Empagliflozin (Jardiance) should not be used in patients with type 1 diabetes.
Diabetic ketoacidosis: Cases of diabetic ketoacidosis (DKA), a serious life-threatening condition requiring urgent hospitalization, have been reported in patients treated with empagliflozin, including fatal cases. In a number of reported cases, the presentation of the condition was atypical with only moderately increased blood glucose values, below 14 mmol/L (250 mg/dL).
The risk of diabetic ketoacidosis must be considered in the event of non-specific symptoms such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness.
Patients should be assessed for ketoacidosis immediately if these symptoms occur, regardless of blood glucose level. If ketoacidosis is suspected, Empagliflozin (Jardiance) should be discontinued, patient should be evaluated, and prompt treatment should be instituted.
Patients who may be at higher risk of ketoacidosis while taking Empagliflozin (Jardiance) include patients on a very low carbohydrate diet (as the combination may further increase ketone body production), patients with an acute illness, pancreatic disorders suggesting insulin deficiency (e.g., type 1 diabetes, history of pancreatitis or pancreatic surgery), insulin dose reduction (including insulin pump failure), alcohol abuse, severe dehydration, and patients with a history of ketoacidosis. Empagliflozin (Jardiance) should be used with caution in these patients. When reducing the insulin dose (see Dosage & Administration), caution should be taken. In patients treated with Empagliflozin (Jardiance) consider monitoring for ketoacidosis and temporarily discontinuing Empagliflozin (Jardiance) in clinical situations known to predispose to ketoacidosis (e.g. prolonged fasting due to acute illness or surgery).
Use in patients with renal impairment: Empagliflozin (Jardiance) is contraindicated for use in patients with persistent eGFR < 45 mL/min/1.73m2 (see Patients with renal impairment under Dosage & Administration and Contraindications).
Monitoring of renal function: Due to the mechanism of action, the efficacy of Empagliflozin (Jardiance) is dependent on renal function. Therefore assessment of renal function is recommended: prior to empagliflozin initiation and periodically during treatment, i.e. at least yearly; prior to initiation of concomitant medicines that may reduce renal function and periodically thereafter.
Empagliflozin (Jardiance) should be discontinued when the eGFR is persistently below 45 mL/min/1.73m2 or CrCl < 45 mL/min (see Contraindications).
Use in patients at risk for volume depletion: Based on the mode of action of SGLT2 inhibitors, osmotic diuresis accompanying therapeutic glucosuria may lead to a modest decrease in blood pressure. Therefore, caution should be exercised in patients for whom an empagliflozin-induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on anti-hypertensive therapy with a history of hypotension or patients aged 75 years and older. In case of conditions that may lead to fluid loss (e.g. gastrointestinal illness), careful monitoring of volume status (e.g. physical examination, blood pressure measurements, laboratory tests including haematocrit) and electrolytes is recommended for patients receiving empagliflozin. Temporary interruption of treatment with Empagliflozin (Jardiance) should be considered until the fluid loss is corrected.
Urinary tract infections: In the pooled placebo-controlled double-blind trials of 18 to 24 weeks duration, the overall frequency of urinary tract infection reported as adverse event was higher than placebo in patients treated with empagliflozin 10 mg and similar to placebo in patients treated with empagliflozin 25 mg (see Side Effects). Post-marketing cases of complicated urinary tract infections including pyelonephritis and urosepsis have been reported in patients treated with empagliflozin. Temporary interruption of Empagliflozin (Jardiance) should be considered in patients with complicated urinary tract infections.
Driving and using machines: No studies on the effects on the ability to drive and use machines have been performed.
Use in Elderly: Patients aged 75 years and older may be at increased risk of volume depletion, therefore, Empagliflozin (Jardiance) should be prescribed with caution in these patients (see Side Effects). Therapeutic experience in patients aged 85 years and older is limited. Initiation of Empagliflozin (Jardiance) therapy in this population is not recommended.