Management of Jardiance and Atorvastatin in Cardiogenic Shock with AKI and Elevated LFTs
Both Jardiance (empagliflozin) and atorvastatin should be held immediately in a patient presenting with cardiogenic shock, acute kidney injury, and elevated liver function tests.
Jardiance (Empagliflozin) Management
Immediate Discontinuation Required
Empagliflozin must be discontinued in cardiogenic shock with AKI due to multiple converging contraindications and safety concerns. 1
Volume depletion risk: Cardiogenic shock represents a state of severe hemodynamic compromise where SGLT2 inhibitors cause intravascular volume contraction through osmotic diuresis, which can worsen hypotension and organ perfusion 1
Acute kidney injury: The FDA label explicitly states to "consider temporarily discontinuing in settings of reduced oral intake or fluid losses" and "if acute kidney injury occurs, discontinue and promptly treat" 1
Ketoacidosis risk: Cardiogenic shock represents an acute illness with reduced oral intake and metabolic stress—precisely the clinical situations where empagliflozin should be temporarily discontinued to prevent euglycemic diabetic ketoacidosis 1
Renal function threshold: Guidelines recommend against using SGLT2 inhibitors in the hospital setting, particularly during acute decompensated states 2
Specific Contraindications in This Clinical Context
The combination of shock (hypoperfusion), AKI, and likely reduced oral intake creates the "perfect storm" for SGLT2 inhibitor-related complications 1
Empagliflozin increases serum creatinine and decreases eGFR, and patients with hypovolemia are more susceptible to these changes 1
Before initiating or continuing empagliflozin, factors predisposing to acute kidney injury must be considered, including hypovolemia, chronic renal insufficiency, congestive heart failure, and concomitant medications (diuretics, ACE inhibitors, ARBs) 1
When to Restart Empagliflozin
Resume empagliflozin only after the patient has recovered from cardiogenic shock, hemodynamic stability is achieved, and normal oral intake is re-established 3
Recheck eGFR and ensure it is ≥25 mL/min/1.73 m² before restarting for cardiovascular/renal protection (or ≥45 mL/min/1.73 m² if glycemic control is the primary indication) 1
Volume status must be assessed and corrected before restarting 3
Atorvastatin Management
Hold During Acute Phase
Atorvastatin should be temporarily held in the setting of cardiogenic shock with elevated liver function tests, but this is a more nuanced decision than with empagliflozin.
Elevated LFTs in the context of cardiogenic shock likely represent hepatic congestion or ischemic hepatitis from hypoperfusion rather than statin-induced hepatotoxicity 2
However, continuing statins during acute hepatic injury (regardless of etiology) may worsen hepatocellular damage and should be avoided until LFTs stabilize 2
Early Reinitiation After Stabilization
Unlike empagliflozin, statins should be restarted relatively early after acute coronary syndrome or cardiogenic shock once hemodynamic stability is achieved 2
The 2025 ACC/AHA guidelines emphasize that "early intensification of lipid-lowering therapy after ACS is justified" and that "statin-eligible patients remain undertreated or untreated" 2
Restart atorvastatin once LFTs are trending downward and the patient is hemodynamically stable, typically within days rather than weeks 2
Monitor LFTs after restarting, but do not delay statin therapy excessively, as the cardiovascular mortality benefit outweighs the hepatotoxicity risk in most cases 2
Clinical Algorithm for Decision-Making
Immediate Actions (Day 0-1)
- Hold both empagliflozin and atorvastatin immediately 1, 2
- Assess volume status and correct hypovolemia with judicious fluid administration 1
- Monitor for signs of diabetic ketoacidosis (check ketones even if glucose is normal) 1
- Check baseline eGFR, creatinine, and LFTs 1
Early Recovery Phase (Days 2-7)
- Continue holding empagliflozin until hemodynamic stability, resolution of AKI, and resumption of normal oral intake 3, 1
- Consider restarting atorvastatin once LFTs begin trending downward and patient is hemodynamically stable (typically by day 3-5) 2
- Monitor renal function daily during AKI recovery 1
Late Recovery Phase (Days 7-30)
- Restart empagliflozin only after: (1) hemodynamic stability achieved, (2) eGFR ≥25 mL/min/1.73 m² confirmed, (3) normal oral intake established, and (4) volume status optimized 3, 1
- Ensure atorvastatin is restarted at appropriate intensity for secondary prevention (high-intensity statin preferred post-ACS) 2
- Recheck eGFR within 1-2 weeks of restarting empagliflozin 3
Common Pitfalls to Avoid
Do not restart empagliflozin prematurely before hemodynamic stability and adequate oral intake are established—this significantly increases ketoacidosis risk 1
Do not delay statin reinitiation excessively due to mildly elevated LFTs if the patient is otherwise stable—the cardiovascular benefit outweighs hepatotoxicity concerns in most cases 2
Do not assume elevated LFTs are statin-induced in the context of cardiogenic shock—hepatic congestion and ischemic hepatitis are far more likely culprits 2
Do not restart empagliflozin without checking eGFR first—if eGFR remains <25 mL/min/1.73 m², empagliflozin should not be restarted 1
Do not forget to reduce diuretic doses when restarting empagliflozin to prevent excessive volume depletion 3, 1