Can empagliflozin (Jardiance) be prescribed for a patient with type 2 diabetes, hemoglobin A1c 10.7% on metformin 1000 mg twice daily, mild hepatic enzyme elevation, mild thrombocytopenia, and a history of alcohol use disorder?

Can Jardiance Be Prescribed for This Patient?

Yes, empagliflozin (Jardiance) can be prescribed for this patient with elevated liver enzymes, mild thrombocytopenia, and alcoholism history, but only after addressing volume status and ensuring eGFR ≥45 mL/min/1.73 m².

Critical Safety Assessment Before Initiation

Volume status and renal function must be evaluated first. Empagliflozin causes intravascular volume contraction and symptomatic hypotension may occur after initiation, particularly in patients with renal impairment, elderly patients, those with low systolic blood pressure, and patients on diuretics 1. Before initiating Jardiance, assess for volume contraction and correct volume status if indicated 1.

• Check eGFR immediately: Jardiance should not be initiated in patients with eGFR <45 mL/min/1.73 m² and is contraindicated when eGFR <30 mL/min/1.73 m² 1.
• Assess hydration status: History of alcoholism increases risk of volume depletion; correct any dehydration before starting therapy 1.
• Verify liver enzymes are stable: While elevated transaminases are not a contraindication, empagliflozin may be hepatotoxic and requires monitoring 2.

Why This Patient Needs Treatment Intensification

With HbA1c 10.7% on metformin 1000 mg twice daily, immediate dual therapy is required. The American Diabetes Association recommends initiating insulin (with or without additional agents) when HbA1c ≥10% because monotherapy cannot achieve adequate control 3. However, empagliflozin offers a compelling alternative or adjunct given its cardiovascular and renal protective benefits independent of glucose lowering 4, 5.

• Metformin should be optimized first: Increase to 2000 mg daily (1000 mg twice daily) if tolerated and eGFR permits, as this provides maximal glucose-lowering effect 3.
• Expected HbA1c reduction with empagliflozin: Adding empagliflozin to metformin yields approximately 0.5–0.8% additional HbA1c reduction 2, 6.
• This patient will likely need triple therapy: Given HbA1c 10.7%, metformin plus empagliflozin alone will be insufficient; plan to add either a GLP-1 receptor agonist or basal insulin within 3 months 3.

Specific Contraindications to Rule Out

Empagliflozin is contraindicated only in severe renal impairment (eGFR <30 mL/min/1.73 m²), end-stage renal disease, dialysis, or history of serious hypersensitivity 1. Neither elevated liver enzymes nor mild thrombocytopenia appear in the contraindication list.

• Hepatic impairment: No dose adjustment is required for hepatic impairment; empagliflozin can be used 6.
• Thrombocytopenia: Not listed as a contraindication or precaution in FDA labeling 1.
• Alcohol use disorder: Not a contraindication, but increases risk of ketoacidosis and volume depletion 1.

Critical Warnings for This Patient Population

Ketoacidosis risk is elevated in patients with alcohol abuse. Reports of ketoacidosis, including fatal cases, have been identified in patients taking empagliflozin 1. Before initiating Jardiance, consider factors that may predispose to ketoacidosis including alcohol abuse 1.

• Educate on ketoacidosis symptoms: Nausea, vomiting, abdominal pain, generalized malaise, and shortness of breath—even with glucose <250 mg/dL 1, 7.
• Temporarily discontinue during illness: Stop empagliflozin during prolonged fasting, acute illness, surgery, or excessive alcohol intake 1.
• Monitor for euglycemic DKA: This patient presented with DKA despite only mild hyperglycemia (glucose 200 mg/dL) while on empagliflozin 7.

Acute kidney injury risk is increased with volume depletion. There have been postmarketing reports of acute kidney injury in patients receiving SGLT2 inhibitors, some requiring hospitalization and dialysis 1. Consider temporarily discontinuing empagliflozin in any setting of reduced oral intake or fluid losses; monitor for signs of acute kidney injury 1.

Cardiovascular and Renal Benefits That Justify Use

Despite the safety concerns, empagliflozin provides mortality benefit in high-risk patients. In the EMPA-REG OUTCOME trial involving 7,020 patients with type 2 diabetes and cardiovascular disease, overall mortality was lower with empagliflozin (5.7% vs 8.3%, p<0.001), mainly due to reduction in cardiovascular mortality from heart failure 2, 5.

• Cardiovascular death reduction: 38% relative risk reduction in cardiovascular death 4, 8.
• Heart failure hospitalization: Significant reduction in heart failure admissions 4, 2.
• Renal protection: Empagliflozin reduces progression of diabetic kidney disease 8.
• These benefits are independent of glucose lowering: The mortality benefit appeared within months and was not related to HbA1c reduction 2.

Practical Implementation Protocol

Start empagliflozin 10 mg once daily in the morning, taken with or without food 1. In patients tolerating empagliflozin, the dose may be increased to 25 mg 1.

1. Baseline assessment:

   • Measure eGFR, electrolytes, liver enzymes, platelet count
   • Assess volume status and blood pressure
   • Screen for genital/urinary infections
   • Counsel on ketoacidosis warning signs 1

2. Concurrent metformin optimization:

   • Increase metformin to 2000 mg daily if not already at this dose 3
   • Never discontinue metformin when adding empagliflozin 3

3. Monitoring schedule:

   • Recheck HbA1c at 3 months 3
   • Monitor renal function periodically; more frequent monitoring if eGFR <60 mL/min/1.73 m² 1
   • Assess for genital infections (most common adverse effect) 2, 6

4. Plan for intensification:

   • If HbA1c remains >7% after 3 months, add GLP-1 receptor agonist (preferred) or basal insulin 3
   • Expected outcome: HbA1c reduction to approximately 9.9–10.2% with empagliflozin alone, requiring third agent 2, 6

Common Pitfalls to Avoid

• Do not start empagliflozin if eGFR <45 mL/min/1.73 m²: This is an absolute threshold for initiation 1.
• Do not ignore volume status: Correct dehydration before starting therapy, especially in patients with alcohol use disorder 1.
• Do not discontinue during acute illness without cause: Temporarily stop during prolonged fasting, surgery, or severe illness to prevent ketoacidosis 1.
• Do not rely on empagliflozin alone for glycemic control: With HbA1c 10.7%, this patient will need triple therapy (metformin + empagliflozin + GLP-1 RA or insulin) 3.
• Do not overlook genital infection risk: Empagliflozin increases risk of genital mycotic infections; counsel on hygiene and early treatment 2, 6.
• Do not assume normal glucose excludes ketoacidosis: Euglycemic DKA can occur with empagliflozin; maintain high clinical suspicion if symptoms develop 1, 7.