Empagliflozin Therapy Considerations

Patient Selection and Monitoring

The American College of Cardiology recommends continuing empagliflozin in patients with moderate renal impairment (eGFR 30-44 mL/min/1.73 m²) for cardiovascular and renal protection, even though glucose-lowering efficacy is minimal 4, 1
Empagliflozin can be continued in patients with severe renal impairment (eGFR as low as 20 mL/min/1.73 m²) for cardiovascular and renal protection, with a 28% reduction in progression of kidney disease or cardiovascular death (HR 0.72, 95% CI 0.64-0.82) 4, 1
The American College of Cardiology suggests monitoring eGFR at least every 3-6 months when eGFR is 45-59 mL/min/1.73 m², or annually if eGFR ≥60 mL/min/1.73 m² 1, 3
Assess for genital mycotic infections (occur in ~6% vs 1% placebo), which should prompt treatment but NOT discontinuation 1, 2

Do NOT discontinue empagliflozin when eGFR drops below 45 mL/min/1.73 m² in patients already taking it, as cardiovascular death or heart failure hospitalization reduction and kidney protection continue at lower eGFR levels 1, 2
Temporarily discontinue empagliflozin during any acute illness with reduced food/fluid intake, particularly with fever, vomiting, or diarrhea, to prevent diabetic ketoacidosis and volume depletion 3
Withhold empagliflozin at least 3 days before major surgery or procedures requiring prolonged fasting to prevent postoperative euglycemic ketoacidosis 1, 3
Hold empagliflozin if there is evidence of severe hypovolemia with hypotension that persists after diuretic dose reduction 4, 3

Never hold empagliflozin in heart failure with reduced ejection fraction (HFrEF) patients due to renal function alone, as EMPEROR-Reduced showed consistent benefits in reducing cardiovascular death or HF hospitalization (HR 0.78 in CKD patients, HR 0.72 in non-CKD patients) regardless of baseline kidney function 4, 1
Check eGFR and creatinine within 1-2 weeks after initiation, and if eGFR decreases >30% from baseline AND there are signs of hypovolemia, reduce diuretic doses first before considering empagliflozin adjustment 4, 3