Jardiance (Empagliflozin) in Patients with Implantable Cardioverter-Defibrillators
Jardiance is safe and recommended for patients with an ICD, particularly those with heart failure or type 2 diabetes with cardiovascular disease, and may actually reduce ventricular arrhythmias and ICD therapies. 1
Primary Recommendation
SGLT2 inhibitors including empagliflozin are specifically recommended in patients with heart failure who have device therapy (ICD, CRT, or CRT-D), as these therapies are complementary rather than contraindicated. 1 The European Society of Cardiology guidelines explicitly state that device therapy with an ICD is recommended in heart failure patients with diabetes, and separately recommend empagliflozin to reduce cardiovascular events and mortality—there is no contraindication or caution regarding their combined use. 1
Anti-Arrhythmic Benefits
Recent high-quality evidence demonstrates that empagliflozin provides anti-arrhythmic benefits in ICD patients:
In a 2024 randomized controlled trial, empagliflozin significantly reduced the frequency and proportion of ventricular tachycardia/fibrillation episodes in heart failure patients with ICDs (P = 0.019 and 0.039, respectively). 2
Empagliflozin tended to reduce both anti-tachycardia pacing (ATP) and shock therapies from the ICD. 2
The anti-arrhythmic effects were most pronounced in patients already taking antiarrhythmic drugs (digoxin, mexiletine, amiodarone, or sotalol), suggesting synergistic benefit rather than drug interaction concerns. 2
A 2025 observational study of dapagliflozin (another SGLT2 inhibitor) in 117 ICD patients showed significant reduction in ventricular arrhythmia burden (2.9 ± 1.8 vs. 4.5 ± 2.0, P = 0.01) and appropriate ATP therapies (0.57 ± 0.80 vs. 0.65 ± 0.91, P = 0.03). 3
Dosing and Initiation
Start empagliflozin at 10 mg once daily in the morning, taken with or without food. 4 The dose may be increased to 25 mg in patients tolerating the medication. 4
Pre-Initiation Requirements:
Assess renal function before starting empagliflozin—do not initiate if eGFR is less than 45 mL/min/1.73 m². 4
Correct volume depletion prior to initiation, as empagliflozin has natriuretic effects. 4
No dose adjustment is needed if eGFR is ≥45 mL/min/1.73 m². 4
Monitoring Parameters
Reassess renal function periodically after initiation—discontinue empagliflozin if eGFR persistently falls below 45 mL/min/1.73 m². 4
Key monitoring points specific to ICD patients:
Monitor for volume depletion, especially when combined with loop diuretics, as empagliflozin enhances natriuresis. 5
Watch for euglycemic ketoacidosis, genital and soft tissue infections, though these are rare. 5
No specific ICD interrogation changes are needed—empagliflozin does not adversely affect defibrillation thresholds (unlike amiodarone, which can increase defibrillation thresholds). 6, 7
Clinical Context and Mechanism
The benefits of empagliflozin in ICD patients likely stem from multiple mechanisms:
Hemodynamic improvement and ventricular reverse remodeling reduce the substrate for ventricular arrhythmias. 3 Patients with worse baseline functional class (NYHA III/IV) and those achieving significant reverse remodeling (ΔLVEF > 15%) showed the greatest reduction in arrhythmic burden. 3
Empagliflozin shifts cardiac metabolism toward more efficient ketone utilization, improves myocardial energetics, and reduces cardiac fibrosis. 5
The drug provides cardiovascular mortality reduction (38% reduction, HR 0.62) and heart failure hospitalization reduction (35% reduction) independent of glucose-lowering effects. 5, 8
Important Caveats
Continue existing guideline-directed medical therapy including beta-blockers, ACE inhibitors/ARBs, and mineralocorticoid receptor antagonists—empagliflozin provides additive benefit on top of these medications. 5 Do not discontinue other heart failure therapies when adding empagliflozin. 5
Avoid saxagliptin (a DPP-4 inhibitor) in patients with high heart failure risk, as it provides no cardiovascular benefit and may worsen outcomes. 1
Hypoglycemia should be avoided in all ICD patients as it can trigger arrhythmias—empagliflozin carries low inherent hypoglycemia risk due to its insulin-independent mechanism. 1, 8