Pharmacology · SGLT2 inhibitors (gliflozins)

Empagliflozin !

An SGLT2 inhibitor: makes the kidney lose glucose in urine and lowers heart failure hospitalizations and kidney decline.

Updated 2026-11-01

Class: SGLT2 inhibitors (gliflozins)
Transporter: Sodium-glucose cotransporter 2 (SGLT2)
ATC code: A10BK03
WHO Model List of Essential Medicines

Sodium-glucose cotransporter 2 (SGLT2)Empagliflozin

The figure shows empagliflozin bound to human SGLT2 (with its partner protein MAP17), in the glucose site, open to the outside of the cell.

Target in 3D: Sodium-glucose cotransporter 2 (SGLT2). PDB structure 7VSI (RCSB PDB, public domain). View the structure at RCSB PDB

Mechanism of action

Empagliflozin is a highly selective inhibitor of SGLT2 in the early proximal tubule. It occupies the glucose site from the urine side and locks the transporter, so filtered glucose and sodium are excreted. Glucose falls independently of insulin, with calorie loss and mild natriuresis. More sodium at the macula densa restores tubuloglomerular feedback and lowers glomerular pressure; lower preload and other metabolic effects are thought to explain the heart benefit.

Binds SGLT2 on the luminal side of the proximal tubule
Filtered glucose and sodium are no longer reabsorbed
Glucose, calories and some fluid leave in the urine
Glucose falls; glomerular pressure and heart load drop

Pharmacokinetics

Absorption: Oral, well absorbed; food does not matter.
Metabolism: Mainly glucuronidation; little CYP450 involvement.
Elimination: In urine and feces; the glucose-lowering effect falls as kidney function falls, while heart and kidney benefits persist.
Half-life: Long enough for once-daily use.

Indications

Type 2 diabetes, with diet and exercise, and to reduce cardiovascular death in those with heart disease Type 2 diabetes mellitus →
Heart failure, to reduce hospitalization and cardiovascular death Heart failure →
Chronic kidney disease, to slow its progression Chronic kidney disease →

Adverse effects

Common

Genital fungal infections (vulvovaginal candidiasis, balanitis)
Urinary tract infections and more frequent urination
Thirst, dizziness and low blood pressure from fluid loss
A small, usually reversible fall in eGFR at the start

Contraindications

Hypersensitivity to the drug
Not used to control glucose in type 1 diabetes, because of ketoacidosis risk

Key interactions

Insulin or sulfonylureas: Higher risk of hypoglycemia; the other drug is often reduced.
Diuretics (loop or thiazide): Add to fluid loss and low blood pressure.
Lithium: Serum lithium can fall; levels are checked.
Urine glucose and 1,5-anhydroglucitol tests: Become unreliable for judging glucose control.

What is monitored

Kidney function and volume status
HbA1c (not urine glucose)
Blood pressure
Ketones if the patient is unwell

Administration and safety

Oral tablet, once a day, with or without food.
Volume status is checked and corrected before the first dose.
Usually paused before planned surgery and during acute illness or fasting, to prevent ketoacidosis.

Nursing care

Before: kidney function, blood pressure, hydration, genital and urinary symptoms.
During: signs of ketoacidosis even with normal glucose; ketones are measured if the patient feels unwell.
Teach genital hygiene and to report pain, redness or swelling of the genital or perineal area with fever.
Teach that urine glucose tests will be positive and that fluids matter in hot weather or with vomiting.

Pregnancy and breastfeeding

Not recommended in the second and third trimesters, based on kidney effects seen in animals; insulin is the usual choice in pregnancy.

Test yourself

Think of the answer, then tap the question to see it.

A patient on empagliflozin has vomiting, abdominal pain and fast breathing after surgery, with glucose only mildly raised. What should be suspected?

Euglycemic diabetic ketoacidosis. Ketones and blood gases are checked; glucose may be misleadingly near normal.

Besides diabetes, which two conditions is empagliflozin used for?

Heart failure and chronic kidney disease, where it reduces hospitalizations and slows decline.

Why is the urine glucose test useless for following a patient on empagliflozin?

The drug makes glucose appear in urine on purpose, so the test is positive whatever the blood glucose; HbA1c or blood glucose is used.

Why is empagliflozin often paused before a planned operation?

Fasting and surgical stress lower insulin and raise ketone production, which with an SGLT2 inhibitor increases the risk of ketoacidosis.

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Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.

Sources: Empagliflozin: MedlinePlus Drug Information (MedlinePlus (U.S. National Library of Medicine), 2026); Structure of human SGLT2-MAP17 complex bound with empagliflozin (RCSB Protein Data Bank, 2021); ATCDDD - ATC/DDD Index (WHO Collaborating Centre for Drug Statistics Methodology, 2026); eEML - Electronic Essential Medicines List (World Health Organization, 2025).

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Representative model, for educational purposes only.