What is the maximum recommended dose of Jardiance (empagliflozin) for patients aged 10 years or older with type 2 diabetes, and how should dosing be adjusted for renal function, pregnancy, hepatic impairment, and missed doses?

Jardiance Maximum Dose

The maximum approved dose of Jardiance (empagliflozin) is 25 mg once daily for adults aged 10 years or older with type 2 diabetes, though the 10 mg dose provides equivalent cardiovascular and renal protection. 1

Standard Dosing Algorithm

• Start with 10 mg once daily for all adult patients with type 2 diabetes and eGFR ≥45 mL/min/1.73 m². 1

• Increase to 25 mg once daily only if additional glycemic control is needed after several weeks on the 10 mg dose. 1

• The 25 mg dose provides no additional cardiovascular or renal benefit beyond the 10 mg dose—the higher dose is purely for enhanced glucose lowering. 1

Renal Function Adjustments

• Do not initiate Jardiance if eGFR <45 mL/min/1.73 m² for glycemic control, as glucose-lowering efficacy is significantly reduced. 1

• For cardiovascular and renal protection, Jardiance 10 mg daily can be initiated when eGFR ≥20 mL/min/1.73 m², based on updated 2025 guidelines. 2

• Continue Jardiance even if eGFR falls below 45 mL/min/1.73 m² during treatment, as cardiovascular and renal benefits persist despite loss of glycemic efficacy. 1

• If eGFR falls below 20 mL/min/1.73 m² during treatment, continue 10 mg daily until dialysis is required. 2

Pregnancy and Breastfeeding

• Jardiance is contraindicated during pregnancy due to potential fetal harm. 2

• Discontinue Jardiance if pregnancy is detected. 2

• Avoid Jardiance during breastfeeding, as excretion in human milk is unknown. 2

Hepatic Impairment

• No dose adjustment is required for hepatic impairment of any severity—Jardiance is primarily renally eliminated. 1

Missed Dose Management

• If a dose is missed, take it as soon as remembered on the same day. 1

• Do not double the dose the next day to make up for a missed dose. 1

• Resume the regular once-daily schedule the following day. 1

Concomitant Medication Adjustments

• Reduce insulin dose by approximately 20% when starting Jardiance if baseline HbA1c is <8.5% to prevent hypoglycemia. 2

• Discontinue sulfonylureas when starting Jardiance if baseline HbA1c is <8.5%, as the combination increases hypoglycemia risk without additional cardiovascular benefit. 2

• Consider reducing loop or thiazide diuretic doses at initiation to avoid excessive volume depletion, especially in elderly patients. 2

• Continue ACE inhibitors or ARBs unchanged when starting Jardiance—no dose adjustment is needed. 2

Critical Safety Precautions

• Withhold Jardiance at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative ketoacidosis. 1

• Temporarily discontinue during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent volume depletion and euglycemic diabetic ketoacidosis. 2

• Maintain at least low-dose insulin in insulin-requiring patients even when Jardiance is held during illness, as complete insulin cessation increases ketoacidosis risk. 1

• Monitor for euglycemic diabetic ketoacidosis even with normal blood glucose levels—instruct patients to seek immediate care for unexplained malaise, nausea, vomiting, or abdominal pain. 2

Common Pitfalls to Avoid

• Do not escalate to 25 mg for cardiovascular or renal protection—all outcome trials used the 10 mg dose, and higher doses provide no additional benefit for these indications. 1

• Do not discontinue Jardiance solely because eGFR falls below 45 mL/min/1.73 m²—cardiovascular and renal benefits persist at lower eGFR levels. 1

• Do not stop Jardiance in response to the expected early eGFR dip of 2–5 mL/min/1.73 m² within the first 2–4 weeks—this change is hemodynamic and reversible, not indicative of kidney injury. 2

• Genital mycotic infections occur in approximately 6% of patients versus 1% with placebo—counsel patients on daily hygiene to reduce risk. 1