Jardiance (Empagliflozin) Dosing
Start Jardiance at 10 mg once daily in the morning, taken with or without food, and increase to 25 mg once daily in patients who tolerate the initial dose and require additional glycemic control. 1
Standard Dosing Regimen
- Initial dose: 10 mg once daily in the morning 1
- Maintenance dose: 10 mg once daily (this is the target dose used in heart failure trials) 2
- Maximum dose: 25 mg once daily (may be used for additional glycemic control in diabetes) 1
- Administration: Take with or without food 1
The 10 mg dose is both the starting and target dose for heart failure indications, as this was the dose proven effective in cardiovascular outcomes trials. 2 The 25 mg dose option exists primarily for patients requiring additional glucose-lowering effects. 1
Renal Function Adjustments
Do not initiate Jardiance if eGFR is less than 45 mL/min/1.73 m² 1
- eGFR ≥45 mL/min/1.73 m²: No dose adjustment required; initiate at standard 10 mg dose 1
- eGFR <45 mL/min/1.73 m²: Do not start therapy 1
- eGFR persistently <45 mL/min/1.73 m²: Discontinue if already on therapy 1
- Severe renal impairment, ESRD, or dialysis: Contraindicated 1
The glucose-lowering efficacy decreases substantially with declining renal function, though cardiovascular and renal protective benefits may persist at lower eGFR levels. 3, 4 The ACC guidelines note that for heart failure care specifically, dapagliflozin should not be used below eGFR <30 mL/min/1.73 m², while empagliflozin should not be used below eGFR <20 mL/min/1.73 m². 2 However, the FDA label is more conservative and should guide prescribing. 1
Volume Status Considerations
Correct volume depletion before initiating Jardiance 1
- Assess volume status prior to starting therapy, particularly in patients with renal impairment, elderly patients, those with low systolic blood pressure, or those on diuretics 1
- Monitor for signs and symptoms of hypotension after initiation 1
- Increase monitoring in clinical situations where volume contraction is expected 1
Perioperative Management
Withhold Jardiance at least 3 days before major surgery or procedures requiring prolonged fasting 3, 4
This prevents the rare but serious risk of euglycemic diabetic ketoacidosis in the perioperative period. 3, 4 Patients presenting with signs of severe metabolic acidosis should be assessed for ketoacidosis regardless of blood glucose levels, as SGLT2-associated ketoacidosis can occur even with glucose <250 mg/dL. 1
Special Populations
Pediatric Patients (Ages 10-17 with Type 2 Diabetes)
- Initial dose: 10 mg once daily 3
- Dose escalation: May increase to 25 mg daily if A1C remains ≥7.0% after 12 weeks 3
Hepatic Impairment
- Mild (Child-Pugh A): No dose adjustment required 2
- Moderate (Child-Pugh B): No specific FDA guidance, but ACC suggests caution 2
- Severe (Child-Pugh C): Contraindicated 2
Concomitant Therapy Adjustments
Reduce insulin or insulin secretagogue doses when initiating Jardiance to minimize hypoglycemia risk 2
The hypoglycemia risk increases when empagliflozin is combined with insulin or sulfonylureas, requiring dose reduction of these agents. 2 When used as monotherapy or with metformin, hypoglycemia risk is minimal (0.5-1.8%). 5
Common Adverse Effects to Monitor
- Genital mycotic infections: Occur in approximately 6% of patients (particularly women) versus 1% on placebo 3, 4
- Urinary tract infections: Mild increase in incidence (approximately 5%) 5
- Volume depletion/hypotension: Monitor blood pressure, especially in at-risk patients 1
- Acute kidney injury: Consider temporarily discontinuing in settings of reduced oral intake or fluid losses 2
Monitoring Requirements
- Renal function: Assess eGFR prior to initiation and periodically thereafter 1
- Volume status: Monitor for signs of intravascular volume contraction 1
- Ketoacidosis risk: Assess patients with metabolic acidosis symptoms regardless of glucose level 1
- Blood pressure: Monitor after initiation, particularly in volume-depleted patients 1