Can Jardiance (empagliflozin) be started or continued in a patient who has recovered from acute kidney injury but now has an estimated glomerular filtration rate of 29 mL/min/1.73 m²?

Can Jardiance Be Started After AKI Recovery with eGFR 29 mL/min/1.73 m²?

Do not start Jardiance (empagliflozin) in this patient because the eGFR of 29 mL/min/1.73 m² falls below the FDA-approved initiation threshold of 45 mL/min/1.73 m², and the recent AKI recovery requires stabilization before considering any SGLT2 inhibitor. 1

FDA Label Restrictions

• The FDA prescribing information explicitly states: "Do not initiate JARDIANCE if eGFR is below 45 mL/min/1.73 m²" 1
• Jardiance is contraindicated in severe renal impairment, end-stage renal disease, or dialysis 1
• The label requires assessment of renal function before initiating Jardiance and discontinuation if eGFR falls persistently below 45 mL/min/1.73 m² 1

Post-AKI Considerations

• Before initiating any SGLT2 inhibitor after AKI recovery, you must systematically exclude ongoing prerenal causes (volume depletion, hypotension), intrinsic causes (nephrotoxic drugs, NSAIDs), and post-renal obstruction 2
• Review the medication list for recent exposure to nephrotoxic agents such as NSAIDs or iodinated contrast, and discontinue these if present 2
• An acute kidney injury is defined by either a serum creatinine increase ≥0.3 mg/dL within 48 hours or an increase to ≥1.5 times baseline within 7 days; confirm the patient meets recovery criteria with stable creatinine values over at least 1–2 weeks 2

Guideline-Based Alternative Approach

While the FDA label prohibits initiation at eGFR <45 mL/min/1.73 m², newer guidelines provide a different perspective for cardiovascular and renal protection:

• The 2025 American Diabetes Association guidelines recommend SGLT2 inhibitors for patients with eGFR ≥20 mL/min/1.73 m² and UACR ≥200 mg/g to reduce chronic kidney disease progression and cardiovascular events 2
• The KDIGO 2022 guideline recommends initiation of an SGLT2 inhibitor for patients with type 2 diabetes and chronic kidney disease who have eGFR ≥20 mL/min/1.73 m² 3
• However, this represents off-label use below eGFR 45 mL/min/1.73 m² 4

Evidence from Clinical Trials

• The EMPA-KIDNEY trial enrolled patients with eGFR as low as 20 mL/min/1.73 m² and demonstrated that empagliflozin reduced progression of kidney disease or cardiovascular death by 28% (HR 0.72,95% CI 0.64–0.82) 5
• Results were consistent across eGFR ranges, including patients with eGFR 20–29 mL/min/1.73 m² 5
• Empagliflozin reduced the risk of acute kidney injury markers by 20% and acute kidney injury adverse events by 27%, even in patients with reduced baseline kidney function 6

Practical Algorithm for This Patient

Step 1: Confirm AKI resolution

• Verify stable serum creatinine for at least 2 weeks with no ongoing acute kidney injury criteria 2
• Exclude volume depletion, hypotension, nephrotoxic medications, and urinary obstruction 2

Step 2: Assess albuminuria status

• Check urine albumin-to-creatinine ratio; if UACR ≥200 mg/g, the evidence for SGLT2 inhibitor benefit is strongest even at eGFR 29 mL/min/1.73 m² 2

Step 3: Consider dapagliflozin instead of empagliflozin

• Dapagliflozin has more robust guideline support for initiation at eGFR ≥25 mL/min/1.73 m² (though still off-label below 45 mL/min/1.73 m²) 2
• The DAPA-CKD trial specifically enrolled patients with eGFR 25–75 mL/min/1.73 m² and demonstrated a 39% reduction in kidney disease progression or cardiovascular death 2

Step 4: If proceeding with off-label SGLT2 inhibitor use

• Correct any volume depletion before initiation 2
• Consider reducing concurrent diuretic doses 2
• Start with standard dose (empagliflozin 10 mg or dapagliflozin 10 mg once daily); no dose adjustment is required for cardiovascular/renal protection 2
• Recheck eGFR within 1–2 weeks; an acute dip of 3–5 mL/min/1.73 m² is expected and should not prompt discontinuation 4

Critical Safety Precautions

• Temporarily withhold the SGLT2 inhibitor during acute illnesses with reduced oral intake, fever, vomiting, or diarrhea 2
• Stop at least 3 days before major surgery or procedures requiring prolonged fasting 2
• Monitor for genital mycotic infections (occur in ~6% of patients) and euglycemic diabetic ketoacidosis 2
• If the patient is on insulin or sulfonylureas, reduce doses by ~20% to prevent hypoglycemia 2

Common Pitfall to Avoid

• Do not assume that the FDA label threshold of eGFR 45 mL/min/1.73 m² applies to cardiovascular and renal protection indications; the label was written primarily for glycemic control, and glucose-lowering efficacy is indeed minimal below eGFR 45 mL/min/1.73 m², but cardiovascular and renal benefits persist at lower eGFR levels 2, 4
• However, initiating below eGFR 45 mL/min/1.73 m² remains off-label and requires shared decision-making with the patient 3, 4

Bottom Line

For strict FDA compliance, do not start Jardiance at eGFR 29 mL/min/1.73 m². 1 If you choose to proceed based on newer guideline recommendations for cardiovascular/renal protection (particularly if UACR ≥200 mg/g), consider dapagliflozin 10 mg daily as an off-label option after confirming complete AKI recovery, correcting volume status, and obtaining informed consent about off-label use. 2, 3 Monitor eGFR closely within 1–2 weeks and educate the patient about sick-day rules. 2, 4