Empagliflozin with metformin

How it works

Empagliflozin increases urinary glucose excretion through SGLT2 inhibition, while metformin reduces hepatic glucose production and improves peripheral insulin sensitivity.

Prescribing in practice

• The most important safety point is risk of euglycaemic diabetic ketoacidosis from empagliflozin and lactic acidosis from metformin; withhold during acute illness, dehydration, sepsis, or surgery (sick-day rules) and avoid in significant renal impairment.
• Empagliflozin predisposes to genital mycotic and urinary infections and rare Fournier's gangrene, and volume depletion may occur, particularly in the elderly or those on diuretics.
• Both components have renal-function thresholds governing initiation and continuation, so confirm renal function before starting and periodically thereafter.

Monitoring

Monitor renal function, HbA1c, volume status and weight, with vigilance for ketoacidosis even when blood glucose is near-normal.

Counselling the patient

• Stop the tablets and seek urgent advice if you become acutely unwell, dehydrated, or develop nausea, vomiting, abdominal pain, or breathlessness.
• Maintain good genital hygiene and report any genital soreness or itching.
• Take with food to reduce stomach upset from the metformin component.

Evidence & guidelines

NICE recommends SGLT2 inhibitors in type 2 diabetes, with empagliflozin's cardiovascular and renal benefits shown in EMPA-REG OUTCOME and subsequent trials.