What are the age limits and precautions for prescribing Jardiance (empagliflozin) or Farxiga (dapagliflozin) to older adults with impaired renal function?

Age Limits for Jardiance and Farxiga

No Upper Age Limit for Either Medication

Both Jardiance (empagliflozin) and Farxiga (dapagliflozin) have no upper age limit for use, but require careful attention to renal function and volume status in older adults, particularly those ≥75 years. 1, 2

Pediatric Restrictions

• Jardiance is not approved for patients under 18 years of age due to lack of established safety and efficacy data 1
• Farxiga similarly lacks pediatric approval for patients under 18 years 2
• The concern in pediatric populations relates to potential effects on developing kidneys, as human kidney maturation occurs in utero and during the first 2 years of life 1

Considerations in Older Adults (≥65 Years)

General Safety Profile

• No dose adjustment is required based on age alone for either medication 1, 3
• In clinical trials, 32% of empagliflozin-treated patients were ≥65 years and 6% were ≥75 years, with consistent cardiovascular and renal benefits across age groups 1

Age-Related Risks Requiring Monitoring

Patients ≥75 years face increased risks that require heightened vigilance but do not contraindicate use:

• Volume depletion risk increases significantly: 4.4% with Jardiance 25 mg vs 2.1% with placebo in patients ≥75 years 1
• Urinary tract infection risk rises: 15.1-15.7% with Jardiance vs 10.5% with placebo in patients ≥75 years 1
• Hypotension risk is elevated in elderly patients, particularly those on concurrent diuretics 4, 5

Renal Function: The Critical Determinant in Older Adults

For Glycemic Control

• Do not initiate if eGFR <45 mL/min/1.73 m² as glucose-lowering efficacy is significantly reduced 3, 2
• Older adults frequently have reduced renal function despite normal serum creatinine due to decreased muscle mass, making eGFR calculation essential 6

For Cardiovascular and Renal Protection

• Both medications can be initiated if eGFR ≥25 mL/min/1.73 m² for heart failure or chronic kidney disease indications, regardless of age 4, 3, 5
• Jardiance was studied down to eGFR 20 mL/min/1.73 m² in EMPA-KIDNEY with consistent benefits 7
• If eGFR falls below 25 mL/min/1.73 m² during treatment, continue the medication until dialysis is required 3, 5

Critical Safety Precautions in Elderly Patients

Volume Status Assessment

• Assess volume status before initiation in all elderly patients, especially those ≥75 years or on loop diuretics 4, 5
• Consider reducing concurrent diuretic doses when starting SGLT2 inhibitors to prevent excessive volume depletion 3, 5

Monitoring Requirements

• Check eGFR within 1-2 weeks after initiation, then every 3-6 months if eGFR 45-59 mL/min/1.73 m², or annually if ≥60 mL/min/1.73 m² 3, 5
• Monitor for genital mycotic infections (occur in ~6% vs 1% placebo), which are more common in elderly women 3, 5

Sick Day Management

• Temporarily discontinue during acute illness with reduced food/fluid intake, fever, vomiting, or diarrhea to prevent diabetic ketoacidosis and volume depletion 3, 5
• Withhold at least 3 days before major surgery or procedures requiring prolonged fasting 3, 5

Common Pitfalls to Avoid in Older Adults

• Do not discontinue solely because eGFR drops below 45 mL/min/1.73 m² in patients already taking these medications, as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost 3, 5
• Do not assume normal renal function based on serum creatinine alone in elderly patients—always calculate eGFR using appropriate equations 6
• Do not combine with other medications increasing volume depletion risk (NSAIDs, high-dose diuretics) without careful monitoring 4