Should I hold Jardiance (Empagliflozin) in a patient with diabetes and Acute Kidney Injury (AKI)?

Should You Hold Jardiance (Empagliflozin) in Acute Kidney Injury?

Temporarily discontinue Jardiance during acute kidney injury and do not restart until the patient has recovered, volume status is optimized, and kidney function has stabilized. 1, 2, 3

Rationale for Holding SGLT2 Inhibitors During AKI

The primary concern is that SGLT2 inhibitors like Jardiance cause intravascular volume contraction, which can worsen kidney perfusion and exacerbate AKI. 3 The FDA label explicitly states to "consider temporarily discontinuing JARDIANCE in any setting of reduced oral intake (such as acute illness or fasting) or fluid losses (such as gastrointestinal illness or excessive heat exposure)" and to "monitor patients for signs and symptoms of acute kidney injury." 3

Key Guideline Recommendations

• KDIGO guidelines recommend temporary discontinuation of potentially nephrotoxic and renally excreted drugs in people with eGFR <60 mL/min/1.73 m² who have serious intercurrent illness that increases the risk of AKI, including SGLT2 inhibitors. 1

• The ADA/KDIGO consensus specifically advises holding SGLT2 inhibitors during acute illness, particularly when patients experience reduced food and fluid intake, fever, vomiting, or diarrhea. 2

• The ADQI workgroup emphasizes that during AKI/AKD episodes, the risk-benefit ratio of continuing medications must be carefully reconsidered, and nephrotoxins should be discontinued when they are the potential cause of AKI. 1

Clinical Context: Why AKI Changes the Equation

While SGLT2 inhibitors paradoxically reduce the risk of AKI in stable patients 1, the situation reverses during an active AKI episode:

• Volume depletion from SGLT2 inhibitors compounds the hemodynamic stress already present in AKI. 3

• Concomitant use of diuretics, ACE inhibitors, or ARBs (common in diabetic patients) amplifies the risk of worsening kidney injury. 1, 3, 4

• The FDA warns that postmarketing reports have documented acute kidney injury requiring hospitalization and dialysis in patients receiving SGLT2 inhibitors, particularly in those with hypovolemia, chronic renal insufficiency, or concomitant nephrotoxic medications. 3

When to Restart Jardiance After AKI

Resume Jardiance only after ALL of the following criteria are met:

• The patient has fully recovered from the acute illness that precipitated AKI. 2

• Normal oral intake has been re-established for at least 24-48 hours. 2

• Volume status has been optimized and the patient is euvolemic. 1, 3

• Serum creatinine has stabilized or is trending back toward baseline. 1, 3

• eGFR has been reassessed and is ≥20 mL/min/1.73 m² (the minimum threshold for continuation). 1, 2

Common Pitfalls to Avoid

• Do not continue Jardiance simply because the patient "needs it for heart failure or CKD protection" during active AKI—the acute risks outweigh chronic benefits during the illness. 1, 3

• Do not restart Jardiance prematurely while the patient is still hospitalized or has ongoing volume losses, even if creatinine is improving. 2, 3

• Remember that SGLT2 inhibitors can cause euglycemic diabetic ketoacidosis during acute illness, which may present with normal blood glucose levels but severe metabolic acidosis. 2, 3

• If the patient is on concurrent ACE inhibitors, ARBs, or diuretics, these should also be held during AKI per KDIGO guidelines. 1

Monitoring After Restarting

• Check eGFR and serum creatinine within 1-2 weeks of restarting Jardiance. 2

• Assess volume status carefully at follow-up, as an expected transient eGFR dip of 3-5 mL/min/1.73 m² may occur. 2

• Consider reducing diuretic doses when restarting to prevent excessive volume depletion. 2