Started for diabetes, increasingly prescribed for the heart and kidneys instead — with sick day rules that genuinely matter.
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Empagliflozin is an SGLT2 inhibitor. It blocks the transporter that reabsorbs glucose in the kidney, so glucose is passed out in the urine rather than returned to the blood.
Glucose lowering is only part of the story. This class turned out to protect the heart and kidneys to a degree that surprised everyone, including in people without diabetes — which is why it is now prescribed for heart failure and chronic kidney disease in their own right.
It also produces modest weight loss and a modest fall in blood pressure, both consequences of losing glucose and fluid in the urine.
Stop empagliflozin during any acute illness where you cannot eat or drink normally, or where you are dehydrated — vomiting, diarrhoea, significant infection, or before surgery. Restart when eating and drinking normally again.
This is not a precaution to skim. Continuing it while dehydrated and not eating is what precipitates ketoacidosis.
Because you are passing sugar in your urine, genital thrush and infections are considerably more likely. Careful washing and drying, and prompt treatment of thrush, prevents most of it.
Caution applies if you follow a very low carbohydrate or ketogenic diet, which raises ketoacidosis risk.
Yes, to continue established treatment where recent kidney function is available and things are stable.
Whenever we do, we will go through sick day rules — because this class needs pausing during acute illness, and that instruction is frequently not given clearly enough at the point of prescribing.
We do not initiate empagliflozin for heart failure or chronic kidney disease remotely. Those indications need objective assessment — echocardiography, urine protein measurement — and specialist input.
Empagliflozin costs considerably more than metformin or gliclazide, though generics are now appearing and prices are falling.
The cost is generally considered justified by the heart and kidney protection, which older cheaper drugs do not provide — that is a genuine difference in what you are buying, not marketing.
Dapagliflozin is a closely related alternative with a similar profile.
Stop during acute illness with dehydration or poor oral intake, and before surgery. Restart when eating and drinking normally. This is temporary, not permanent.
It is treatable and often preventable — careful hygiene, prompt antifungal treatment, and sometimes a preventive course. It is worth trying to keep the drug given what it protects against.
Because it protects the heart and kidneys independently of its effect on glucose. That was a genuine surprise in the trials, and it changed how the drug is used.
Stop it when you are acutely unwell and not eating or drinking normally; restart when you are. This prevents ketoacidosis and kidney injury, and it is the single most important practical instruction.
Because you are passing sugar in your urine, which feeds yeast. Careful washing and drying, and treating episodes promptly, usually keeps it manageable.
An initial small dip is expected and is not damage. It reflects a change in pressure within the kidney, and long-term kidney function is better on the drug than off it.
Take advice first. Very low carbohydrate diets raise ketone levels, and combined with this drug that increases ketoacidosis risk.
Usually two to three kilograms, from losing glucose in the urine. Useful, but far less than a GLP-1 agonist.
Clinically reviewed by Dr Mohammad Zubair Khan, GMC 7563469
Last reviewed
August 30, 2026
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