What is the estimated glomerular filtration rate (eGFR) cutoff for initiating or continuing Jardiance (empagliflozin) in patients with type 2 diabetes?

eGFR Cutoff for Jardiance (Empagliflozin)

For cardiovascular or renal protection, initiate Jardiance at 10 mg once daily when eGFR is ≥20 mL/min/1.73 m²; for glycemic control, initiate only when eGFR is ≥45 mL/min/1.73 m². 1

Initiation Thresholds by Clinical Indication

Cardiovascular and Renal Protection

• Start Jardiance 10 mg daily when eGFR ≥20 mL/min/1.73 m² for patients with type 2 diabetes, heart failure, or chronic kidney disease, regardless of whether additional glucose lowering is needed. 1
• The 2025 guideline update lowered the initiation threshold from 25 to 20 mL/min/1.73 m² based on evidence that cardiorenal benefits persist at very low kidney function. 1
• Use the fixed 10 mg dose for all cardiovascular and renal indications—titration to 25 mg provides no additional mortality or cardiovascular benefit. 1, 2

Glycemic Control in Type 2 Diabetes

• Initiate Jardiance only when eGFR ≥45 mL/min/1.73 m² if the primary goal is glucose lowering. 1, 3
• Start with 10 mg once daily; after 4–12 weeks, increase to 25 mg daily only if HbA1c remains above target and eGFR remains ≥45 mL/min/1.73 m². 1
• Below 45 mL/min/1.73 m², glucose-lowering efficacy is markedly reduced due to decreased renal glucose excretion, making initiation for glycemic control inappropriate. 1, 4

Continuation Thresholds

eGFR (mL/min/1.73 m²)	Action	Rationale
≥45	Continue current dose (10 or 25 mg)	Full glucose-lowering and cardiorenal efficacy maintained [1]
30–44	Continue 10 mg daily	Glucose-lowering effect reduced, but cardiovascular and renal benefits persist [1,5]
20–29	Continue 10 mg daily	Minimal glycemic benefit, but cardiorenal protection remains [1]
<20	May continue 10 mg until dialysis if already established	Initiation not recommended; continuation may still confer CV benefit [1]

• Do not discontinue Jardiance when eGFR falls below 45 mL/min/1.73 m²—cardiovascular death reduction (38%), heart failure hospitalization reduction (35%), and renal protection (39% reduction in incident or worsening nephropathy) persist at lower kidney function. 1, 6, 5
• The FDA label explicitly states that dose modifications are driven by glucose-lowering efficacy, not safety, and cardiovascular benefits continue down to eGFR 30 mL/min/1.73 m² with the 10 mg dose. 1

Evidence for Cardiorenal Protection Across eGFR Ranges

• In EMPA-REG OUTCOME, empagliflozin reduced cardiovascular death by 38% (HR 0.62) and all-cause mortality by 32% (HR 0.68) in patients with type 2 diabetes and established cardiovascular disease. 1
• Among patients with prevalent kidney disease (eGFR <60 mL/min/1.73 m² and/or urine albumin-creatinine ratio >300 mg/g), empagliflozin reduced cardiovascular death by 29%, all-cause mortality by 24%, and heart failure hospitalization by 39%. 5
• The drug lowered the risk of incident or worsening nephropathy by 39% (HR 0.61), including a 44% reduction in doubling of serum creatinine. 1, 6
• Effects on cardiovascular and renal outcomes were consistent across baseline eGFR categories (<45–<60–<90, ≥90 mL/min/1.73 m²). 5

Dose Selection: 10 mg vs 25 mg

• Both 10 mg and 25 mg doses produced identical reductions in cardiovascular death, heart failure hospitalization, and major adverse cardiovascular events in EMPA-REG OUTCOME, indicating no dose-response relationship for cardiorenal protection. 1, 2
• The 25 mg dose increases genital mycotic infections (6% vs 4% with 10 mg) and volume depletion risk, particularly in elderly patients or those with reduced renal function. 1
• For cardiovascular or renal protection, use 10 mg daily as the fixed dose—do not escalate to 25 mg, as the higher dose offers no additional benefit and raises adverse-event risk. 1, 2

Common Pitfalls to Avoid

• Do not stop Jardiance solely because eGFR falls below 45 mL/min/1.73 m²; cardiovascular and renal benefits persist despite loss of glycemic efficacy. 1
• Do not discontinue in response to the expected early eGFR dip (3–5 mL/min/1.73 m²) within the first 2–4 weeks; this hemodynamic change is reversible and protective. 1
• Do not increase from 10 mg to 25 mg for cardiovascular or renal protection, as the higher dose provides no additional mortality or cardiovascular benefit. 1, 2
• Do not initiate Jardiance for glycemic control when eGFR <45 mL/min/1.73 m², as glucose-lowering efficacy is minimal at lower kidney function. 1, 3

Safety Precautions

• Hold Jardiance ≥3 days before major surgery or any procedure requiring prolonged fasting to avoid postoperative euglycemic ketoacidosis. 1
• Temporarily discontinue during acute illnesses with reduced oral intake, fever, vomiting, or diarrhea to prevent volume depletion and ketoacidosis. 1
• Assess and correct volume status before initiation; consider reducing concurrent diuretic doses, especially in elderly patients or those on loop diuretics. 1
• Genital mycotic infections occur in ~4% (10 mg) and ~6% (25 mg) versus 1% with placebo; good daily hygiene mitigates risk. 1

Monitoring Recommendations

• Check eGFR at baseline, then 1–2 weeks after initiation to document the expected hemodynamic dip. 1
• Monitor eGFR every 3–6 months if eGFR 30–59 mL/min/1.73 m²; annually if eGFR ≥60 mL/min/1.73 m². 1
• Intensively monitor blood glucose for the first 2–4 weeks, especially when combined with insulin or sulfonylureas. 1