Is it suitable for a patient with impaired renal function (GFR of 44), hyperlipidemia (total cholesterol 206, triglycerides 303, LDL 112), and impaired glucose regulation (A1c 5.9) to take Jardiance (empagliflozin) and metformin?

Should This Patient Take Jardiance and Metformin?

Yes, this patient should take both Jardiance (empagliflozin) and metformin. With a GFR of 44 mL/min/1.73 m², this patient falls into CKD stage 3b, which is within the acceptable range for both medications, and the combination offers significant cardiorenal protection even in the prediabetic state.

Metformin Use at GFR 44

Metformin can be continued but requires dose adjustment and careful monitoring at this GFR level. 1

• The FDA guidance states that metformin should not be initiated when eGFR is <45 mL/min/1.73 m², but if already on therapy, benefits and risks should be reassessed when eGFR falls to <45 mL/min/1.73 m² 1
• At GFR 44, halve the metformin dose from the standard maximum to reduce lactic acidosis risk 1
• Metformin is only contraindicated when eGFR falls below 30 mL/min/1.73 m² 1
• Monitor eGFR every 3-6 months at this level of renal function 1
• Temporarily discontinue metformin before any iodinated contrast procedures 1

Common pitfall: Many clinicians unnecessarily stop metformin at GFR 44, but current guidelines support continued use with dose reduction. 1

Jardiance (Empagliflozin) Use at GFR 44

Empagliflozin is strongly recommended at this GFR level for cardiorenal protection, independent of diabetes status. 1

• SGLT2 inhibitors are recommended for patients with eGFR ≥20 mL/min/1.73 m² to slow CKD progression and reduce heart failure risk 1
• The 2024 ADA/KDIGO consensus algorithm places SGLT2 inhibitors as foundational therapy for CKD stage 3, even before considering the A1c level 1
• Empagliflozin reduced incident or worsening nephropathy by 39% and doubling of serum creatinine by 44% in patients with baseline renal impairment 1, 2
• The glucose-lowering effect is diminished at GFR 44, but the renoprotective and cardioprotective benefits persist through mechanisms independent of glycemic control 1, 3

Addressing the Prediabetic State (A1c 5.9%)

Despite the A1c being in the prediabetic range, both medications are justified based on cardiorenal risk reduction. 1

• This patient has established CKD (GFR 44) and dyslipidemia (triglycerides 303), indicating high cardiovascular risk 1
• SGLT2 inhibitors reduce cardiovascular events and slow CKD progression independent of glucose management 1
• The primary indication here is CKD protection, not glucose lowering 1
• Metformin remains appropriate for prediabetes prevention and has favorable effects on weight and lipids 1

Practical Implementation Algorithm

Start with the following approach:

1. Initiate or continue empagliflozin 10 mg daily (the 25 mg dose can be used, but 10 mg is reasonable given the reduced GFR) 4, 3
2. Adjust metformin to half the current dose if on standard dosing (e.g., if on 2000 mg/day, reduce to 1000 mg/day) 1
3. Monitor for volume depletion in the first 2-4 weeks after starting empagliflozin, especially given the triglycerides of 303 suggest possible metabolic syndrome with potential for blood pressure effects 4, 5
4. Recheck eGFR in 1-2 weeks after empagliflozin initiation; expect a transient dip of 3-5 mL/min/1.73 m² that is hemodynamic and reversible 6
5. Educate on sick day rules: hold empagliflozin during acute illness, fever, vomiting, or reduced oral intake to prevent euglycemic DKA 6

Monitoring Strategy

Establish the following monitoring schedule:

• eGFR every 3-6 months while on metformin at this level of renal function 1
• Vitamin B12 annually if metformin continued for >4 years 1
• Genital and urinary symptoms given SGLT2 inhibitor use 7
• Blood pressure monitoring as empagliflozin reduces systolic BP by 2-4 mmHg 4, 8

Critical Safety Considerations

Avoid these common errors:

• Do not discontinue empagliflozin solely due to the initial hemodynamic eGFR dip unless it persists or falls below 20 mL/min/1.73 m² 6
• Do not stop metformin abruptly at GFR 44; dose reduction is the appropriate action 1
• Do not withhold SGLT2 inhibitors based on A1c alone; the indication is CKD, not diabetes 1
• Ensure the patient is not volume depleted before starting empagliflozin, particularly if on other diuretics 4, 5

Additional Cardiovascular Risk Management

Given the lipid profile, consider adding:

• Statin therapy for LDL 112 and triglycerides 303 in the context of CKD 1
• ACE inhibitor or ARB if not already on one, especially if albuminuria develops 1
• The combination of SGLT2 inhibitor plus RAAS blockade provides additive renoprotection 1

The evidence strongly supports using both medications in this patient, with the primary goal being cardiorenal protection rather than glycemic control. 1