Jardiance (Empagliflozin) Renal Dosing
Do not initiate Jardiance if eGFR is below 45 mL/min/1.73 m², and discontinue if eGFR falls persistently below 45 mL/min/1.73 m². 1
Initiation Criteria
- Assess renal function before starting Jardiance using eGFR calculation 1
- Jardiance should not be initiated in patients with eGFR <45 mL/min/1.73 m² 1
- Contraindicated in severe renal impairment, end-stage renal disease, or patients on dialysis 1
Dosing by Renal Function
eGFR ≥45 mL/min/1.73 m²
- No dose adjustment required 1
- Start with 10 mg once daily in the morning, with or without food 1
- May increase to 25 mg once daily in patients tolerating the medication 1
eGFR <45 mL/min/1.73 m²
- Discontinue Jardiance if eGFR persistently falls below 45 mL/min/1.73 m² 1
- The FDA label explicitly states discontinuation is required at this threshold 1
Monitoring Requirements
- Assess renal function periodically after initiation to detect declining eGFR 1
- Monitor for volume depletion before and during therapy, particularly in patients with renal impairment, elderly patients, those with low systolic blood pressure, and patients on diuretics 1
- Correct volume status before initiating Jardiance in volume-depleted patients 1
Important Clinical Context
Recent Evidence on Lower eGFR Thresholds
While the FDA label maintains the 45 mL/min/1.73 m² threshold, the EMPA-KIDNEY trial demonstrated kidney and cardiovascular benefits in patients with eGFR as low as 20 mL/min/1.73 m² 2. This landmark trial showed a 28% reduction in kidney disease progression or cardiovascular death (hazard ratio 0.72,95% CI 0.64-0.82) across a broad range of chronic kidney disease patients 2. The benefits were consistent regardless of diabetes status and across all eGFR ranges studied 2, 3.
However, for prescribing purposes, you must follow the FDA-approved labeling, which requires discontinuation at eGFR <45 mL/min/1.73 m² 1. The glycemic efficacy of Jardiance decreases with declining renal function, though renal and cardiovascular protective effects may persist 4.
Pharmacokinetic Considerations
- Empagliflozin exposure increases with worsening renal function (up to 52% higher in severe impairment), but this increase is <2-fold and does not require dose adjustment when eGFR ≥45 4
- Urinary glucose excretion decreases as renal function declines, correlating with reduced glycemic efficacy 4
- Renal clearance of empagliflozin decreases proportionally with eGFR 4
Critical Safety Warnings
- Assess for volume depletion before initiation, especially in patients with renal impairment, as Jardiance causes intravascular volume contraction and may lead to symptomatic hypotension 1
- Monitor for ketoacidosis in patients presenting with metabolic acidosis symptoms, regardless of blood glucose levels 1
- Consider temporary discontinuation in settings of reduced oral intake or fluid losses to prevent acute kidney injury 1