Published: 3 December 2020
Publications
Spotlight on empagliflozin
Published: 3 December 2020
Prescriber Update 41(4): 66
December 2020
The Spotlight series continues with this article on empagliflozin.
PHARMAC is considering funding empagliflozin (Jardiance) and empagliflozin
+ metformin (Jardiamet).
Mechanism of action
Empagliflozin is a sodium glucose co-transporter 2 (SGLT2) inhibitor, it is indicated as a complement to diet and exercise for the improvement of glycaemic control in type 2 diabetes. SGLT2 is the main transporter that mediates reabsorption of glucose in the kidneys, from the glomerular filtrate back into the circulation. Empagliflozin improves glycaemic control by competitively inhibiting SGLT2, thereby reducing renal glucose reabsorption.1
Empagliflozin can be used as monotherapy or in combination with other glucose lowering medicines. It is also indicated in patients with type 2 diabetes and established cardiovascular disease to reduce the risk of cardiovascular death.1
Considerations for use
Diabetic ketoacidosis
Serious cases of diabetic ketoacidosis (DKA) have been reported in patients taking SGLT2 inhibitors, including empagliflozin.2 In some of these cases, blood glucose was only slightly increased.
DKA should be considered in the event of non-specific symptoms such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, or unusual fatigue or sleepiness, regardless of blood glucose level. Advise patients to seek immediate medical attention if they experience any of these symptoms.2 If DKA is suspected, discontinue treatment with empagliflozin, evaluate the patient and initiate treatment.1
Monitoring of ketones should be considered in situations where DKA is a risk, such as fasting prior to surgery.1
Necrotising fasciitis of the perineum
Cases of necrotising fasciitis of the perineum (Fournier’s gangrene) have been reported in patients taking SGLT2 inhibitors, including empagliflozin. This risk of this rare but life-threatening infection should be evaluated in patients presenting with pain, redness or swelling in the genital or perineal area, fever or malaise.1
Adequate renal function
The glucose-lowering action of empagliflozin requires adequate renal function. Renal function should be monitored prior to initiation, at least yearly during treatment, and before and after starting medicines that may reduce renal function. Empagliflozin is contraindicated in patients with severely impaired renal function (an eGFR less than 30 mL/min/1.73 m2 or CrCl less than 30 mL/min).1
Interactions
Empagliflozin may increase the diuretic effect of thiazide or loop diuretics.1
Concomitant use with insulin or sulfonylureas may increase the risk of hypoglycaemia. A lower dose of insulin or sulfonylureas may be required.1
Adverse drug reactions
The most commonly reported adverse reactions are hypoglycaemia (when used with insulin or a sulfonylurea), genital infections, urinary tract infection, itch, allergic skin reactions, increased urination, thirst and increased serum lipids.1
More information
See the medicine data sheets for full prescribing information, available on the Medsafe website.
See also ‘SGLT2 Inhibitors and Diabetic Ketoacidosis’ in the December 2015 edition of Prescriber Update.
References
- Boehringer Ingelheim (NZ) Limited. 2015. Jardiance New Zealand Data Sheet December 2019. URL: medsafe.govt.nz/profs/Datasheet/j/jardiancetab.pdf (accessed 22 September 2020).
- Medsafe. 2015. SGLT2 inhibitors and diabetic ketoacidosis. Prescriber Update 36(4): 57–8. URL: medsafe.govt.nz/profs/PUArticles/December2015/SGLT2InhibitorsAndDiabeticKetoacidosis.htm (accessed 22 September 2020).
