Jardiance (Empagliflozin) Renal Dosing
Jardiance should not be initiated in patients with eGFR <45 mL/min/1.73 m², requires no dose adjustment when eGFR ≥45 mL/min/1.73 m², and must be discontinued if eGFR falls persistently below 45 mL/min/1.73 m². 1
Initiation Criteria
- Do not start Jardiance if baseline eGFR is less than 45 mL/min/1.73 m² 1
- Assess renal function prior to initiation and periodically thereafter 1
- In patients with volume depletion, correct this condition before starting empagliflozin 1
Dosing by Renal Function
- eGFR ≥45 mL/min/1.73 m²: Standard dosing applies—start with 10 mg once daily in the morning, with or without food, and may increase to 25 mg daily in tolerating patients 1
- eGFR <45 mL/min/1.73 m²: Do not initiate therapy 1
- Persistent eGFR <45 mL/min/1.73 m²: Discontinue Jardiance 1
Important Clinical Context
While the FDA label restricts initiation at eGFR <45 mL/min/1.73 m², recent landmark evidence demonstrates cardiovascular and renal benefits in patients with chronic kidney disease. The EMPA-KIDNEY trial enrolled patients with eGFR as low as 20 mL/min/1.73 m² and showed that empagliflozin reduced the composite outcome of kidney disease progression or cardiovascular death by 28% (hazard ratio 0.72,95% CI 0.64-0.82) 2. This benefit was consistent across all eGFR ranges studied, including those with eGFR 20-45 mL/min/1.73 m² 2, 3.
Pharmacokinetic Considerations
- Empagliflozin exposure increases modestly with worsening renal function—by approximately 28-52% in patients with mild to severe renal impairment compared to normal function 4
- However, urinary glucose excretion (the primary mechanism of action) decreases substantially as renal function declines, correlating directly with eGFR 4
- In severe renal impairment (eGFR 15-30 mL/min/1.73 m²), urinary glucose excretion is reduced by approximately 68% compared to normal renal function 4
- No dose adjustment is pharmacokinetically necessary since exposure increases are less than 2-fold 4
Monitoring Requirements
- Assess eGFR before starting therapy 1
- Monitor renal function periodically during treatment 1
- Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 1
Common Pitfalls
- Do not confuse with other SGLT2 inhibitors: Different agents in this class have varying eGFR thresholds for initiation and continuation
- Volume status matters: Correct hypovolemia before starting to reduce risk of acute kidney injury 1
- "Persistently" is key: A single eGFR measurement <45 mL/min/1.73 m² during acute illness may not warrant discontinuation; confirm with repeat testing 1