Empagliflozin in Diabetic CKD Stage 2 Without Albuminuria

Introduction to Empagliflozin Recommendations

The American Diabetes Association and Kidney Disease: Improving Global Outcomes (KDIGO) recommend SGLT2 inhibitors for patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m² and urine albumin ranging from normal to 200 mg/g creatinine (Class I, Level A recommendation) 2
The American College of Cardiology gives a Class I recommendation for SGLT2 inhibitors in patients with CKD and type 2 diabetes to reduce the risk of major adverse cardiovascular events 3

The FDA-approved dose of empagliflozin is 10 mg once daily, and no dose adjustment is required for patients with CKD stage 2 (eGFR 60-89 mL/min/1.73 m²) 1
Assess eGFR before initiating empagliflozin and periodically thereafter, and continue monitoring eGFR at least annually when ≥60 mL/min/1.73 m² 2

Before initiating empagliflozin, assess for volume contraction and correct volume status if indicated, particularly in elderly patients or those on concurrent diuretics 1
Educate patients to withhold empagliflozin during acute illness, particularly with reduced oral intake, fever, vomiting, or diarrhea, to prevent diabetic ketoacidosis 1, 5
Counsel patients about genital mycotic infections, which occur in approximately 6% of patients on SGLT2 inhibitors versus 1% on placebo 1

Do not discontinue empagliflozin if eGFR falls below 60 mL/min/1.73 m² during treatment, as cardiovascular and renal protective benefits persist even when glycemic efficacy is reduced 1, 5
Continue empagliflozin even if eGFR falls below 45 mL/min/1.73 m² during treatment, unless the patient is not tolerating therapy or requires kidney replacement therapy 1

If the patient is on insulin and HbA1c is well-controlled at baseline, reduce total daily insulin dose by approximately 20% when initiating empagliflozin 4
Consider weaning or stopping sulfonylureas or glinides to prevent hypoglycemia, as empagliflozin adds glucose-lowering effect 4