Can a patient with impaired glycemic control (A1c) and impaired renal function (GFR 32) take Jardiance (Empagliflozin)?

Can a Patient with A1c and GFR 32 Take Jardiance?

No, Jardiance (empagliflozin) should not be used for glycemic control in a patient with GFR 32 mL/min/1.73 m², as it is not recommended below GFR 45 mL/min/1.73 m² for this indication and will have minimal glucose-lowering efficacy at this level of renal function. 1

FDA-Approved Dosing and Renal Function Restrictions

Empagliflozin is not recommended for glycemic control when eGFR is persistently <45 mL/min/1.73 m². 1, 2 The FDA labeling explicitly states:

• No dose adjustment required if eGFR ≥45 mL/min/1.73 m² 1
• Avoid use and discontinue in patients with eGFR persistently <45 mL/min/1.73 m² 1
• Excretion of 25% to 50% of unchanged drug occurs in urine 1

At GFR 32, this patient falls well below the threshold for glycemic efficacy.

Mechanism and Efficacy Limitations in Advanced CKD

The glucose-lowering effect of SGLT2 inhibitors depends on adequate renal filtration, which is severely compromised at GFR 32:

• Urinary glucose excretion decreases progressively with declining renal function and correlates directly with eGFR 3
• In Japanese patients with severe renal impairment (eGFR 15-<30 mL/min/1.73 m²), urinary glucose excretion was only 23.7g compared to 75.0g in those with normal function 3
• SGLT2 inhibitors are expected not to be effective for glycemic control in advanced CKD 1

Alternative Indications in CKD (Non-Glycemic)

While empagliflozin cannot be used for glucose control at GFR 32, there is emerging evidence for cardiovascular and renal protection benefits independent of glycemic effects:

• Canagliflozin has FDA approval to reduce risk of end-stage kidney disease, doubling of serum creatinine, CV death, and hospitalization for heart failure in patients with T2D and diabetic nephropathy with albuminuria 1
• The EMPA-REG OUTCOME trial showed empagliflozin reduced progression of kidney disease (incident or worsening nephropathy HR 0.61, p<0.001) and lowered rates of renal-replacement therapy by 55% 4
• However, these cardiovascular/renal benefits were studied in patients with baseline eGFR ≥30 mL/min/1.73 m² 4

At GFR 32, empagliflozin would not be initiated for glycemic control, but continuation might be considered if already established for cardiorenal protection in consultation with nephrology. 1, 4

Recommended Glycemic Management at GFR 32

For a patient with impaired glycemic control (elevated A1c) and GFR 32, appropriate alternatives include:

First-Line Options:

• Metformin can be continued with dose reduction when eGFR is 30-45 mL/min/1.73 m², but should not be initiated if eGFR <45 mL/min/1.73 m² 1
• Metformin is contraindicated when eGFR <30 mL/min/1.73 m² 1

Preferred Agents at This GFR Level:

• DPP-4 inhibitors with appropriate dose adjustment: 1

  • Sitagliptin: 25 mg daily if eGFR <30 mL/min/1.73 m² 1
  • Saxagliptin: 2.5 mg daily if eGFR ≤45 mL/min/1.73 m² 1
  • Linagliptin: No dose adjustment needed 1
  • Alogliptin: 6.25 mg daily if eGFR <30 mL/min/1.73 m² 1

• GLP-1 receptor agonists (select agents): 1

  • Liraglutide, dulaglutide, and semaglutide require no dose adjustment but monitor for gastrointestinal reactions 1
  • Exenatide is contraindicated at eGFR <30 mL/min/1.73 m² 1

• Insulin therapy: Remains effective at all levels of renal function, though doses may need reduction due to decreased renal clearance 1

Agents to Avoid:

• Glyburide: Contraindicated 1
• Sulfonylureas generally require caution due to hypoglycemia risk with prolonged half-life 1

Critical Monitoring Considerations

• HbA1c may underestimate glycemic control in advanced CKD due to shortened red cell lifespan, anemia, and carbamylation 1
• The correlation between HbA1c and ambient glucose is weaker in patients with eGFR <60 mL/min/1.73 m² 1
• Consider continuous glucose monitoring or more frequent self-monitoring of blood glucose for accurate assessment 1
• Monitor serum potassium when using ACE inhibitors or ARBs concurrently 1

Common Pitfalls to Avoid

• Do not initiate empagliflozin for glycemic control at GFR 32 - it will be ineffective and represents inappropriate prescribing 1
• Avoid assuming HbA1c accurately reflects glycemic control - it may be falsely low or high in CKD stage 3-4 1
• Do not overlook medication dose adjustments - many diabetes medications require renal dosing modifications 1
• Beware of increased hypoglycemia risk - insulin and sulfonylurea doses often need reduction as GFR declines due to decreased drug clearance 1