Dr. Nirmal Nair

Why Your Doctor Prescribed Jardiance—Even If Your Blood Sugar Looks Fine

If you are a diabetic, you may have heard of, taken, or know someone who takes medications like Jardiance, Farxiga, or Invokana. These medications all belong to a class of medications called sodium-glucose-cotransporter inhibitor-2. 

In most people without diabetes, kidneys help reabsorb glucose into the bloodstream, instead of letting it remain in the urine. This process is mediated by the sodium-glucose-cotransporter. Medications like Jardiance, Farxiga, and Invokana block this mechanism, allowing us to dump more sugar into the urine, ultimately helping us lower blood sugar. 

Developed in the early 2010s, the SGLT2i, as they are called, rapidly became popular. Studies began to show their protective effects on the heart and kidney, and they became commonplace even in cardiology and nephrology offices alike. 

Some people follow their doctor’s advice without question, while others worry about being on yet another lifelong medication. Why am I being prescribed a drug even when my blood sugars look okay?

The answer to that, in one sense lies in the way we practice medicine. We are to some degree, population physicians – in other words, we want to be able to use things that we can give to ANYONE with diabetes or heart disease, and feel safe that there’s a good chance that it would give the average person SOME benefit. If you give 100 people one drug and don’t give it to another 100 people, which group is better off? At the end of the day, most of us would prefer to avoid a dialysis, a heart attack, stroke. 

This is where “randomized controlled studies” came into being. These studies in reality, originated from the pressures on the pharmaceutical industry by the FDA to prove that the medications actually did what they were claiming to do. If a drug is “FDA approved” it means that at the very least the drug has undergone multiple rounds of testing. Yet, I would say the most cringeworthy thing a physician can say to a patient who is worried about starting a medication is to say “this medication is FDA approved for xyz, don’t worry.” As if we should expect ANYONE to be reassured by that. 

I think its worth, therefore to translate these studies into English. To understand why one is taking a medication, we should understand how much of an intended effect there is. The landmark trial that showed us that it is indeed worth starting someone on Jardiance was called the EMPA-REG trial, short for 

By the late 2000’s an older diabetes drug called Avandia (rosiglitazone) was found in studies to have increased the risks for heart attack and heart failure. The FDA by 2010 had issued a black box warning on the drug, which lead to it being taken off the market. By 2013, the FDA mandated that all diabetic medications would require extensive testing to prove that aside from any blood sugar lowering effect, that they were safe from a cardiovascular standpoint. With Jardiance beginning to be used for diabetes control, now it became necessary, to test the cardiovascular outcomes of this medication. 

And so began the EMPA-REG trial. 

The EMPA-REG OUTCOME study aimed to answer a critical question: Can empagliflozin do more than just lower blood sugar? Can it help decrease cardiovascular events?

How Big Was the Study? 

The study aimed to select out 7000 people with diabetes AND worst cardiovascular disease. Those who’ve had heart attacks, stroke, or peripheral vascular disease. They also included people with more than 50 percent blockage in their arteries. It’s like selecting 7000 of the most beat-up cars with failing engines, giving them a special type of engine oil, and seeing if we can prevent total engine failure.

• 2/3 of these people received empagliflozin (Jardiance 10mg or Jardiance 25) 
• 1/3 received a placebo (dummy pill) 
• They were followed for 3 years to see what happened to them 

It reduced the risk of cardiovascular death 

Normally, in diabetics with cardiovascular disease, the rate of death in 3 years was 10 out of 100. 

• With empagliflozin, this dropped to 6 out of 100 
• That means 4 more people per 100 avoided a fatal heart attack or heart failure 

Imagine a bus with 100 passengers. Normally, 10 people wouldn’t have made it to the final stop. With empagliflozin, 4 of those people who otherwise wouldn’t have made it, survived to their destination. 

It lowered the risk of heart failure hospitalizations

People with diabetes are at high risk of developing heart failure, where the heart becomes weak and struggles to pump blood.
–  Empagliflozin reduced heart failure hospitalizations by 35%.
–  This means for every 100 people, 3-4 people were saved from needing an emergency hospital stay for heart failure.

It reduced death of any cause 

Normally, 9-10 out of 100 people with diabetes and heart disease die from various causes (heart disease, stroke, kidney failure, infections) over a few years

•  Empagliflozin reduced this risk by 32%, meaning about 3 extra lives were saved per 100 people.
• For every 39 people treated, one extra life was saved.

Empagliflozin protected the kidneys

Even though this trial focused on the heart, empagliflozin surprisingly reduced how likely study participants had worsening or new kidney disease.

• Risk of new or worsening kidney disease dropped by 39%
• Risk of requiring dialysis dropped by 44%

Put in another way, if 100 people with heart disease are destined to develop kidney disease of any kind, with empagliflozin ONLY 60 would now develop it. 

If another 100 are destined to develop kidney failure bad enough to require dialysis, now only 56 of those people would develop it. 

Final Takeaway: Why Does this Matter for You?

At the end of the day, most people don’t care whether something is “evidence-based” or “FDA approved.” What matters is avoiding a heart attack, stroke, or dialysis. If you’ve ever seen a loved one go through these events—or have experienced one yourself—you know how drastically life changes afterward.

The point of these medications isn’t just to lower blood sugar. It’s to reduce your risk of catastrophic health events.

You can follow the best diet in the world, exercise religiously, and still be at risk if you already have significant cardiovascular disease or advanced diabetes. Lifestyle changes help, but they don’t reverse established heart disease.

We don’t have a crystal ball to see who will suffer a stroke or end up on dialysis. But we do have studies like EMPA-REG that suggest we have a real shot at preventing that fate for some people. And sometimes, that’s reason enough to take the pill.