What is the lowest dose of Jardiance (empagliflozin) that can be prescribed?

Lowest Dose of Jardiance (Empagliflozin)

The lowest dose of Jardiance that can be prescribed is 10 mg once daily, taken orally in the morning with or without food. 1

FDA-Approved Dosing

• The recommended starting dose is 10 mg once daily. 1
• For patients requiring additional glycemic control, the dose may be increased to 25 mg once daily after tolerating the 10 mg dose. 1
• No lower dose formulation (e.g., 5 mg) exists for empagliflozin, unlike dapagliflozin which is available in a 5 mg formulation. 2

Evidence-Based Dosing for Cardiovascular and Renal Protection

• The 10 mg dose is the evidence-based dose tested in major cardiovascular and heart failure outcomes trials (EMPA-REG OUTCOME, EMPEROR-Reduced, EMPEROR-Preserved). 3, 4
• Because there is no evidence of a graded dose-response regarding cardiovascular and renal effects, SGLT2 inhibitors with cardiovascular benefit should be initiated at the lowest dose tested in cardiovascular and renal outcomes trials—which for empagliflozin is 10 mg. 3
• No further dose titration is needed for cardiovascular or renal risk reduction, though dose increases to 25 mg may provide additional glucose reduction if indicated. 3

Renal Function Considerations for the 10 mg Dose

• Empagliflozin 10 mg may be initiated when eGFR is ≥45 mL/min/1.73 m² for all indications (glycemic control, cardiovascular death reduction, heart failure). 1, 3
• Do not initiate empagliflozin when eGFR is <45 mL/min/1.73 m², as this violates FDA labeling and guideline recommendations. 1, 5
• For glycemic control specifically, use is not recommended when eGFR is <30 mL/min/1.73 m² because the glucose-lowering effect is diminished due to reduced glomerular filtration. 1
• For heart failure indications, insufficient data exist to support dosing recommendations when eGFR is <20 mL/min/1.73 m². 1
• Empagliflozin is contraindicated in patients on dialysis. 1

Clinical Pearls

• The 10 mg dose provides robust cardiovascular and renal protection across the full spectrum of heart failure (HFrEF and HFpEF) and in patients with type 2 diabetes and established cardiovascular disease. 6, 7, 8
• In the EMPEROR trials, 10 mg daily was the sole dose studied and demonstrated significant reductions in heart failure hospitalization and cardiovascular death. 6
• Starting at 10 mg minimizes the risk of volume depletion, hypotension, and genital mycotic infections while delivering full cardioprotective benefit. 3
• The acute eGFR dip of approximately 2 mL/min/1.73 m² (6% reduction) in the first 2 months is expected and reversible; it does not indicate kidney injury. 9

Common Pitfalls

• Do not attempt to prescribe a dose lower than 10 mg—no such formulation exists, and splitting tablets is not recommended. 1
• Do not withhold the 10 mg dose in patients with eGFR 45–60 mL/min/1.73 m² who have heart failure or established cardiovascular disease, as this population derives significant benefit. 1, 9
• Avoid initiating empagliflozin at eGFR <45 mL/min/1.73 m²; if an SGLT2 inhibitor is desired in this range, dapagliflozin (which can be started at eGFR ≥25 mL/min/1.73 m²) is the appropriate choice. 5