When should I introduce Jardiance (empagliflozin) in a patient with type 2 diabetes and established cardiovascular disease or multiple risk factors for cardiovascular disease, considering their renal function and potential benefits versus risks?

When to Introduce Jardiance (Empagliflozin)

Introduce Jardiance immediately in patients with type 2 diabetes who have established cardiovascular disease (prior MI, stroke, coronary artery disease) or established heart failure, regardless of their current HbA1c level or other glucose-lowering medications. 1

Primary Indications for Jardiance Initiation

Established Cardiovascular Disease (Highest Priority)

• Start Jardiance in any patient with type 2 diabetes and documented atherosclerotic cardiovascular disease, including prior myocardial infarction, stroke, coronary artery disease, or peripheral artery disease 1
• The cardiovascular benefit is independent of glucose-lowering effect and occurs within months of initiation 2
• EMPA-REG OUTCOME demonstrated 38% reduction in cardiovascular death, 35% reduction in heart failure hospitalization, and 32% reduction in all-cause mortality 2

Established Heart Failure (Any Ejection Fraction)

• Jardiance is recommended for patients with type 2 diabetes and heart failure with either reduced OR preserved ejection fraction to reduce worsening heart failure and cardiovascular death 1
• This indication applies regardless of glycemic control status 1

Chronic Kidney Disease with Albuminuria

• Initiate Jardiance in patients with type 2 diabetes and chronic kidney disease (eGFR 25-75 mL/min/1.73 m²) with albuminuria (UACR 200-5,000 mg/g) 1
• DAPA-CKD trial showed 39% reduction in composite renal outcomes 1
• Benefits extend to patients with eGFR as low as 30 mL/min/1.73 m² 3

Multiple Cardiovascular Risk Factors

• Consider Jardiance in patients with type 2 diabetes who have multiple atherosclerotic cardiovascular disease risk factors (age ≥55 years with coronary, carotid, or lower extremity artery stenosis >50%, left ventricular hypertrophy, eGFR <60 mL/min/1.73 m², or albuminuria) 1

Renal Function Requirements

eGFR Thresholds (Critical)

• Do not initiate Jardiance if eGFR is below 45 mL/min/1.73 m² 4
• Discontinue Jardiance if eGFR falls persistently below 45 mL/min/1.73 m² 4
• Assess renal function before initiating and monitor periodically during therapy 4
• Contraindicated in severe renal impairment, end-stage renal disease, or dialysis 4

Important Nuance on Renal Function

• While glucose-lowering efficacy decreases with declining renal function, cardiovascular and renal benefits persist even in patients with eGFR 30-60 mL/min/1.73 m² 3
• In the EMPA-REG OUTCOME trial, empagliflozin reduced cardiovascular death by 29% and heart failure hospitalization by 39% in patients with prevalent kidney disease at baseline 3

Dosing Strategy

Standard Dosing

• Start with 10 mg once daily in the morning, with or without food 4
• May increase to 25 mg once daily if additional glycemic control is needed 4
• Both doses showed similar cardiovascular benefits in clinical trials 2

Combination Therapy Considerations

With GLP-1 Receptor Agonists

• Combined therapy with an SGLT2 inhibitor (like Jardiance) and a GLP-1 receptor agonist with demonstrated cardiovascular benefit may be considered for additive reduction in cardiovascular and kidney events in patients with established ASCVD or multiple risk factors 1, 5

With Insulin or Sulfonylureas

• Reduce insulin or sulfonylurea doses when adding Jardiance to minimize hypoglycemia risk 4
• Jardiance carries low inherent hypoglycemia risk due to insulin-independent mechanism 6

Critical Safety Considerations and Contraindications

Volume Status Assessment

• Before initiating Jardiance, assess and correct volume status in patients with renal impairment, elderly patients, those with low systolic blood pressure, and those on diuretics 4
• Monitor for signs of hypotension during therapy due to diuretic effect 4

Ketoacidosis Risk

• Consider temporarily discontinuing Jardiance in clinical situations predisposing to ketoacidosis: reduced oral intake, acute illness, surgery, or excessive alcohol intake 4
• Instruct patients to check ketones if symptoms occur (nausea, vomiting, abdominal pain, dyspnea) even with normal blood glucose 4

Acute Kidney Injury Prevention

• Temporarily discontinue Jardiance in settings of reduced oral intake or increased fluid losses (vomiting, diarrhea, excessive heat exposure) 4
• If acute kidney injury occurs, discontinue immediately and treat promptly 4

Absolute Contraindications

• History of serious hypersensitivity reaction to empagliflozin 4
• Severe renal impairment (eGFR <30 mL/min/1.73 m²), end-stage renal disease, or dialysis 4

Common Pitfalls to Avoid

• Do not wait for inadequate glycemic control to initiate Jardiance in patients with established CVD or heart failure—the cardiovascular indication is independent of HbA1c 1
• Do not withhold Jardiance solely based on modest renal impairment (eGFR 45-60 mL/min/1.73 m²)—cardiovascular benefits persist in this population 3
• Do not forget to assess volume status before initiation, especially in elderly patients or those on loop diuretics 4
• Do not continue Jardiance if eGFR persistently falls below 45 mL/min/1.73 m² 4

Monitoring Requirements

• Assess renal function before initiation and periodically during therapy 4
• Monitor for signs of volume depletion, especially in first weeks of therapy 4
• Educate patients on genital mycotic infections (5% incidence) and urinary tract infections 4, 6
• Monitor LDL-C as modest increases may occur 4