What are the current guidelines for using Jardiance (empagliflozin) in adults with type 2 diabetes?

Current Guidelines for Jardiance (Empagliflozin) Use in Adults with Type 2 Diabetes

Jardiance (empagliflozin) should be added to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control, with strong prioritization for patients with heart failure or chronic kidney disease to reduce all-cause mortality, major adverse cardiovascular events, and progression of kidney disease. 1

Primary Indications and Patient Selection

Add empagliflozin to metformin when:

• HbA1c remains between 7-8% despite metformin and lifestyle modifications 1
• Patient has established cardiovascular disease, heart failure, or chronic kidney disease 1
• eGFR is ≥45 mL/min/1.73 m² for glycemic control, or ≥25 mL/min/1.73 m² for cardiovascular/renal protection 2

Prioritize empagliflozin specifically in patients with:

• Congestive heart failure (CHF) or chronic kidney disease (CKD) as the primary indication 1
• Established cardiovascular disease requiring mortality reduction 1

Dosing Algorithm

Standard dosing:

• Start with 10 mg orally once daily, taken in the morning with or without food 2, 3
• May increase to 25 mg once daily if additional glycemic control is needed 2, 3
• No dose titration required for cardiovascular or renal benefits—10 mg provides full protection 3

Renal function-based dosing:

• eGFR ≥45 mL/min/1.73 m²: Initiate at 10 mg daily for glycemic control 2, 3
• eGFR 25-44 mL/min/1.73 m²: Do not initiate for glycemic control, but may initiate 10 mg daily for cardiovascular/renal protection 2, 3
• eGFR <25 mL/min/1.73 m²: Do not initiate 2
• If eGFR falls below 45 mL/min/1.73 m² during treatment: Discontinue if used solely for glycemic control; continue if used for cardiovascular/renal protection 2

Medication Adjustments When Starting Empagliflozin

Reduce hypoglycemia risk by:

• Decreasing sulfonylurea or glinide doses when adding empagliflozin 3
• Reducing total daily insulin dose by approximately 20% when adding empagliflozin 3
• No adjustment needed for metformin or DPP-4 inhibitors (low hypoglycemia risk) 3

Critical Safety Precautions

Withhold empagliflozin:

• At least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis 2, 3
• During acute illness with reduced oral intake, fever, vomiting, or diarrhea 4
• In settings of volume depletion until corrected 2

Monitor for:

• Genital mycotic infections (occur in approximately 6% of patients) 4, 3
• Euglycemic diabetic ketoacidosis, even with normal blood glucose levels 4, 2
• Volume depletion, especially in elderly patients, those on diuretics, or with low baseline blood pressure 2
• Urinary tract infections and treat promptly 2

Contraindications

Do not use empagliflozin in:

• Severe renal impairment, end-stage renal disease, or dialysis 2
• History of serious hypersensitivity reaction to empagliflozin 2
• Type 1 diabetes mellitus or diabetic ketoacidosis 2

Pediatric Use

For children aged 10-17 years with type 2 diabetes:

• Empagliflozin 10 mg daily is now approved and demonstrated significant A1C reduction of 0.84% compared to placebo (P = 0.012) 1
• No episodes of severe hypoglycemia occurred in pediatric trials 1
• Consider dose escalation to 25 mg if A1C remains ≥7.0% after 12 weeks 1

Comparative Positioning

Empagliflozin is superior to:

• DPP-4 inhibitors for reducing morbidity and all-cause mortality (strong recommendation against adding DPP-4 inhibitors) 1
• Sulfonylureas and long-acting insulins for reducing all-cause mortality and morbidity 1

When to choose GLP-1 agonist instead:

• Patients with increased stroke risk 1
• Patients for whom total body weight loss is the primary treatment goal 1

Common Pitfalls to Avoid

Do not:

• Discontinue empagliflozin solely because eGFR falls below 45 mL/min/1.73 m² if cardiovascular/renal protection is the indication 3
• Continue sulfonylureas or long-acting insulins at full doses when adding empagliflozin (increases severe hypoglycemia risk) 1
• Initiate in patients with severe renal impairment (eGFR <30 mL/min/1.73 m²) 2, 3
• Forget to discontinue before surgical procedures 2, 3

Monitoring Requirements

Assess before initiation:

• Renal function (eGFR) 2
• Volume status, especially in elderly or those on diuretics 2
• Blood pressure 2

Ongoing monitoring:

• Recheck eGFR within 1-2 weeks after initiation, then every 3-6 months if eGFR 45-59 mL/min/1.73 m² 4
• Self-monitoring of blood glucose may be unnecessary in patients on metformin plus empagliflozin alone 1
• Monitor for genital infections and educate patients on hygiene measures 4, 2

Target HbA1c Goals

Aim for HbA1c between 7-8% in most adults with type 2 diabetes 1

• Deintensify pharmacologic treatments if HbA1c falls below 6.5% 1
• Individualize based on hypoglycemia risk, life expectancy, diabetes duration, established vascular complications, and major comorbidities 1