Can Jardiance (Empagliflozin) Be Started in This Patient?
Yes, empagliflozin should be initiated at 10 mg once daily for cardiovascular and renal protection in this 70-year-old man with preserved kidney function (eGFR 95 mL/min/1.73 m²) and severe albuminuria (UACR ~956 mg/g), even though he does not have diabetes (HbA1c 5.8%).
Primary Indication: Renal Protection for Chronic Kidney Disease with Albuminuria
The 2024 American Diabetes Association guidelines recommend SGLT2 inhibitors for patients with chronic kidney disease when eGFR ≥20 mL/min/1.73 m² and UACR ≥200 mg/g to reduce CKD progression and cardiovascular events, regardless of diabetes status 1.
This patient's UACR of ~956 mg/g places him in the severe albuminuria category, which is a strong indication for SGLT2 inhibitor therapy independent of glycemic status 1.
The EMPA-REG OUTCOME trial demonstrated that empagliflozin reduces incident or worsening nephropathy by 39% (HR 0.61,95% CI 0.53–0.70), including a 38% reduction in progression to macroalbuminuria and 44% reduction in doubling of creatinine 1, 2.
Dosing and Renal Function Considerations
The FDA-approved dose is empagliflozin 10 mg once daily, which can be initiated when eGFR ≥45 mL/min/1.73 m²; this patient's eGFR of 95 mL/min/1.73 m² is well above this threshold 3.
No dose adjustment is needed when eGFR is ≥45 mL/min/1.73 m² 3.
Although the FDA label states empagliflozin should not be initiated when eGFR <45 mL/min/1.73 m², the 2024 ADA guidelines support initiation down to eGFR ≥20 mL/min/1.73 m² for cardiovascular and renal protection based on newer trial data 1.
Expected Renal Effects and Monitoring
An acute, reversible eGFR decline of 2–5 mL/min/1.73 m² typically occurs within the first 2–4 weeks, reflecting hemodynamic changes (reduced intraglomerular pressure) rather than kidney injury; this should not prompt discontinuation 4, 5.
After the initial dip, empagliflozin slows the annual rate of eGFR decline; in EMPA-REG OUTCOME, the chronic maintenance slope was +0.23 mL/min/1.73 m² per year with empagliflozin versus –1.46 mL/min/1.73 m² per year with placebo (P<0.001) 4.
Recheck eGFR and creatinine 1–2 weeks after initiation to document the expected hemodynamic dip, then monitor every 3–6 months 5.
Cardiovascular Benefits in Non-Diabetic Patients
Empagliflozin reduces cardiovascular death by 38% and all-cause mortality by 32% in patients with established cardiovascular disease, with benefits consistent across subgroups including those without diabetes 1, 2.
The drug reduces hospitalization for heart failure by 35% (HR 0.65,95% CI 0.50–0.85), a benefit observed even in patients without prior heart failure 2.
Pre-Initiation Assessment and Safety Precautions
Assess volume status before starting empagliflozin; correct any volume depletion and consider reducing concurrent diuretic doses in elderly patients 3, 5.
This patient's potassium of 4.1 mmol/L is normal; empagliflozin does not significantly affect potassium levels and may actually reduce hyperkalemia risk 5.
Counsel the patient about genital mycotic infections (occur in ~6% of users versus 1% with placebo) and emphasize daily hygiene 5.
Educate about euglycemic diabetic ketoacidosis risk and instruct the patient to withhold empagliflozin during acute illness with reduced oral intake, fever, vomiting, or diarrhea, and to stop at least 3 days before major surgery 3, 5.
Common Pitfalls to Avoid
Do not withhold empagliflozin because the patient lacks diabetes; the renal and cardiovascular benefits are independent of glycemic control 1, 6.
Do not discontinue empagliflozin in response to the expected early eGFR dip of 2–5 mL/min/1.73 m²; this hemodynamic change is reversible and does not indicate kidney injury 4, 5.
Do not reduce the dose below 10 mg for cardiovascular or renal indications; all outcome trials used the fixed 10 mg dose 5, 7.
Integration with Other Therapies
Continue ACE inhibitors or ARBs unchanged when starting empagliflozin; more than 99% of trial participants were on renin-angiotensin system blockers, and the combination provides additive renal protection 5.
If the patient is on diuretics, consider a modest dose reduction at initiation to avoid excessive volume depletion, especially given his age of 70 years 3, 5.