Is Acute Kidney Injury (AKI) a contraindication for Jariance in a patient with Chronic Obstructive Pulmonary Disease (COPD)?

Is AKI a Contraindication for Jardiance in Patients with COPD?

AKI is not an absolute contraindication for Jardiance (empagliflozin), but the drug should be temporarily discontinued during acute kidney injury and withheld until kidney function stabilizes. COPD itself does not create additional contraindications for Jardiance use beyond standard renal considerations.

Acute Kidney Injury and SGLT2 Inhibitors

Temporarily discontinue Jardiance during AKI episodes. The KDIGO guidelines recommend temporary discontinuation of potentially nephrotoxic and renally excreted drugs in patients with serious intercurrent illness that increases the risk of AKI, and this includes SGLT2 inhibitors like Jardiance 1. During acute illness, the risk-benefit balance shifts unfavorably due to:

• Volume depletion risk: SGLT2 inhibitors cause osmotic diuresis, which can worsen intravascular volume depletion during AKI 1
• Impaired drug clearance: Reduced GFR during AKI affects medication metabolism and excretion 1
• Hemodynamic instability: AKI often occurs in the context of hemodynamic compromise where additional volume loss is detrimental 1

COPD-Specific Considerations

COPD does not independently contraindicate Jardiance use. The key concern with COPD patients is the high prevalence of AKI during acute exacerbations:

• AKI occurs in approximately 21% of hospitalized COPD exacerbation patients 2, 3
• Community-acquired AKI prevalence is 15.8% and hospital-acquired AKI is 5.5% in AECOPD patients 4
• AKI in COPD exacerbations carries significant mortality risk, with rates of 521/1,000 person-years when both conditions coexist 2

Beta-blockers, not SGLT2 inhibitors, are the primary cardiac medication with COPD-specific restrictions. Asthma is an absolute contraindication for beta-blockers, while COPD is not, though beta-selective agents like bisoprolol are preferred 1.

Practical Management Algorithm

Before initiating or continuing Jardiance in COPD patients:

1. Assess baseline renal function: Check serum creatinine and calculate eGFR 1
2. Evaluate volume status: Ensure adequate hydration before starting therapy 1
3. Review concurrent medications: Identify other nephrotoxic agents (NSAIDs, aminoglycosides, contrast agents) that may compound AKI risk 1

During acute COPD exacerbations:

1. Hold Jardiance immediately if patient develops signs of AKI (rising creatinine, oliguria) 1
2. Monitor renal function daily during hospitalization with measurement of urea, creatinine, and electrolytes 5
3. Assess for AKI risk factors: Advanced age, coronary artery disease, chronic kidney disease, mechanical ventilation, and hypercapnic encephalopathy all increase AKI risk in AECOPD 3

Restarting Jardiance post-AKI:

1. Wait for renal recovery: Resume only after creatinine returns to baseline or stabilizes 1
2. Ensure hemodynamic stability: Patient should be euvolemic and off vasopressors 5
3. Reassess GFR: Jardiance efficacy decreases with eGFR <45 mL/min/1.73 m² and should be discontinued if eGFR falls below 30 mL/min/1.73 m² 1

Critical Pitfalls to Avoid

Do not continue Jardiance during intercurrent illness. The KDIGO guidelines explicitly recommend temporary discontinuation of RAAS blockers, diuretics, and other renally excreted drugs during serious illness in patients with GFR <60 mL/min/1.73 m² 1. This principle applies to SGLT2 inhibitors.

Do not confuse chronic kidney disease with acute kidney injury. While CKD requires dose adjustment considerations, AKI requires immediate drug discontinuation 1. In COPD patients, distinguish between:

• Baseline CKD (present in 10.9% of COPD patients) 6
• Acute-on-chronic kidney injury during exacerbations
• Pure AKI without underlying CKD

Monitor for hospital-acquired AKI. Patients with AECOPD who develop HA-AKI have worse outcomes than those with CA-AKI, including higher mortality (32.0% vs 13.2%), longer hospitalization, and greater need for mechanical ventilation 4. Medications like Jardiance that affect volume status should remain held throughout hospitalization if AKI develops.

Recognize that AKI severity predicts mortality in COPD. Patients with stage 3 AKI have a 6.0-fold increased risk of in-hospital death compared to those without AKI 3. Any medication that could theoretically worsen renal perfusion should be avoided during the acute phase.