Empagliflozin

# Empagliflozin ## Overview SGLT2 inhibitor; reduces renal glucose reabsorption, inducing glucosuria. Also improves outcomes in heart failure and chronic kidney disease. ## Primary Indications - **Type 2 diabetes mellitus** (adjunct to diet/exercise; with or without metformin) - **Heart failure** (reduced or preserved ejection fraction) - **Chronic kidney disease** (with or without diabetes, to slow progression) ## Adult Dosing - **Standard**: 10 mg orally once daily - **Heart failure/CKD**: 10 mg once daily regardless of eGFR (if eGFR ≥20 mL/min/1.73 m² for initiation) - **Maximum**: 25 mg once daily (higher dose may be used for additional glycemic control if tolerated; note: 25 mg is approved in some regions, 10 mg standard for most indications) ## Pediatric Dosing - **No established pediatric dosing** as of current guidelines. Not approved for patients <18 years. - (Off-label use may be considered in some settings; consult local pediatric endocrinology protocols) ## Dose Adjustments - **Renal impairment**: Do not initiate if eGFR <30 mL/min/1.73 m² (except for heart failure benefit per some guidelines; check local protocol). No dose adjustment needed for eGFR ≥30. - **Hepatic impairment**: No adjustment for mild-moderate; not studied in severe. - **Discontinue** prior to scheduled surgery or prolonged fasting (avoid ketoacidosis risk). ## Contraindications - **History of diabetic ketoacidosis** - **Severe renal impairment** (eGFR <20-30), dialysis, or acute kidney injury - **Pregnancy/lactation** - **Active bladder cancer** (theoretical risk; see adverse effects) ## Adverse Effects - **Genitourinary infections** (Candida, UTI) - **Volume depletion/hypotension** (especially in elderly or diuretic use) - **Ketoacidosis** (euglycemic, even with normal glucose) - **Acute kidney injury** (rare) - **Lower limb amputation** (increased risk, especially with prior history) - **Bladder cancer** (rare; may be monitored) ## Key Drug Interactions - **Diuretics** (additive hypotension; consider dose reduction) - **Insulin/sulfonylureas** (hypoglycemia risk; dose adjustment may be needed) - **Lithium** (may increase lithium levels; monitor) - **NSAIDs** (may reduce efficacy; monitor renal function) ## Monitoring - **Renal function** (eGFR, creatinine) at baseline and periodically (especially if eGFR <45) - **Ketones** (if unexplained illness, fasting, or symptoms of DKA) - **Volume status** (signs of dehydration/hypotension) - **Signs of infection** (UTI, genital candidiasis) - **Amputation risk** (periodic foot exams; counsel on hygiene) ## Clinical Pearls - **Do not use for glycemic control in type 1 diabetes** (increased DKA risk). - **Hold before major surgery** (especially GI surgery) to prevent euglycemic DKA. - **Benefit in heart failure** independent of diabetes status. - **May reduce cardiovascular mortality** and slow CKD progression. --- **Educational Disclaimer:** This information is for educational purposes and may not reflect recent updates. Always verify with current local prescribing information (e.g., SmPC, FDA labeling) and consult clinical protocols before prescribing.