What is the recommended dosage of Empagliflozin (Empagliflozin) for adults with type 2 diabetes?

Empagliflozin Dosing for Type 2 Diabetes

Start empagliflozin at 10 mg orally once daily in adults with type 2 diabetes, which can be increased to 25 mg once daily if additional glycemic control is needed, but do not exceed 10 mg daily if eGFR is below 45 mL/min/1.73 m². 1, 2

Standard Dosing Algorithm

Initial dose: Begin with 10 mg orally once daily 1, 2

• This starting dose provides optimal cardiovascular and renal protection benefits 2
• The 10 mg dose demonstrated significant reductions in cardiovascular death (38% relative risk reduction), heart failure hospitalization (35% relative risk reduction), and all-cause mortality (32% relative risk reduction) in the EMPA-REG OUTCOME trial 3

Dose escalation: May increase to 25 mg once daily if glycemic targets are not achieved 1, 2

• The 25 mg dose provides additional glucose-lowering efficacy but does not offer greater cardiovascular or renal protection compared to 10 mg 2, 4
• Both 10 mg and 25 mg doses achieve near-maximal glucose lowering, targeting 80-90% of maximum efficacy 5

Renal Function-Based Dosing

eGFR ≥45 mL/min/1.73 m²: No dose adjustment required 1

• Both 10 mg and 25 mg doses can be used 2, 4

eGFR <45 mL/min/1.73 m²: Do not initiate empagliflozin 1

• If already established on therapy, discontinue if eGFR persistently remains below 45 mL/min/1.73 m² 1
• Glucose-lowering efficacy is substantially reduced at this level of renal function 1, 2

Severe renal impairment, ESRD, or dialysis: Contraindicated 1, 2

Critical Safety Adjustments

When initiating empagliflozin with insulin: Reduce total daily insulin dose by approximately 20% to prevent hypoglycemia 2, 4

When initiating with sulfonylureas or glinides: Consider reducing or stopping these medications if HbA1c is well-controlled at baseline or if the patient has frequent hypoglycemia 2, 4

Before surgery: Discontinue empagliflozin at least 3 days before planned surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis 2, 4

Volume depletion risk: Assess volume status before initiation and use caution with concurrent diuretics, particularly in elderly patients (>75 years), those with low systolic blood pressure, or those with renal impairment 1, 4

Common Pitfalls to Avoid

Do not initiate empagliflozin in patients with eGFR <45 mL/min/1.73 m² for glycemic control, as efficacy is markedly reduced 1, 2

Do not increase to 25 mg solely for cardiovascular protection - the 10 mg dose provides equivalent cardiovascular and renal benefits 2, 4

Do not forget to reduce insulin or sulfonylurea doses when starting empagliflozin, as this significantly increases hypoglycemia risk 2, 4

Do not continue empagliflozin through surgical procedures - the risk of euglycemic ketoacidosis is substantially elevated in perioperative settings 1, 2

Pharmacokinetic Considerations

Empagliflozin is rapidly absorbed, reaching peak plasma concentrations within 1 to 1.5 hours, with a terminal elimination half-life of approximately 12-14 hours, supporting once-daily dosing 6, 7

The drug demonstrates dose-proportional pharmacokinetics between 10 mg and 25 mg doses 5, 6

Adverse Event Profile

The most common adverse events include genital mycotic infections (4.7-5.0 per 100 patient-years with empagliflozin vs 1.3 with placebo), though these rarely require hospitalization 8

Urinary tract infection rates are similar to placebo (9.4-11.3 per 100 patient-years) 8

Hypoglycemia risk is not increased except when combined with sulfonylureas or insulin 1, 8

Volume depletion events occur at similar rates to placebo overall (1.3-1.5 per 100 patient-years), but are higher in patients >75 years (4.4 per 100 patient-years with 25 mg dose) 8