Empagliflozin Use in Adults with Type 2 Diabetes

Primary Indications and Patient Selection

The American College of Physicians recommends adding empagliflozin to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control, with strong prioritization for patients with heart failure or chronic kidney disease to reduce all-cause mortality, major adverse cardiovascular events, and progression of kidney disease 1, 2
Empagliflozin should be added to metformin when HbA1c remains between 7-8% despite metformin and lifestyle modifications, or when the patient has established cardiovascular disease, heart failure, or chronic kidney disease 1, 2, 3
The American Heart Association prioritizes empagliflozin specifically in patients with congestive heart failure or chronic kidney disease as the primary indication, or in those with established cardiovascular disease requiring mortality reduction 1, 2

Empagliflozin is superior to DPP-4 inhibitors for reducing morbidity and all-cause mortality, and to sulfonylureas and long-acting insulins for reducing all-cause mortality and morbidity 1, 2, 3
A GLP-1 agonist may be chosen instead of empagliflozin in patients with increased stroke risk, or in those for whom total body weight loss is the primary treatment goal 1, 2

For children aged 10-17 years with type 2 diabetes, empagliflozin 10 mg daily is now approved and demonstrated significant A1C reduction of 0.84% compared to placebo 6
No episodes of severe hypoglycemia occurred in pediatric trials, and dose escalation to 25 mg may be considered if A1C remains ≥7.0% after 12 weeks 6

The American Diabetes Association aims for HbA1c between 7-8% in most adults with type 2 diabetes, with deintensification of pharmacologic treatments if HbA1c falls below 6.5% 1, 2, 3
HbA1c goals should be individualized based on hypoglycemia risk, life expectancy, diabetes duration, established vascular complications, and major comorbidities 1, 2, 3

The European Association for the Study of Diabetes recommends reducing hypoglycemia risk by decreasing sulfonylurea or glinide doses when adding empagliflozin, and reducing total daily insulin dose by approximately 20% 4
No adjustment is needed for metformin or DPP-4 inhibitors, which have a low hypoglycemia risk 4

Ongoing monitoring should include rechecking eGFR within 1-2 weeks after initiation, then every 3-6 months if eGFR 45-59 mL/min/1.73 m², as well as monitoring for genital infections and educating patients on hygiene measures 5
Self-monitoring of blood glucose may be unnecessary in patients on metformin plus empagliflozin alone 1, 2