Jardiance (Empagliflozin) Treatment Plan for Type 2 Diabetes
Jardiance (empagliflozin) is FDA-approved 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
Patient Selection and Initiation
Primary Indications for Empagliflozin
Initiate empagliflozin in patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD) to reduce cardiovascular death (Class I recommendation). 2
Start empagliflozin in patients with type 2 diabetes and heart failure with reduced ejection fraction (LVEF ≤40%) to reduce cardiovascular death and heart failure hospitalization, regardless of diabetes status. 3, 2
Consider empagliflozin in patients with type 2 diabetes and heart failure with preserved ejection fraction (LVEF >40%) to decrease heart failure hospitalizations and improve quality of life. 2
Use empagliflozin in patients with type 2 diabetes and chronic kidney disease (CKD) to reduce CKD progression and cardiovascular events. 3, 4
eGFR-Based Initiation Criteria
Initiate empagliflozin when eGFR ≥20 mL/min/1.73 m² based on updated 2022 KDIGO/ADA guidelines and EMPEROR trial data. 4
FDA approval permits initiation at eGFR >30 mL/min/1.73 m², though pivotal trials demonstrated benefit in subgroups with eGFR <30 mL/min/1.73 m². 3, 4
Continue empagliflozin even if eGFR falls below initiation threshold during treatment, unless the patient is not tolerating therapy or requires kidney replacement therapy. 4
Dosing Strategy
Standard Dosing
Start with empagliflozin 10 mg once daily, taken in the morning with or without food. 1
Increase to 25 mg once daily if additional glycemic control is needed and the patient tolerates the 10 mg dose. 1
Medication Adjustments When Starting Empagliflozin
Reduce total daily insulin dose by approximately 20% when starting empagliflozin if HbA1c is well-controlled at baseline to prevent hypoglycemia. 2, 4
Consider weaning or stopping sulfonylureas or glinides to prevent hypoglycemia. 2, 4
Consider reducing diuretic doses if there are signs of volume contraction when using empagliflozin. 2, 4
Safety Monitoring and Precautions
Pre-Treatment Assessment
Verify eGFR ≥20 mL/min/1.73 m² before initiating empagliflozin. 4
Assess volume status, particularly in patients on diuretics, elderly patients, or those with impaired renal function. 4
Screen for history of genital mycotic infections and counsel patients on this risk. 2
Ongoing Monitoring
Monitor eGFR at least annually when ≥60 mL/min/1.73 m², increasing to every 3-6 months when <60 mL/min/1.73 m². 4
Monitor for signs of volume depletion, particularly during the first weeks of therapy. 4
Educate patients on signs and symptoms of diabetic ketoacidosis (DKA) for early recognition. 4
Situations Requiring Temporary Discontinuation
Hold empagliflozin during acute illness to prevent volume depletion. 4
Discontinue empagliflozin at least 3 days before planned surgery to prevent postoperative ketoacidosis. 2, 4
Contraindications and Special Populations
Absolute Contraindications
Do not use empagliflozin in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. 1
Empagliflozin is not expected to be effective in patients with severe renal impairment, ESRD, or those receiving dialysis. 1
High-Risk Situations
Use extreme caution in patients with autoimmune diabetes or insulin deficiency due to significantly higher risk of euglycemic diabetic ketoacidosis. 5
Maintain at least low-dose insulin in insulin-requiring individuals when using empagliflozin. 4
Expected Clinical Benefits
Glycemic Control
Expect HbA1c reduction of approximately 0.8% with empagliflozin monotherapy or add-on therapy. 6, 7
Glycemic efficacy increases with higher baseline glucose levels but decreases in patients with renal insufficiency. 6
Cardiovascular and Renal Outcomes
Empagliflozin reduces cardiovascular death by 38% and hospitalization for heart failure by 35% in patients with type 2 diabetes and established cardiovascular disease. 3, 8
Empagliflozin reduces the risk of major adverse cardiovascular events (MACE) by 14% relative to placebo. 8
Empagliflozin reduces all-cause mortality by 32% in high-risk cardiovascular populations. 8
Additional Benefits
Expect systolic blood pressure reduction of approximately 4 mmHg and diastolic reduction of approximately 2 mmHg. 6, 7
Common Adverse Effects and Management
Genital Mycotic Infections
Genital mycotic infections occur more frequently with empagliflozin, especially in women, but are usually straightforward to manage. 2, 6, 8
Counsel patients on hygiene measures and provide treatment guidance for these infections. 2
Urinary Tract Infections
- A negligible increase in mild urinary tract infections may be observed. 6
Volume Depletion
Risk of hypotension and volume depletion is low but should be carefully monitored in fragile and at-risk patients. 6
Proactively reduce diuretic doses in high-risk patients to prevent hypovolemia. 4
Hypoglycemia
Empagliflozin has no intrinsic risk of hypoglycemia when used as monotherapy. 7
Hypoglycemia occurs more frequently when empagliflozin is coadministered with insulin and/or sulfonylureas, necessitating dose adjustments of these agents. 6, 7
Clinical Pearls
Empagliflozin works independently of β-cell function and insulin secretion, making it effective regardless of diabetes duration, provided renal function is acceptable. 5, 1
The urinary glucose excretion averages approximately 64 grams per day with 10 mg and 78 grams per day with 25 mg empagliflozin. 1
Empagliflozin's cardiovascular and renal benefits are largely independent of glycemic control, making it valuable even in patients with well-controlled diabetes who have cardiovascular or renal disease. 3, 9
Unlike canagliflozin, empagliflozin has not been associated with an increased risk of amputation or bone fractures. 9