At what estimated glomerular filtration rate (GFR) should Jardiance (empagliflozin) be stopped in a patient with type 2 diabetes?

Jardiance (Empagliflozin) GFR Thresholds

Stop Jardiance when eGFR persistently falls below 45 mL/min/1.73 m² according to the FDA label, though recent guidelines support continuation down to 20 mL/min/1.73 m² for cardiovascular and renal protection. 1

FDA-Approved Discontinuation Threshold

The official FDA prescribing information is clear and unequivocal:

• Do not initiate Jardiance if eGFR is below 45 mL/min/1.73 m² 1
• Discontinue Jardiance if eGFR falls persistently below 45 mL/min/1.73 m² 1
• Jardiance is contraindicated in severe renal impairment, end-stage renal disease, or dialysis 1

Guideline-Based Approach (More Permissive)

Recent high-quality guidelines diverge significantly from the FDA label, reflecting newer evidence:

For Cardiovascular and Renal Protection

• The 2023-2024 American Diabetes Association guidelines recommend SGLT2 inhibitors (including empagliflozin) can be used down to eGFR ≥20 mL/min/1.73 m² for reducing CKD progression and cardiovascular events 2
• This represents a major shift from the FDA label, based on trials like EMPA-REG OUTCOME which demonstrated renal benefits even at lower eGFR levels 3, 4

For Glycemic Control Specifically

• Do not use Jardiance for glucose lowering when eGFR <45 mL/min/1.73 m² as the glucose-lowering efficacy is significantly reduced due to its mechanism of action 2, 5
• The drug works by blocking glucose reabsorption in the kidney, which becomes ineffective as kidney function declines 5

Clinical Decision Algorithm

If eGFR 45-60 mL/min/1.73 m²:

• Continue Jardiance without dose adjustment 1
• Monitor eGFR every 3-6 months 2

If eGFR 30-44 mL/min/1.73 m²:

• FDA label says discontinue 1
• However, 2023-2024 guidelines support continuation for cardiovascular/renal protection if patient has heart failure, established cardiovascular disease, or albuminuria 2
• Expect minimal glucose-lowering effect; consider adding GLP-1 receptor agonist for glycemic control 2, 6

If eGFR 20-29 mL/min/1.73 m²:

• FDA label says discontinue 1
• Guidelines support continuation for cardiovascular/renal protection in patients already on therapy 2, 6
• Do not initiate at this level 6
• Switch to GLP-1 receptor agonist for glycemic management 2, 7

If eGFR <20 mL/min/1.73 m²:

• Discontinue Jardiance 2, 1
• This is a hard stop per both FDA and guidelines 6, 1

Critical Monitoring Points

• Assess renal function before initiating and periodically thereafter 1
• Expect an initial eGFR dip of 3-5 mL/min/1.73 m² within the first 1-4 weeks, which is hemodynamic and reversible 8
• Do not discontinue for this initial dip alone unless accompanied by volume depletion 8
• Confirm persistent eGFR decline with repeat measurement before stopping 1

Common Pitfalls to Avoid

• Don't stop Jardiance solely because eGFR drops below 45 mL/min/1.73 m² if the patient has heart failure or CKD with albuminuria – the cardiovascular and renal protective benefits persist even when glucose-lowering effects are lost 2, 3
• Don't confuse the initial hemodynamic eGFR dip with true kidney injury – this early decline actually predicts better long-term renal outcomes 8
• Assess volume status before discontinuing, as volume depletion may be the culprit rather than true kidney function decline 1

Practical Recommendation

For real-world practice: Follow FDA labeling and discontinue at eGFR <45 mL/min/1.73 m² unless the patient has compelling cardiovascular or renal indications (heart failure, established CVD, or albuminuria), in which case continuation down to eGFR 20 mL/min/1.73 m² is supported by strong guideline evidence. 2, 1