Can Jardiance (empagliflozin) be used in a patient with impaired renal function?

Jardiance Use in Patients with eGFR 38 mL/min/1.73 m²

Yes, Jardiance (empagliflozin) can be safely initiated and used in a patient with eGFR 38 mL/min/1.73 m² for cardiovascular and renal protection, though it should not be started for glycemic control at this level of kidney function. 1

Evidence-Based Rationale for Use

The 2025 American Diabetes Association guidelines now support initiating empagliflozin at eGFR ≥20 mL/min/1.73 m² specifically for renal and cardiovascular protection, representing a significant expansion from previous thresholds. 1 At an eGFR of 38 mL/min/1.73 m², this patient falls well within the approved range for cardiovascular and renal benefits, though the glucose-lowering efficacy will be significantly diminished. 2, 3

The EMPA-KIDNEY trial demonstrated a 28% reduction in progression of kidney disease or cardiovascular death (HR 0.72,95% CI 0.64-0.82) in patients with eGFR as low as 20 mL/min/1.73 m². 1 More specifically, empagliflozin reduced incident or worsening nephropathy by 39% (HR 0.61,95% CI 0.53-0.70) and doubled serum creatinine occurred 44% less frequently compared to placebo. 4

Dosing and Administration

• Standard dose: 10 mg orally once daily for cardiovascular and renal protection—no dose adjustment is required at eGFR 38 mL/min/1.73 m². 1
• No titration needed: This is a fixed dose for all cardiovascular and renal indications, regardless of kidney function down to eGFR 20 mL/min/1.73 m². 1
• Do not use for glycemic control: At eGFR <45 mL/min/1.73 m², empagliflozin is ineffective for glucose lowering due to its mechanism of action, but cardiovascular and renal benefits remain fully intact. 2, 5

Expected Initial eGFR Changes

An acute, reversible eGFR decline of approximately 3-5 mL/min/1.73 m² typically occurs within the first 2-4 weeks of empagliflozin initiation. 1 This hemodynamic "dip" reflects reduced intraglomerular pressure through restoration of tubuloglomerular feedback and should not prompt discontinuation of the medication. 6 After this initial decline, empagliflozin actually slows the chronic rate of eGFR decline—the annual mean slope during chronic treatment was +0.23 mL/min/1.73 m² per year with empagliflozin versus -1.46 mL/min/1.73 m² per year with placebo. 6

Monitoring Requirements

• Check eGFR and creatinine within 1-2 weeks after initiation to document the expected transient decrease. 1
• Assess volume status before starting empagliflozin and correct any volume depletion; consider reducing concurrent diuretic doses in patients at high risk for further volume loss. 7, 1
• Continue monitoring eGFR at least every 3-6 months if eGFR remains 30-59 mL/min/1.73 m². 7

Critical Safety Precautions

• Withhold during acute illness: Temporarily stop empagliflozin during fever, vomiting, diarrhea, or reduced oral intake to prevent volume depletion and euglycemic diabetic ketoacidosis. 1, 2
• Stop 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis. 7, 8
• Monitor for genital mycotic infections (occur in ~6% of patients vs. 1% with placebo) and urinary tract infections (risk increases with declining renal function). 2, 3
• Watch for volume depletion: Elderly patients (≥75 years) and those on concurrent diuretics face increased risk—volume depletion occurred in 4.4% of patients ≥75 years on empagliflozin 25 mg versus 2.1% on placebo. 2

Integration with Other Medications

• Continue ACE inhibitors or ARBs without dose adjustment when starting empagliflozin—these provide complementary renal protection through different mechanisms. 1
• If on insulin or sulfonylureas: Reduce doses of these agents to mitigate hypoglycemia risk, as empagliflozin will still provide modest glucose-lowering effects at eGFR 38 mL/min/1.73 m². 7
• Consider reducing loop or thiazide diuretics at initiation to avoid excessive volume depletion. 7

Common Pitfalls to Avoid

• Do not discontinue empagliflozin if eGFR falls below 45 mL/min/1.73 m² or even below 30 mL/min/1.73 m²—cardiovascular and renal benefits persist independently of glycemic effects. 1, 8
• Do not stop the drug because of the expected initial eGFR dip in the first 2-4 weeks unless there are signs of true tubular injury (which can be assessed with urine microscopy). 9, 6
• Do not reduce the dose below 10 mg for cardiovascular or renal indications, even as kidney function declines. 1

Comparison with Dapagliflozin

If you are considering alternatives, dapagliflozin can be initiated at eGFR ≥25 mL/min/1.73 m² (versus empagliflozin's threshold of ≥20 mL/min/1.73 m² per updated 2025 guidelines), making both drugs appropriate at eGFR 38 mL/min/1.73 m². 8 Both provide comparable cardiovascular and renal benefits with nearly identical safety profiles. 8 The choice between them at this eGFR level is clinically equivalent, though dapagliflozin has a slightly higher approved threshold in some older guidelines. 8