Empagliflozin Management During Acute Infection
Empagliflozin (Jardiance) should be temporarily withheld during acute illness when there is risk for dehydration or reduced oral intake, to lower the risk of euglycemic diabetic ketoacidosis. [1, 2]
Jardiance labeling specifically identifies acute febrile illness and prolonged fasting due to acute illness as situations that can predispose to ketoacidosis and supports temporary discontinuation/monitoring in such settings. [2]
Medication Hold Triggers During Infection
Temporary discontinuation of SGLT2 inhibitor therapy is recommended during acute illness when sick-day risk features are present. [1, 3]
Common hold triggers include the following:
- Reduced caloric intake or inability to maintain normal eating and drinking (including prolonged fasting during acute illness). [1, 2]
- Dehydration risk from poor fluid intake or volume depletion during illness. [1]
- Acute febrile illness associated with increased ketoacidosis risk. [2]
- Severe or complicated infection requiring clinical escalation (including urosepsis/pyelonephritis), when temporary discontinuation is specifically recommended in kidney guidance. [3]
When Reinitiation Is Appropriate
Reinitiation should occur after clinical recovery with resolution of the acute illness and ability to maintain normal oral intake and hydration. [1, 2]
Monitoring and Escalation for Ketoacidosis Risk
If ketoacidosis is suspected, Jardiance should be discontinued and urgent medical evaluation should be obtained. [2]
Ketoacidosis can occur even with normal or mildly elevated glucose levels with SGLT2 inhibitors, so monitoring should focus on symptoms and ketones when indicated by sick-day protocols. [1, 2]
Practical Sick-Day Approach
A sick-day protocol for SGLT2 inhibitors supports temporary withholding during acute illness while maintaining hydration and carbohydrate intake if possible. [1]
Common Pitfalls to Avoid
Continuing empagliflozin during acute illness with markedly reduced oral intake increases the risk of ketoacidosis-related complications. [1, 2]
Perioperative and High-Risk Context
Additional temporary discontinuation is recommended for other ketoacidosis-predisposing contexts (including surgery and fasting), reflecting the same risk mechanism that applies during acute infection with reduced intake. [2]
Clarification of “Infection” Scenarios
In most outpatient sick-day frameworks, any acute infection that meaningfully reduces oral intake or increases dehydration risk is treated as an indication to withhold the SGLT2 inhibitor temporarily. [1, 3]
If the infection is mild and oral intake and hydration remain normal, hold decisions should be aligned with the presence or absence of sick-day risk features described in the infection-management guidance. [1, 2]
Medication Safety Actions During the Hold
During temporary withholding, alternative diabetes management should be used to avoid hyperglycemia when needed, and clinicians should be contacted for individualized adjustment during prolonged illness. [1, 2]
When Immediate Medical Care Is Needed
Immediate medical evaluation is needed for suspected ketoacidosis, including symptoms consistent with ketoacidosis during SGLT2 inhibitor use. [2]