Consider dose adjustments or temporary holds of these medications during acute illness 3.

Important Clinical Context

Despite FDA warnings about AKI risk with SGLT2 inhibitors, randomized clinical trials of empagliflozin in advanced kidney disease and high cardiovascular risk populations have not demonstrated increased AKI rates 3. In fact, empagliflozin may have protective effects against AKI compared to other SGLT2 inhibitors 4. However, individual case reports of tubulointerstitial nephritis exist 5, emphasizing the need for vigilance.

Acarbose Precautions

Renal Function Thresholds

• Acarbose use is not recommended when eGFR is below 25 mL/min/1.73 m² 3.
• Although acarbose is minimally absorbed, serum levels of the drug and its metabolites increase significantly with reduced kidney function 3.

Evidence Supporting Safety in Severe CKD

Recent evidence challenges traditional contraindications: a large propensity-matched cohort study found that acarbose users with stage 5 CKD/ESRD did not exhibit increased liver injury compared to non-users, regardless of chronic liver disease presence 6. This suggests acarbose may be safer than previously thought in severe renal insufficiency, though the primary concern remains drug accumulation rather than AKI precipitation.

Monitoring Approach

• Unlike Jardiance, acarbose does not directly affect renal hemodynamics or volume status 3.
• Standard annual monitoring of eGFR and albuminuria is sufficient unless other risk factors are present 3.
• No specific temporary discontinuation is required during acute illness, as acarbose does not alter renal blood flow 3.

Common Pitfalls to Avoid

For Jardiance

• Do not continue Jardiance during acute illness with poor oral intake or dehydration - this is the most common preventable cause of SGLT2 inhibitor-associated AKI 1.
• Do not confuse the expected modest creatinine increase (up to 30%) with initiation of therapy with true AKI 3.
• Avoid combining with multiple nephrotoxic agents, as each additional nephrotoxin increases AKI odds by 53% 2.

For Acarbose

• Do not automatically discontinue acarbose in patients with eGFR 25-45 mL/min/1.73 m² - it can be continued with monitoring 3, 6.
• Recognize that acarbose does not require the same acute illness precautions as Jardiance since it doesn't affect volume status 3.

General AKI Risk Management

• Monitor serum creatinine and potassium at least annually, or more frequently (every 2-4 weeks) when eGFR is below 60 mL/min/1.73 m² 3.
• Minimize exposure to nephrotoxins including NSAIDs and iodinated contrast in all patients with diabetes and reduced eGFR 3.
• Educate patients on "sick day rules" - when to temporarily stop medications during acute illness 3.