Should Jardiance Be Continued with Insulin?
Yes, Jardiance (empagliflozin) should be continued when insulin is initiated in patients with type 2 diabetes, as current guidelines explicitly recommend maintaining glucose-lowering agents with cardiometabolic or kidney benefits alongside insulin therapy. 1
Guideline-Based Recommendation
The 2024 American Diabetes Association Standards of Care provides clear direction on this question:
Glucose-lowering agents may be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits (i.e., weight, cardiometabolic, or kidney benefits). 1
SGLT2 inhibitors like empagliflozin specifically provide benefits beyond glucose control, including cardiovascular death reduction, heart failure hospitalization prevention, and kidney disease progression slowing. 1
Clinical Algorithm for Decision-Making
Continue Jardiance with Insulin If:
Patient has established cardiovascular disease or heart failure: Empagliflozin reduces cardiovascular death by 38% and heart failure hospitalizations in these populations. 1
Patient has chronic kidney disease (eGFR 20-60 mL/min/1.73 m² with albuminuria): SGLT2 inhibitors minimize CKD progression and reduce cardiovascular events. 1
Patient requires weight management: Empagliflozin causes modest weight loss (2-3 kg), which counterbalances insulin-associated weight gain. 1, 2
eGFR ≥25 mL/min/1.73 m²: Cardiovascular and renal protective benefits persist even when glycemic efficacy diminishes at lower eGFR levels. 3
Medication Adjustments When Combining:
Insulin dosing must be reassessed and reduced when adding or continuing empagliflozin to minimize hypoglycemia risk. 1 The 2024 ADA guidelines specifically state that insulin dosing should be reassessed upon addition or dose escalation of glucose-lowering agents. 1
Discontinue or reduce sulfonylureas if present in the regimen, as these medications cause hypoglycemia and should be reassessed when starting insulin. 1 The 2022 ADA/EASD consensus explicitly states that sulfonylureas should be discontinued once insulin is started. 1
Evidence Supporting Combination Therapy
The 2017 ADA guidelines note that adjunctive use of an SGLT-2 inhibitor may improve control and reduce the amount of insulin required in patients with suboptimal blood glucose control, especially those requiring large doses of insulin. 1
A 2023 Chinese phase III trial demonstrated that empagliflozin combined with insulin ± oral antidiabetic drugs:
- Reduced HbA1c by an additional 0.99% compared to placebo over 24 weeks 4
- Did not increase hypoglycemia risk (17.8% vs 11.0% in placebo group, p=0.24) 4
- Was well tolerated without increased diabetic ketoacidosis events 4
Critical Safety Considerations
Withhold Jardiance Temporarily During:
Major surgery or procedures requiring prolonged fasting (hold at least 3 days before) to prevent postoperative ketoacidosis. 3
Acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent volume depletion and euglycemic diabetic ketoacidosis. 3
Important: Maintain at least low-dose insulin even when Jardiance is held during illness, as complete insulin cessation increases DKA risk. 3
Monitor For:
Genital mycotic infections (occur in ~6% of patients on SGLT2 inhibitors vs 1% on placebo). 3
Volume depletion, especially in patients on concurrent diuretics or with low systolic blood pressure. 3
Euglycemic diabetic ketoacidosis - can occur even with normal blood glucose levels; check ketones if patient develops malaise, nausea, or vomiting. 3
Renal Function Considerations
eGFR ≥45 mL/min/1.73 m²: Full glycemic efficacy; continue standard 10 mg or 25 mg daily dose. 3
eGFR 25-44 mL/min/1.73 m²: Reduced glycemic efficacy but preserved cardiovascular/renal benefits; continue 10 mg daily. 3
eGFR <25 mL/min/1.73 m²: Do not initiate, but may continue if already on therapy until dialysis. 3
Common Pitfall to Avoid
Do not discontinue empagliflozin solely because eGFR falls below 45 mL/min/1.73 m², as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost. 3 The 2020 ESC guidelines recommend SGLT2 inhibitors to lower risk of heart failure hospitalization and insulin treatment in heart failure may be considered, indicating these therapies are complementary. 1