Is Jardiance (empagliflozin) safe to use in an adult patient with type 2 diabetes and impaired renal function, specifically a glomerular filtration rate (GFR) of 24?

Jardiance Use with GFR 24

Jardiance (empagliflozin) should NOT be initiated in a patient with a GFR of 24 mL/min/1.73 m², but if the patient is already taking it, continuation may be reasonable for cardiovascular and renal protection until dialysis is required. 1

Guideline-Based Initiation Threshold

The most recent KDIGO 2024 guidelines provide the clearest direction on this clinical scenario:

• SGLT2 inhibitors are recommended for initiation only when eGFR ≥20 mL/min/1.73 m² for patients with type 2 diabetes and CKD (Recommendation 3.7.1, Grade 1A). 1
• At a GFR of 24 mL/min/1.73 m², this patient falls just above the minimum threshold of 20 mL/min/1.73 m², making initiation technically permissible but requiring careful consideration. 1
• Once initiated, SGLT2 inhibitors should be continued even if eGFR falls below 20 mL/min/1.73 m² unless not tolerated or kidney replacement therapy is initiated (Practice Point 3.7.1). 1

Critical Distinction: Glycemic Control vs. Cardiorenal Protection

This is the most important clinical nuance at this level of renal function:

• Do NOT use Jardiance for glycemic control at GFR 24 mL/min/1.73 m² - the glucose-lowering efficacy is minimal to absent due to the drug's mechanism requiring adequate renal filtration. 2, 3
• The FDA label explicitly states that glucose-lowering efficacy decreases significantly when eGFR <45 mL/min/1.73 m², with least square mean HbA1c reductions of only -0.2% at eGFR 30-45 mL/min/1.73 m². 2
• However, cardiovascular and renal protective benefits are preserved at lower eGFR levels, independent of glycemic effects. 1, 4

Evidence Supporting Use at Low eGFR

The EMPA-KIDNEY trial provides the strongest recent evidence:

• Empagliflozin reduced progression of kidney disease and cardiovascular death by 28% (HR 0.72,95% CI 0.64-0.82) in patients with eGFR as low as 20 mL/min/1.73 m². 1
• Approximately half of the 6,609 participants had diabetes, demonstrating benefit regardless of diabetes status. 1
• The trial specifically enrolled patients with eGFR ≥20 but <45 mL/min/1.73 m² or those with eGFR 45-90 mL/min/1.73 m² with significant albuminuria. 1

Clinical Decision Algorithm for GFR 24

If considering NEW initiation:

1. Assess the primary indication - Is this for glycemic control or cardiorenal protection? 1
2. If for glycemic control alone: Do NOT initiate Jardiance; use alternative agents (insulin, GLP-1 RA with dose adjustment). 1, 2
3. If for cardiorenal protection (heart failure, CKD with albuminuria ≥200 mg/g, or established cardiovascular disease):
   • Check that eGFR is ≥20 mL/min/1.73 m² (at 24, this criterion is met). 1
   • Assess volume status and correct any volume depletion before initiation. 1
   • Consider reducing concurrent diuretic doses to prevent excessive volume depletion. 1
   • Initiate at 10 mg once daily (no dose adjustment needed; this is the standard dose for cardiorenal protection). 1, 2

If patient is ALREADY on Jardiance:

• Continue 10 mg daily for cardiorenal protection even though glycemic efficacy is lost. 1
• Monitor closely for adverse effects (volume depletion, genital infections, ketoacidosis risk if on insulin). 1, 2
• Continue until dialysis is initiated or drug is not tolerated. 1

Monitoring and Safety Considerations at GFR 24

• Expect a transient eGFR dip of 3-5 mL/min/1.73 m² within the first 2-4 weeks - this is hemodynamic, reversible, and does NOT indicate harm. 1
• Check eGFR and serum creatinine within 2-4 weeks of initiation. 1
• Withhold Jardiance during acute illness, prolonged fasting, or major surgery to prevent ketoacidosis and volume depletion. 1
• Monitor for genital mycotic infections (occurs in ~6% of patients) and urinary tract infections. 2, 5
• Risk of euglycemic diabetic ketoacidosis exists, particularly in insulin-requiring patients - educate patients to check ketones if experiencing malaise, nausea, or vomiting even with normal glucose. 1, 2

Common Pitfalls to Avoid

• Do NOT discontinue Jardiance solely because eGFR is <45 mL/min/1.73 m² - the cardiorenal benefits persist even when glycemic efficacy is lost. 1
• Do NOT use Jardiance as a glucose-lowering agent at this eGFR - it will be ineffective and may lead to inadequate diabetes management. 2
• Do NOT forget to adjust other medications - metformin should be discontinued if eGFR <30 mL/min/1.73 m²; DPP-4 inhibitors require dose reduction. 1
• Do NOT initiate in patients with type 1 diabetes at this eGFR - significantly elevated ketoacidosis risk without proven benefit. 6

Alternative Agents for Glycemic Control at GFR 24

If additional glucose lowering is needed:

• Insulin remains the most reliable option at this level of renal function (no dose adjustment based on eGFR, though clearance is reduced). 1
• GLP-1 receptor agonists may be used for cardiovascular protection and can provide some glycemic benefit, though some require dose adjustment at eGFR <30 mL/min/1.73 m². 1
• DPP-4 inhibitors can be used with appropriate dose reductions (e.g., sitagliptin 25 mg daily, linagliptin 5 mg daily without adjustment). 1