Should Jardiance (Empagliflozin) and Acarbose be held in a post-operative patient with impaired renal function (stage 3 CKD) and elevated creatinine?

Hold Jardiance temporarily; continue acarbose with caution

In this post-operative patient with acute-on-chronic kidney injury (creatinine 2.0→2.5, stage 3 CKD), Jardiance (empagliflozin) should be temporarily discontinued until renal function stabilizes, while acarbose can be continued with close monitoring.

Jardiance (Empagliflozin) Management

Jardiance must be held in this acute setting. The FDA label explicitly states that empagliflozin should be "temporarily discontinued in clinical situations known to predispose to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery)" and that "use of JARDIANCE is not recommended when eGFR is persistently less than 45 mL/min/1.73 m²" 1.

Key Considerations for Holding Jardiance:

• Volume depletion risk: Post-operative day 2 patients are at high risk for intravascular volume contraction, and empagliflozin causes additional volume depletion through osmotic diuresis 1
• Acute kidney injury: The FDA warns that SGLT2 inhibitors can cause acute kidney injury requiring hospitalization and dialysis, particularly in patients with "hypovolemia, chronic renal insufficiency, congestive heart failure and concomitant medications" 1
• Rising creatinine: The 25% increase in creatinine (2.0→2.5) represents acute kidney disease (AKD) superimposed on CKD, meeting criteria for medication reassessment 2
• Perioperative nephrotoxin avoidance: Guidelines recommend avoiding or discontinuing nephrotoxic agents in the perioperative period when acute renal failure risk is elevated 2

When to Restart Jardiance:

• Resume empagliflozin only after creatinine returns to baseline (2.0) and volume status is optimized 1
• Ensure adequate oral intake is re-established and no ongoing fluid losses exist 1
• Verify eGFR remains >45 mL/min/1.73 m² before restarting 1
• Monitor renal function within 2-4 weeks after restarting 2

Acarbose Management

Acarbose can be continued but requires heightened vigilance. The KDOQI guidelines state that "acarbose use in patients with a GFR < 25 mL/min/1.73 m² is not recommended" 2. With stage 3 CKD (baseline creatinine 2.0, estimated eGFR likely 30-45 mL/min/1.73 m²), this patient remains above the contraindication threshold.

Rationale for Continuing Acarbose:

• Minimal systemic absorption: Acarbose acts locally in the GI tract with minimal absorption, though metabolites do accumulate with reduced kidney function 2
• No hypoglycemia risk: Unlike sulfonylureas or insulin, acarbose does not cause hypoglycemia, making it safer in the acute setting 2
• Above contraindication threshold: Current renal function (creatinine 2.5) likely corresponds to eGFR >25 mL/min/1.73 m², where acarbose remains permissible 2

Monitoring Requirements:

• Calculate precise eGFR using MDRD or CKD-EPI formula to confirm it remains >25 mL/min/1.73 m² 2
• If creatinine continues rising or eGFR falls below 25 mL/min/1.73 m², discontinue acarbose 2
• Monitor for GI side effects (diarrhea, abdominal pain) which may worsen dehydration 2

Clinical Algorithm for This Patient

Immediate actions (POD #2):

1. Hold Jardiance until further notice 1
2. Continue acarbose if calculated eGFR >25 mL/min/1.73 m² 2
3. Optimize volume status with IV fluids as needed 1
4. Avoid other nephrotoxins (NSAIDs, contrast) 2
5. Monitor creatinine daily until trending downward 2

Before hospital discharge:

1. Reassess renal function - if creatinine returns to 2.0, Jardiance can be restarted 1
2. If creatinine remains elevated >2.0, continue holding Jardiance 1
3. Provide patient education about signs of volume depletion and when to withhold Jardiance (illness, reduced oral intake) 1

Outpatient follow-up (within 2-4 weeks):

1. Recheck creatinine and calculate eGFR 2
2. If stable at baseline, restart Jardiance with close monitoring 1
3. If eGFR <45 mL/min/1.73 m², do not restart Jardiance 1
4. Continue acarbose unless eGFR falls <25 mL/min/1.73 m² 2

Common Pitfalls to Avoid

• Do not restart Jardiance prematurely: Waiting until volume status and renal function normalize is critical to prevent worsening AKI 1
• Do not assume all diabetes medications need holding: Acarbose has a different safety profile than SGLT2 inhibitors and can often be continued 2
• Do not use serum creatinine alone: Calculate actual eGFR to guide medication decisions, as creatinine varies by age, weight, and race 2
• Do not forget post-discharge monitoring: AKI increases long-term CKD progression risk; ensure nephrology follow-up is arranged 2