Is it appropriate to add Jardiance (Empagliflozin) to the treatment regimen of a patient with type 2 diabetes currently taking metformin 1000 mg twice daily with an HbA1c of 6.5?

Adding Jardiance to Metformin for HbA1c 6.5%

Adding Jardiance (empagliflozin) to metformin 1000 mg twice daily is not appropriate for a patient with HbA1c 6.5%, as this patient has already achieved excellent glycemic control below the recommended target of <7% for most adults. 1

Current Glycemic Status Assessment

• The patient's HbA1c of 6.5% is already below the recommended target of <7% for most nonpregnant adults with type 2 diabetes 1
• The American College of Physicians specifically recommends deintensifying pharmacologic therapy in patients who achieve HbA1c levels less than 6.5%, as no trials demonstrate clinical benefit from targeting below this threshold 1
• Metformin monotherapy at 2000 mg daily has successfully achieved glycemic control, demonstrating adequate disease management with current therapy 1

Rationale Against Treatment Intensification

• The harms of intensifying therapy outweigh any potential benefits at this HbA1c level, including increased hypoglycemia risk, treatment burden, and medication costs without demonstrated improvement in clinical outcomes 1
• The ACCORD trial, which targeted HbA1c <6.5%, was discontinued early due to increased overall and cardiovascular-related death with intensive treatment 1
• Adding Jardiance would increase medication burden and cost (median monthly cost for empagliflozin 25 mg is substantially higher than metformin alone) without evidence of additional benefit at this glycemic level 1

When Jardiance Addition Would Be Appropriate

• Jardiance should be considered if HbA1c rises to ≥7% despite metformin therapy, particularly in patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease 1
• For patients with HbA1c ≥1.5% above target (≥8.5% if target is 7%), dual therapy initiation is recommended to achieve glycemic goals more rapidly 1
• The FDA-approved indication for Jardiance includes use "as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus" when glycemic control is inadequate 2

Recommended Management Strategy

• Continue metformin 1000 mg twice daily as monotherapy and maintain current lifestyle modifications 1
• Recheck HbA1c every 6 months to monitor for glycemic deterioration, as the patient has achieved stable glycemic control 1
• Consider periodic vitamin B12 monitoring with long-term metformin use, especially if anemia or peripheral neuropathy develops 1
• Reassess need for treatment intensification only if HbA1c rises to ≥7% on repeat testing 1

Special Cardiovascular Considerations

• While Jardiance has proven cardiovascular benefits in patients with established cardiovascular disease (reducing cardiovascular death), these benefits were demonstrated in patients requiring glycemic control improvement 1, 2
• If this patient has established atherosclerotic cardiovascular disease or heart failure, Jardiance could be considered for cardiovascular protection independent of glycemic control, but this represents off-label use for cardiovascular indication rather than glycemic management 1
• The decision to add Jardiance purely for cardiovascular benefit in a patient with HbA1c 6.5% should weigh the proven cardiovascular mortality reduction against the lack of glycemic indication 1

Critical Pitfall to Avoid

• Do not intensify diabetes therapy based solely on the desire to use newer medications when glycemic targets are already achieved, as this increases treatment burden and costs without improving outcomes 1
• Avoid the misconception that "lower is always better" for HbA1c—targets below 6.5% have not shown benefit and may cause harm 1