How to manage a patient with diabetes taking Jardiance (Empagliflozin) who has an active leg wound?

Management of Jardiance in Diabetic Patients with Active Leg Wounds

Continue Jardiance (empagliflozin) in most patients with active leg wounds while implementing comprehensive wound care, but temporarily discontinue if there are signs of infection requiring antibiotics, significant volume depletion risk, or severe ischemia (ABI <0.5 or ankle pressure <50 mmHg).

Initial Wound Assessment Algorithm

Evaluate for Infection

• Document at least 2 signs of inflammation: erythema, warmth, swelling, tenderness, pain, or purulent discharge 1
• Measure the extent of erythema—if >2 cm around the wound, this indicates moderate infection requiring broad-spectrum antibiotics 2
• Note that infection signs may be blunted by neuropathy or ischemia, and systemic findings (fever, elevated WBC) are often absent 3
• If infection is present, obtain tissue specimens from the wound base (not swabs) for culture before starting antibiotics 1, 4

Assess Vascular Status

• Check dorsalis pedis and posterior tibial pulses bilaterally—if palpable, arterial supply is generally adequate 3
• Measure ankle pressure and ankle-brachial index (ABI) 3
• If ankle pressure <50 mmHg or ABI <0.5, obtain urgent vascular imaging and consider revascularization 3
• This degree of ischemia warrants temporary discontinuation of Jardiance until perfusion is restored

Screen for Charcot Foot

• Use infrared thermometry to measure bilateral skin temperatures—a difference >2°C suggests active Charcot requiring immediate non-weight-bearing 2

Jardiance-Specific Considerations

When to Continue Jardiance

• Non-infected wounds with adequate perfusion can continue empagliflozin as it does not impair wound healing 5, 6
• Recent research demonstrates that empagliflozin-pretreated mesenchymal stem cell exosomes actually enhance angiogenesis and accelerate diabetic wound healing via the PTEN/AKT/VEGF pathway 7
• The drug's modest diuretic effect and blood pressure reduction may be beneficial in patients without volume depletion 5, 8

When to Temporarily Discontinue Jardiance

• Active infection requiring systemic antibiotics: The increased risk of genital and urinary tract infections with SGLT2 inhibitors 6 may complicate management of concurrent leg wound infections
• Severe ischemia (ABI <0.5 or ankle pressure <50 mmHg): Volume depletion from empagliflozin's diuretic effect could worsen perfusion 8, 6
• eGFR <45 mL/min: Empagliflozin efficacy decreases significantly below this threshold and should be discontinued 9
• Signs of volume depletion or hypotension: Especially in elderly or frail patients, or those on concurrent diuretics 9, 6

Comprehensive Wound Care Protocol

Debridement

• Sharp debridement with scalpel, scissors, or tissue nippers is the preferred technique and should be repeated as often as needed if nonviable tissue continues to form 1, 3
• Following debridement, measure and record wound size, extent of surrounding cellulitis, and drainage characteristics 1

Off-Loading (Critical Component)

• For neuropathic plantar ulcers, prescribe a non-removable knee-high off-loading device (total contact cast) 1, 3
• The total contact cast is the "gold standard" but should only be used with caution in patients with severe PAD or active infection, as it precludes viewing the wound 1
• For leg wounds, ensure appropriate pressure relief based on wound location 1

Wound Dressing Selection

• Do not use topical antiseptic or antimicrobial dressings, honey, collagen, or alginate dressings for routine wound healing 1
• Consider sucrose-octasulfate impregnated dressing for non-infected, neuro-ischemic ulcers that have shown insufficient healing after 2 weeks of standard care 1

Footwear and Prevention

• Prescribe properly fitting therapeutic footwear with demonstrated plantar pressure-relieving effect 1, 2
• Educate patients to never walk barefoot, in socks only, or in thin-soled slippers—even indoors 1, 2
• For patients with foot deformities, consider extra-depth shoes, custom-made footwear, or toe orthoses 1, 4

Patient Education Requirements

• Instruct daily foot inspection including between all toes, using a mirror or caregiver assistance if needed 2, 4
• Wash feet daily with lukewarm water (<37°C), dry carefully especially between toes 2, 4
• Apply emollients to dry skin but NOT between toes to prevent maceration 2
• Immediately contact healthcare provider if new lesions, increased redness, warmth, or drainage develop 1, 4

Follow-Up Schedule

• High-risk patients (history of ulcer/amputation, loss of protective sensation, PAD, or foot deformity) require follow-up every 1-3 months 2
• Re-evaluate hospitalized patients at least daily, or in 3-5 days (or sooner if worsening) for outpatients 3
• If wound shows no signs of healing within 6 weeks despite optimal management, consider revascularization regardless of initial vascular test results 3

Critical Pitfalls to Avoid

• Do not prescribe prophylactic antibiotics for uninfected wounds—this promotes antibiotic resistance without benefit 4
• Do not delay treatment of pre-ulcerative lesions or blisters, as they can rapidly progress to serious ulceration and infection 4
• Failure to recognize underlying osteomyelitis: Consider this in any infected, deep, or large foot ulcer, especially chronic wounds or those overlying bony prominences 3
• Premature removal of stable, dry eschar (especially on the heel) can lead to unnecessary tissue damage—leave in place until it softens unless infection is present 3

When to Resume Jardiance

• Once infection is controlled, perfusion is adequate, and volume status is stable, empagliflozin can be safely resumed 5, 6
• The cardiovascular and renal benefits of empagliflozin (demonstrated in EMPA-REG OUTCOME trial) make it worthy of preferential consideration once the acute wound complications are managed 5, 8