When to Discontinue ARBs and Jardiance (Empagliflozin) in CKD
ARBs should generally be continued even when eGFR falls below 30 ml/min/1.73 m² and only discontinued for specific clinical indications: symptomatic hypotension, uncontrolled hyperkalemia despite medical management, serum creatinine rise >30% within 4 weeks of initiation/dose increase, or to reduce uremic symptoms when eGFR <15 ml/min/1.73 m². 1 Jardiance (empagliflozin) should be continued even if eGFR falls below 20 ml/min/1.73 m² once initiated, unless intolerance develops or kidney replacement therapy is started. 1
ARB Discontinuation Guidelines
Do NOT Routinely Discontinue ARBs Based on eGFR Alone
- Continue ARBs even when eGFR falls below 30 ml/min/1.73 m² as they remain nephroprotective. 1
- The 2024 KDIGO guidelines explicitly state to continue ARBs in advanced CKD, representing a paradigm shift from older practices that discontinued these medications at specific eGFR thresholds. 1
Specific Indications for ARB Discontinuation
Consider reducing dose or discontinuing ARBs only in these situations: 1, 2
- Symptomatic hypotension - when blood pressure drops cause dizziness, syncope, or other symptoms 1, 2
- Uncontrolled hyperkalemia despite medical treatment - particularly when potassium >6.5 mEq/L persists after interventions 1, 2
- Serum creatinine rise >30% within 4 weeks of starting ARB or increasing dose 1, 3, 2
- eGFR <15 ml/min/1.73 m² with uremic symptoms - to reduce uremic manifestations while treating kidney failure 1, 2
Management Algorithm Before Discontinuing ARBs
Before discontinuing an ARB for creatinine rise or hyperkalemia, systematically address reversible causes: 3, 2
- Assess volume status - check for dehydration, excessive diuresis, or gastrointestinal losses causing prerenal azotemia 3, 2
- Review concurrent medications - identify nephrotoxic drugs (NSAIDs, aminoglycosides) and potassium-altering agents 1, 3, 2
- Manage hyperkalemia medically before stopping ARB:
- For K+ 5.0-5.5 mmol/L: reduce/stop potassium supplements and potassium-sparing diuretics, add/increase loop or thiazide diuretics 1, 2
- For K+ 5.5-6.0 mmol/L: implement dietary potassium restriction, consider potassium binders 2
- For K+ >6.0 mmol/L: stop ARB immediately and initiate acute hyperkalemia treatment 2
Monitoring Requirements
- Check serum creatinine and potassium within 2-4 weeks after starting ARB or changing dose 1, 2
- For stable patients on maintenance therapy, monitor every 3-6 months 2
- For patients with eGFR <30 ml/min/1.73 m², monitor every 1-3 months 3
- More frequent monitoring (every 1-2 weeks) may be needed in advanced CKD or after dose adjustments 2
Temporary Suspension vs. Permanent Discontinuation
Temporarily suspend ARBs during: 1
- Intercurrent illness with reduced oral intake or fluid losses 1
- Planned IV radiocontrast administration 1
- Bowel preparation prior to colonoscopy 1
- Prior to major surgery 1
Resume ARB after the acute situation resolves unless permanent contraindications develop. 1
Jardiance (Empagliflozin) Discontinuation Guidelines
Do NOT Discontinue Based on eGFR Decline
- Once empagliflozin is initiated, continue even if eGFR falls below 20 ml/min/1.73 m², unless intolerance develops or kidney replacement therapy is started. 1
- The initial reversible decrease in eGFR after starting empagliflozin is expected and not an indication to discontinue therapy. 1
- SGLT2i initiation does not necessitate alteration of CKD monitoring frequency. 1
When to Initiate Empagliflozin
- Start empagliflozin when eGFR ≥20 ml/min/1.73 m² in patients with type 2 diabetes and CKD (1A recommendation). 1
- For adults with CKD and urine ACR ≥200 mg/g or heart failure, start when eGFR ≥20 ml/min/1.73 m². 1
- The FDA label states: "Do not initiate JARDIANCE if eGFR is below 45 mL/min/1.73 m²" but this conflicts with newer KDIGO guidelines that recommend initiation at eGFR ≥20 ml/min/1.73 m². 4 Follow the more recent 2024 KDIGO guidelines over the older FDA label. 1
Specific Situations Requiring Temporary Withholding
Temporarily withhold empagliflozin during: 1
- Prolonged fasting 1
- Surgery 1
- Critical medical illness when patients may be at greater risk for ketosis 1
Resume empagliflozin after the acute situation resolves.
Permanent Discontinuation Indications
Discontinue empagliflozin only when: 1
- Intolerance develops (e.g., recurrent genital mycotic infections, urinary tract infections) 4
- Kidney replacement therapy is initiated 1
- Diabetic ketoacidosis occurs (assess patients with metabolic acidosis signs regardless of blood glucose) 4
Evidence Supporting Continuation in Advanced CKD
- The EMPA-KIDNEY trial demonstrated that empagliflozin reduced progression of kidney disease or cardiovascular death in patients with eGFR as low as 20 ml/min/1.73 m², with consistent benefits across eGFR ranges. 5
- Hospitalization rates were lower with empagliflozin, and serious adverse event rates were similar to placebo. 5
Common Pitfalls to Avoid
- Do not automatically discontinue ARBs when eGFR reaches 30 ml/min/1.73 m² - this outdated practice removes nephroprotective therapy. 1
- Do not stop ARBs for mild hyperkalemia (K+ 5.0-5.5 mmol/L) without first attempting medical management with diuretics and dietary restriction. 1, 2
- Do not discontinue empagliflozin for the expected initial eGFR dip after starting therapy - this is a hemodynamic effect, not kidney injury. 1
- Do not confuse FDA label restrictions (eGFR <45 for initiation) with continuation thresholds - newer guidelines support continuing both medications at much lower eGFR levels. 1, 4
- Do not stop ARBs for creatinine rise <30% - this modest increase is expected and associated with long-term renoprotection. 1, 3