Is it recommended to start Jardiance (Empagliflozin) in a patient with an elevated Hemoglobin A1c (HbA1c) level of 9.5%?

Should You Start Jardiance with A1c of 9.5%?

Yes, you should strongly consider starting Jardiance (empagliflozin) in a patient with A1c of 9.5%, but the decision depends critically on whether the patient has established cardiovascular disease, heart failure, or chronic kidney disease—in which case Jardiance is strongly recommended—or if this is newly diagnosed diabetes without these comorbidities, in which case dual therapy including Jardiance should be initiated alongside metformin. 1, 2

Initial Treatment Strategy Based on Clinical Context

For Newly Diagnosed Type 2 Diabetes at A1c 9.5%

• Dual therapy should be initiated immediately when A1c is ≥1.5% above the glycemic target (typically 7%), which clearly applies at 9.5% 1
• The preferred initial approach is metformin plus a second agent, with the choice of second agent guided by comorbidities 1
• At this A1c level (9.5%), monotherapy with metformin alone will be insufficient, as most oral agents reduce A1c by only 0.7-1.0%, and you need approximately a 2.5% reduction to reach goal 1

When Jardiance is Strongly Recommended as Part of Initial Therapy

• If the patient has established atherosclerotic cardiovascular disease (ASCVD), SGLT2 inhibitors like Jardiance are recommended as part of the antihyperglycemic regimen regardless of A1c level 1
• If the patient has heart failure or is at high risk for heart failure, SGLT2 inhibitors are the preferred class 1
• If the patient has chronic kidney disease, SGLT2 inhibitors provide both glycemic control and renal protection 1
• In these scenarios, start metformin plus Jardiance 10 mg daily (the lowest dose for cardiovascular benefit), with no need to uptitrate for CV risk reduction 1

When to Consider Insulin Instead

• Insulin should be strongly considered if there is evidence of ongoing catabolism (weight loss), symptoms of hyperglycemia (polyuria, polydipsia), or when A1c levels are >10% or blood glucose levels are ≥300 mg/dL 1
• At A1c 9.5% without catabolic features or severe symptoms, non-insulin regimens including Jardiance are appropriate and effective 1, 3
• Recent evidence demonstrates that GLP-1 receptor agonists and dual GIP/GLP-1 receptor agonists can effectively treat patients even with A1c >10%, challenging the traditional threshold for mandatory insulin use 1, 4, 3

Efficacy of Jardiance at High A1c Levels

• Jardiance demonstrates dose-dependent A1c reductions of 0.4-0.6% when used as monotherapy in clinical trials 5
• When combined with metformin in patients with baseline A1c around 8%, Jardiance 25 mg produces A1c reductions of approximately 0.7% 6
• In combination with other agents (such as DPP-4 inhibitors), Jardiance can produce A1c reductions exceeding 1% 7
• At A1c 9.5%, dual therapy with metformin plus Jardiance would be expected to reduce A1c by approximately 1.5-2%, bringing most patients close to goal 1, 7

Practical Implementation

Recommended Starting Regimen

• Start metformin (if not contraindicated) at 500-850 mg daily, titrating to 2000 mg daily over 2-4 weeks to minimize gastrointestinal side effects 1
• Add Jardiance 10 mg daily immediately, which can be increased to 25 mg if additional glycemic control is needed after 3 months 1, 6
• If cardiovascular or renal comorbidities exist, Jardiance 10 mg is sufficient for organ protection and does not require uptitration for CV benefit 1

Monitoring and Follow-Up

• Reassess A1c in 3 months to evaluate treatment effectiveness 2
• Monitor for genitourinary infections (genital mycotic infections occur in approximately 2% of patients, urinary tract infections in 1.6%) 5
• Check renal function before starting and periodically thereafter, as Jardiance is contraindicated with eGFR <30 mL/min/1.73 m² 1
• Monitor for volume depletion, particularly in elderly patients or those on diuretics 6
• Assess for diabetic ketoacidosis risk, though this is rare with SGLT2 inhibitors in type 2 diabetes 1

Additional Benefits Beyond Glycemic Control

• Weight reduction of 2-4% from baseline is expected with Jardiance, which is beneficial for most patients with type 2 diabetes 6, 5
• Systolic blood pressure reduction of 3-4 mmHg occurs with Jardiance treatment 6
• Cardiovascular mortality reduction has been demonstrated in patients with established ASCVD 1
• Heart failure hospitalization reduction is a key benefit, particularly important if the patient has or is at risk for heart failure 1

Critical Pitfalls to Avoid

• Do not delay dual therapy by trying metformin monotherapy first at A1c 9.5%—this prolongs exposure to severe hyperglycemia and increases complication risk 1, 2, 8
• Do not use Jardiance as monotherapy in newly diagnosed patients; metformin should be the foundation unless contraindicated 1
• Do not assume insulin is mandatory at A1c 9.5% if the patient lacks catabolic features or severe symptoms—effective non-insulin regimens exist 1, 4, 3
• Do not overlook cardiovascular and renal comorbidities when making treatment decisions, as these strongly favor SGLT2 inhibitor use regardless of A1c level 1
• Do not continue sulfonylureas if you later need to add complex insulin regimens, as this significantly increases hypoglycemia risk 8

Alternative Considerations

• If cost is prohibitive for Jardiance, consider a GLP-1 receptor agonist as an alternative, which also provides cardiovascular benefit and superior A1c reduction at high baseline levels 1, 3
• If the patient has contraindications to metformin (eGFR <30 mL/min/1.73 m²), Jardiance can be combined with other agents or used as part of a different dual therapy regimen 1
• Tirzepatide (dual GIP/GLP-1 RA) is an alternative high-potency option that can reduce A1c by 2.1-2.4% and may be considered if the patient prefers injectable therapy 4