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SGLT2 Inhibitor Pregnancy: Avoid — animal studies show fetal harm; insufficient human data.

Empagliflozin (Elderly HFpEF/HFrEF)

Brand names: Jardiance

Adult dose

Dose: 10 mg oral once daily (HF indication — regardless of diabetes status)
Route: Oral
Frequency: Once daily
Max: 10 mg/day (HF); 25 mg/day (T2DM)
Geriatric HF first-line: EMPEROR-Reduced and EMPEROR-Preserved established empagliflozin as standard of care in both HFrEF and HFpEF. Particularly valuable in elderly HFpEF (no other evidence-based disease-modifying therapy prior to SGLT2i). Monitor for volume depletion in elderly (falls, hypotension).

Paediatric dose

Route:
Not licensed for HF indication in children.

Dose adjustments

Renal

eGFR ≥20 mL/min: standard dose (10 mg). eGFR <20: avoid (limited glycosuric efficacy, though renal protective effect may still occur — specialist decision). Dose not adjusted based on eGFR for HF indication.

Hepatic

Caution in severe hepatic impairment.

Clinical pearls

  • EMPEROR-Preserved (Anker et al. NEJM 2021): empagliflozin in HFpEF (EF ≥40%) — 21% reduction in CV death/HF hospitalisation; first drug to show benefit in HFpEF. Critically, benefit was irrespective of diabetes status — pure cardiac effect. HFpEF predominantly affects elderly women — this trial transformed geriatric heart failure management
  • EMPEROR-Reduced (Packer et al. NEJM 2020): empagliflozin in HFrEF — 25% reduction in CV death/HF hospitalisation. Renal protection was an additional benefit (slower eGFR decline).
  • Volume depletion in elderly: empagliflozin causes osmotic diuresis — in frail elderly patients on loop diuretics, this combination can cause excessive dehydration, AKI, and falls. NICE recommends monitoring fluid status and considering loop diuretic dose reduction when starting SGLT2i

Contraindications

  • eGFR <20 mL/min (insufficient data; avoid for glycaemic indication)
  • Type 1 diabetes (DKA risk)
  • Recurrent UTIs or urogenital infections

Side effects

  • Genital mycotic infections (candidiasis — commoner in women)
  • UTI (increased urinary glucose)
  • Polyuria/nocturia (volume depletion — significant in elderly)
  • DKA (rare, especially type 1 or peri-operative period)
  • Fournier's gangrene (rare necrotising fasciitis of perineum — MHRA 2019)
  • Lower limb amputation risk (dapagliflozin mainly — empagliflozin less clear)
  • Hypotension and falls in elderly (osmotic diuresis)

Interactions

  • Loop diuretics (additive volume depletion — monitor closely in elderly)
  • Insulin/sulfonylureas (hypoglycaemia risk when combined)
  • NSAIDs (worsens renal function — avoid in elderly on SGLT2i)

Monitoring

  • BP and hydration status (weekly initially in elderly frail patients)
  • eGFR and serum creatinine (at 1–2 weeks after initiation)
  • Blood glucose (if diabetic — hypoglycaemia risk with insulin/SU)
  • Genital/urinary symptoms
  • Signs of DKA (nausea, vomiting, abdominal pain — ketones on urinalysis)

Reference: BNFc; BNF 90; EMPEROR-Preserved (Anker et al. NEJM 2021); EMPEROR-Reduced (Packer et al. NEJM 2020); NICE NG106 Heart Failure Guidelines; ESC Heart Failure Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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