Can Jardiance (Empagliflozin) Be Given to Patients with Possible Liver Disease?
Yes, Jardiance (empagliflozin) can be safely used in patients with liver disease, including those with compensated cirrhosis, as the FDA label explicitly states that empagliflozin may be used in patients with hepatic impairment without dose adjustment. 1
Safety Profile in Liver Disease
The FDA drug label confirms that JARDIANCE may be used in patients with hepatic impairment without requiring dose modifications, as empagliflozin pharmacokinetics are not significantly altered by liver dysfunction 1
In patients with metabolic dysfunction-associated steatotic liver disease (MASLD/MASH) without cirrhosis (F0-F3), SGLT2 inhibitors like empagliflozin are explicitly recommended as preferred treatment options for coexisting type 2 diabetes 2
For patients with compensated cirrhosis (Child-Pugh class A and B), SGLT2 inhibitors can be used safely, though the evidence is weaker (Level of Evidence 4, weak recommendation) 2
Clinical Evidence Supporting Use in Liver Disease
Empagliflozin significantly reduces liver fat content in patients with NAFLD and type 2 diabetes, with one randomized controlled trial showing a mean reduction in MRI-measured liver fat of 4.0% compared to control (p < 0.0001) 3
Long-term empagliflozin therapy improves markers of hepatic fibrosis (FIB-4 index and Mac-2 Binding Protein Glucosylation Isomer) and hepatic function (ALBI score) in patients with NAFLD and type 2 diabetes over one year of treatment 4
Empagliflozin reduces liver enzyme levels (ALT, AST, GGT) in patients with type 2 diabetes and NAFLD, with mean ALT reductions of approximately 15 U/L 5, 3
Even in advanced chronic liver disease with ascites, empagliflozin was found to be safe and well-tolerated in a phase 2 trial, with adverse event rates similar to previous phase 3 trials in other populations 6
Specific Recommendations by Liver Disease Stage
MASLD/MASH Without Cirrhosis (F0-F3)
- Empagliflozin is a preferred pharmacological option for treating type 2 diabetes in this population, alongside GLP-1 receptor agonists 2
- The drug provides dual benefits: glycemic control and reduction in hepatic steatosis 2, 5, 3
Compensated Cirrhosis (Child-Pugh Class A)
- SGLT2 inhibitors including empagliflozin can be used, though guidelines note this is based on lower-quality evidence 2
- Monitor renal function closely, as the glucose-lowering efficacy diminishes with declining eGFR, though cardiovascular and renal protective benefits persist 1
Decompensated Cirrhosis
- While the FDA label permits use in hepatic impairment, exercise caution in decompensated cirrhosis due to increased risk of volume depletion and potential complications 1
- Consider alternative agents like insulin in patients with decompensated cirrhosis, as recommended by EASL-EASD-EASO guidelines 2
Important Safety Considerations
Volume depletion risk is increased in patients with liver disease, particularly those on concurrent diuretics or with ascites; assess volume status before initiation 1, 6
Monitor for urinary tract infections and genital mycotic infections, which occur more frequently with SGLT2 inhibitors (approximately 6% vs 1% with placebo) 1
Withhold empagliflozin during acute illness, particularly with reduced oral intake, fever, vomiting, or diarrhea, to prevent diabetic ketoacidosis and volume depletion 7
Renal function should be assessed before initiation and monitored periodically, as empagliflozin's glucose-lowering efficacy decreases with eGFR <45 mL/min/1.73 m², though it can still be used for cardiovascular/renal protection down to eGFR ≥25 mL/min/1.73 m² 1
Cardiovascular and Renal Benefits Remain Intact
The cardiovascular mortality benefits of empagliflozin are maintained regardless of liver disease status, as demonstrated in the EMPA-REG OUTCOME trial where effects were consistent across steatosis and fibrosis risk categories 8
Empagliflozin is recommended to reduce cardiovascular events and death in patients with type 2 diabetes and cardiovascular disease, independent of liver status 2
Common Pitfall to Avoid
Do not withhold empagliflozin solely because of "possible liver disease" or elevated liver enzymes, as the drug is actually beneficial for hepatic steatosis and is explicitly approved for use in hepatic impairment 2, 1, 5, 3. The only scenario requiring caution is severe decompensated cirrhosis with ascites, where volume status must be carefully monitored 6.