empagliflozin
SGLT2 inhibitor· Brands: JardiancePO
Mechanism of action
Empagliflozin inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal renal tubule, reducing glucose reabsorption and increasing urinary glucose excretion. This lowers blood glucose independently of insulin. It also enhances sodium delivery to the distal nephron, increasing osmotic diuresis and natriuresis, which contributes to its beneficial effects on cardiovascular and renal outcomes.
Pharmacokinetics
Empagliflozin is well absorbed orally, with absolute bioavailability of approximately 68%, and peak plasma concentrations about 1.5 hours after dosing.
Indications & dosing
Type 2 diabetes mellitus
Usually started at 10 mg daily; may be increased to 25 mg if glycaemic control inadequate.
- adult · PO: 10–25 mg once daily · Usually started at 10 mg daily; may be increased to 25 mg if glycaemic control inadequate.
Heart failure (with reduced or preserved ejection fraction)
Used in patients with heart failure regardless of diabetes status.
- adult · PO: 10 mg once daily · Used in patients with heart failure regardless of diabetes status.
Chronic kidney disease
Slows progression of kidney disease in patients with or without diabetes.
- adult · PO: 10 mg once daily · Slows progression of kidney disease in patients with or without diabetes.
Contraindications & precautions
- Hypersensitivity to empagliflozin or any excipient
- Type 1 diabetes · Not indicated; increased risk of diabetic ketoacidosis
- Severe renal impairment (eGFR <30 mL/min/1.73m²) in type 2 diabetes · For heart failure, use only if eGFR ≥20 mL/min/1.73m²
- Pregnancy and breastfeeding · Not recommended; limited data
- Assess renal function before initiation and periodically; avoid in type 2 diabetes if eGFR falls below 30 mL/min/1.73m².
- Monitor for diabetic ketoacidosis; discontinue if suspected, even if blood glucose is normal.
- Correct volume depletion before starting; use caution in conditions that increase risk of dehydration.
- Advise on the risk of genital infections and appropriate hygiene measures.
- Temporarily discontinue before major surgery or during acute serious illness to reduce ketoacidosis risk.
Adverse effects
- Genital mycotic infections (e.g. candidiasis)
- Urinary tract infection
- Polyuria
- Volume depletion and hypotensionserious
- Diabetic ketoacidosis (euglycaemic)serious
- Fournier's gangrene (necrotising fasciitis of perineum)serious
- Acute kidney injuryserious
- Hypoglycaemia (when used with insulin or sulfonylureas)
Renal & hepatic adjustment
- eGFR 45+: No dosage adjustment required.
- eGFR 30–44: For type 2 diabetes, not recommended to initiate therapy; if already receiving, continue with regular monitoring of renal function. For heart failure or chronic kidney disease, no adjustment required.
- eGFR 20–29: For type 2 diabetes, not recommended. For heart failure or chronic kidney disease, use with caution; can be continued if eGFR is >= 20 mL/min.
- eGFR 0–19: Avoid for all indications; discontinue if eGFR falls below 20 mL/min. (avoid)
Monitoring, pregnancy & toxicity
- eGFR (renal function) · Baseline and at least annually, or more frequently if declining.
- Blood pressure · At each visit, especially in patients with volume depletion or on antihypertensives.
- Signs and symptoms of ketoacidosis · Advise patient to seek medical attention if unwell, with nausea, vomiting, abdominal pain, or breathing difficulties.
- Genital mycotic infections · Assess for symptoms; treat as required.
- Blood glucose and HbA1c · In patients with diabetes, regularly monitor glycaemic control.
- Volume status · Assess for dehydration, especially during periods of reduced fluid intake or concurrent diuretic use.
- Pregnancy: Not recommended during pregnancy. Discontinue if pregnancy is planned or occurs. Insufficient human data; possible adverse effects on fetal renal development based on animal studies.
- Toxicity: Dehydration and hypotension, especially with concurrent diuretic therapy or reduced fluid intake. · Supportive care: replace fluids and electrolytes, monitor blood pressure and renal function.
- Toxicity: Euglycaemic ketoacidosis, a rare but serious adverse event that can occur even with normal glucose levels. · Recognize early, discontinue drug, treat with insulin and dextrose, and monitor ketones and acid-base status.
Clinical notes
Empagliflozin is used in type 2 diabetes for glycaemic control, and in heart failure with reduced ejection fraction and chronic kidney disease to reduce cardiovascular and renal risk. It can cause genital mycotic infections, urinary tract infections, and volume depletion, particularly in older patients. There is a risk of euglycaemic diabetic ketoacidosis, especially with intercurrent illness or dose reduction. Avoid in type 1 diabetes. Monitor renal function and advocate sick-day rules. Doses: 10 mg or 25 mg once daily; adjust according to eGFR and indications.
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BNF; local formulary; Summary of Product Characteristics