Jardiance (Empagliflozin) Treatment Plan for Type 2 Diabetes
Jardiance is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus, and to reduce the risk of cardiovascular death in adult patients with type 2 diabetes and established cardiovascular disease. 1
Primary Indications and Patient Selection
Core FDA-Approved Uses
- Glycemic control improvement in adults with T2DM as adjunct to diet and exercise 1
- Cardiovascular death reduction in patients with T2DM and established cardiovascular disease 1
- Not recommended for type 1 diabetes or diabetic ketoacidosis treatment 1
Prioritize Empagliflozin in These High-Risk Populations
Patients with established cardiovascular disease: Empagliflozin carries a Class I recommendation from the American College of Cardiology and European Heart Journal to reduce cardiovascular events and death in patients with T2DM and established CVD 2. The EMPA-REG OUTCOME trial demonstrated a 38% reduction in cardiovascular death and 35% reduction in heart failure hospitalization 3, 4.
Patients with heart failure:
- HFrEF (LVEF ≤40%): Class I recommendation to reduce cardiovascular death and heart failure hospitalization, regardless of diabetes status 2
- HFpEF (LVEF >40%): Class IIa recommendation to decrease heart failure hospitalizations and improve quality of life 2
Patients with chronic kidney disease:
- Initiate empagliflozin when eGFR ≥20 mL/min/1.73 m² based on updated 2022 KDIGO/ADA guidelines 5
- FDA approval requires eGFR >30 mL/min/1.73 m², though pivotal trials showed benefit in subgroups with eGFR <30 mL/min/1.73 m² 6, 5
- Class I recommendation to reduce CKD progression and cardiovascular events 6, 5
Dosing and Initiation
Standard dosing: 10 mg or 25 mg once daily orally 7, 8
Starting dose: Begin with 10 mg daily; may increase to 25 mg daily if additional glycemic control is needed and the patient tolerates the lower dose 8
Medication Adjustments When Starting Empagliflozin
Insulin Dose Reduction
Reduce total daily insulin dose by approximately 20% when starting empagliflozin if HbA1c is well-controlled at baseline to prevent hypoglycemia 2, 5
Sulfonylurea/Glinide Management
Consider weaning or stopping sulfonylureas or glinides to prevent hypoglycemia when initiating empagliflozin 2, 5
Diuretic Adjustment
Consider stopping or reducing diuretic doses if signs of volume contraction develop when using empagliflozin 2. Monitor for hypovolemia and proactively reduce diuretic doses in high-risk patients 5.
Expected Clinical Benefits
Glycemic Control
- HbA1c reduction of approximately 0.8% compared to placebo 7, 9
- Efficacy comparable to metformin, glimepiride, and sitagliptin 7
- Glucose-lowering effect increases with higher baseline hyperglycemia but decreases with declining renal function 7, 4
Weight and Blood Pressure
- Weight reduction of approximately 2 kg 7, 9
- Systolic blood pressure reduction of approximately 4 mmHg and diastolic reduction of approximately 2 mmHg 7, 9
Cardiovascular and Renal Protection
- 14% reduction in MACE (cardiovascular death, non-fatal MI, or non-fatal stroke) 4
- 32% reduction in all-cause mortality 4
- Renoprotective effects with reduced progression of diabetic kidney disease 3, 4
Critical Safety Monitoring and Precautions
Diabetic Ketoacidosis Prevention
Discontinue empagliflozin at least 3 days before planned surgery to prevent postoperative ketoacidosis 2, 5
Hold during acute illness to prevent volume depletion and ketoacidosis risk 5
Educate patients on DKA signs/symptoms for early recognition, and maintain at least low-dose insulin in insulin-requiring individuals 5
Volume Depletion Risk
- Monitor for hypotension and volume depletion, especially in elderly patients, those on diuretics, or with impaired renal function 5, 9
- Small increases in hematocrit may occur due to hemoconcentration 9
Genital and Urinary Infections
Genital mycotic infections occur more frequently, especially in women, though most are mild to moderate and straightforward to manage 7, 3, 4
Negligible increase in mild urinary tract infections may be observed 7
Lipid Monitoring
Small but clinically insignificant increases in lipid levels have been observed 9
Renal Function Monitoring and Continuation
Monitor eGFR at least annually when ≥60 mL/min/1.73 m², increasing frequency to every 3-6 months when <60 mL/min/1.73 m² 5
Continue empagliflozin even if eGFR falls below initiation threshold during treatment, unless the patient is not tolerating therapy or requires kidney replacement therapy 5. The glucose-lowering efficacy decreases with declining renal function (eGFR <45 mL/min/1.73 m²), but cardiovascular and renal benefits persist 4.
Absolute Contraindications
Do not use in patients with type 1 diabetes or for treatment of diabetic ketoacidosis 1
Avoid in patients who have developed autoimmune diabetes due to significantly higher risk of euglycemic diabetic ketoacidosis from insulin-deficient state 10
Hypoglycemia Risk
No intrinsic risk of hypoglycemia as monotherapy or add-on therapy due to insulin-independent mechanism of action 7, 8, 9
Hypoglycemia occurs more frequently when empagliflozin is coadministered with insulin and/or sulfonylureas, necessitating dose adjustments of these agents 7, 8, 9