What precautions should be taken when using Empagliflozin (Sodium-Glucose Cotransporter 2 inhibitor) in a diabetic patient with pneumonia?

Empagliflozin Management in Diabetic Patients with Pneumonia

Temporarily discontinue empagliflozin during acute pneumonia and do not restart until the patient has fully recovered with normal oral intake re-established. 1

Critical Safety Rationale for Holding SGLT2 Inhibitors During Acute Illness

Empagliflozin must be withheld during any acute illness, particularly pneumonia, to prevent life-threatening euglycemic diabetic ketoacidosis (DKA) and volume depletion. 1, 2 The FDA label explicitly warns that ketoacidosis can occur even with normal blood glucose levels (<250 mg/dL), presenting with nonspecific symptoms like malaise, nausea, vomiting, or shortness of breath—symptoms that overlap significantly with pneumonia. 2

When to Hold Empagliflozin

• Immediately discontinue when pneumonia is diagnosed, especially if the patient experiences reduced food/fluid intake, fever, vomiting, or requires hospitalization. 1
• The Kidney International guidelines specifically recommend holding SGLT2 inhibitors during fever, vomiting, diarrhea, or any intercurrent illness requiring hospitalization. 1
• Empagliflozin should be withheld at least 3 days before any major surgery or procedures requiring prolonged fasting. 1

Volume Depletion Risk During Pneumonia

• Empagliflozin causes intravascular volume contraction through its diuretic effect, which combined with illness-related fluid losses from fever, tachypnea, and reduced oral intake significantly increases hypovolemia risk. 1, 2
• The FDA label mandates assessing volume status before initiating empagliflozin and monitoring for signs of hypotension, particularly in elderly patients, those with renal impairment, low systolic blood pressure, or concurrent diuretic use. 2
• Consider proactively reducing concurrent diuretic doses in patients at high risk for volume depletion before illness worsens. 1

Ketoacidosis Monitoring

• Check blood or urine ketones if the patient develops malaise, nausea, vomiting, or abdominal pain during pneumonia, even if blood glucose is normal. 1, 2
• Fatal cases of ketoacidosis have been reported with empagliflozin, particularly when predisposing factors are present: acute febrile illness (like pneumonia), reduced caloric intake, insulin dose reduction, or dehydration. 2
• The risk is highest in insulin-requiring patients—maintain at least low-dose insulin even when empagliflozin is held, as complete insulin cessation dramatically increases DKA risk. 1

Infection Risk Considerations

Interestingly, real-world evidence suggests SGLT2 inhibitors may actually reduce pneumonia and sepsis risk compared to DPP-4 inhibitors (HR 0.63 for pneumonia, HR 0.52 for sepsis), with lower infection-related mortality. 3 However, this protective effect does not override the acute safety concerns during active infection requiring the drug to be held.

Common Adverse Effects to Monitor

• Genital mycotic infections occur in approximately 6% of patients on SGLT2 inhibitors versus 1% on placebo—counsel patients on daily hygienic measures. 1, 4
• Urinary tract infections are relatively rare but should be evaluated and treated promptly if suspected. 5, 2
• Unlike sotagliflozin (a dual SGLT1/SGLT2 inhibitor), empagliflozin does not cause significant diarrhea. 5

When to Restart Empagliflozin

• Resume empagliflozin only after the patient has recovered from pneumonia, normal oral intake is re-established, and volume status is stable. 1
• Reassess renal function (eGFR) before restarting—empagliflozin should not be initiated or restarted if eGFR is persistently <45 mL/min/1.73 m². 2
• If the patient was on empagliflozin for cardiovascular/renal protection (not just glycemic control), prioritize restarting once medically stable, as the drug reduces cardiovascular death by 38% and heart failure hospitalization by 35% in high-risk patients. 6

Patient Education Requirements

• Instruct patients to stop empagliflozin immediately when they become sick and contact their healthcare provider. 1
• Educate on specific triggers: fever, inability to eat/drink normally, vomiting, diarrhea, or any hospitalization. 1
• Seek immediate medical attention if symptoms of DKA develop (nausea, vomiting, abdominal pain, shortness of breath, generalized malaise) or severe genital/urinary infections occur. 1, 2

Renal Function Considerations

• Empagliflozin is contraindicated in severe renal impairment (eGFR <45 mL/min/1.73 m²), end-stage renal disease, or dialysis. 2
• Consider temporarily discontinuing empagliflozin in settings of acute kidney injury or reduced oral intake during pneumonia, as the drug can worsen renal function in volume-depleted states. 2
• Monitor renal function closely during and after pneumonia—if eGFR falls persistently below 45 mL/min/1.73 m², discontinue empagliflozin permanently. 2

Common Pitfall to Avoid

Do not continue empagliflozin during active pneumonia simply because the patient's blood glucose is elevated. The risk of euglycemic DKA and volume depletion far outweighs any glycemic benefit during acute illness. 1, 2 Temporary insulin therapy is safer for glucose management during hospitalization for pneumonia. 7