What is the difference between dabagliflozin and Jardiance (empagliflozin) in managing type 2 diabetes?

Dapagliflozin vs. Empagliflozin in Type 2 Diabetes Management

Both dapagliflozin and empagliflozin are effective SGLT2 inhibitors for managing type 2 diabetes, with empagliflozin having stronger evidence for cardiovascular mortality reduction, while both medications provide similar benefits for heart failure and renal protection.

Mechanism of Action

Both medications work by inhibiting sodium-glucose co-transporter-2 (SGLT2) in the kidney's proximal tubules, which:

• Blocks reabsorption of filtered glucose
• Increases urinary glucose excretion
• Reduces blood glucose levels independent of insulin action

Comparative Efficacy

Glycemic Control

• Both medications provide similar HbA1c reductions:
  • Dapagliflozin: 0.5-0.8% reduction
  • Empagliflozin: 0.7-1.0% reduction 1

Cardiovascular Outcomes

• Empagliflozin demonstrated a 38% reduction in cardiovascular mortality and 35% reduction in hospitalization for heart failure in patients with established cardiovascular disease (EMPA-REG OUTCOME trial) 2, 1
• Dapagliflozin showed significant reduction in the composite of heart failure worsening or CV death (DAPA-HF trial) 2
• Recent comparative studies show no significant difference between the two medications for major adverse cardiovascular events (MACE) 3, 4, 5

Heart Failure Benefits

• Both medications significantly reduce hospitalization for heart failure:
  • Empagliflozin: 35% reduction 2
  • Dapagliflozin: 27% reduction 2
• These benefits extend to patients with heart failure with reduced ejection fraction (HFrEF) regardless of diabetes status 2

Renal Protection

• Both medications demonstrate significant renal protective effects:
  • Dapagliflozin reduced the risk of sustained decline in eGFR, end-stage kidney disease, or renal death by 39% 2
  • Empagliflozin showed similar renal protection 2

Safety Considerations

Common Side Effects

• Both medications share similar adverse effects:
  • Genital mycotic infections (more common than with other diabetes medications)
  • Urinary tract infections
  • Volume depletion/hypotension

Special Concerns

• Euglycemic diabetic ketoacidosis: Rare but serious risk with both medications, particularly in patients with poor food intake 2
• Both medications should be used cautiously in patients with renal impairment (eGFR <45 mL/min/1.73 m²) 2
• Neither medication is recommended for routine use in hospital settings 2

Key Differences

1. Cardiovascular Mortality Evidence:

   • Empagliflozin has stronger evidence for cardiovascular mortality reduction in patients with established cardiovascular disease 2, 1

2. Atrial Fibrillation:

   • Recent evidence suggests dapagliflozin may be superior for preventing atrial fibrillation 6

3. Selectivity:

   • Dapagliflozin and empagliflozin are both highly selective for SGLT2 receptors compared to other SGLT2 inhibitors 2

Clinical Decision Algorithm

1. For patients with established cardiovascular disease:

   • Empagliflozin is preferred due to proven cardiovascular mortality benefit 2, 1

2. For patients with heart failure (with or without diabetes):

   • Either medication is appropriate as both have proven benefits 2

3. For patients with chronic kidney disease:

   • Either medication is appropriate as both have demonstrated renal protection 2

4. For patients with history of or at risk for atrial fibrillation:

   • Dapagliflozin may be preferred 6

5. For patients without established cardiovascular disease, heart failure, or CKD:

   • Either medication is appropriate based on individual factors and formulary considerations 5

Practical Considerations

• Monitor for genital mycotic infections and urinary tract infections with both medications
• Discontinue either medication in patients at risk for lactic acidosis (acute kidney injury, hypoxia, shock)
• Assess for risk of euglycemic diabetic ketoacidosis, particularly in patients with poor food intake
• Neither medication should be initiated in patients with eGFR <45 mL/min/1.73 m²

In summary, while both medications offer similar benefits for glycemic control, heart failure, and renal protection, empagliflozin has more robust evidence for cardiovascular mortality reduction in patients with established cardiovascular disease, making it the preferred choice for this specific population.