What are comparable alternatives to Jardiance (empagliflozin) for treating type 2 diabetes?

Comparable Alternatives to Jardiance (Empagliflozin) for Type 2 Diabetes

Dapagliflozin, canagliflozin, and ertugliflozin are the most comparable alternatives to Jardiance (empagliflozin) as they belong to the same SGLT2 inhibitor class with similar efficacy, safety profiles, and cardiovascular benefits. 1, 2

SGLT2 Inhibitor Alternatives

• Dapagliflozin (Farxiga): Highly selective SGLT2 inhibitor with demonstrated cardiovascular benefits, particularly in reducing heart failure hospitalization risk 3, 4
• Canagliflozin (Invokana): SGLT2 inhibitor with proven cardiovascular and renal benefits in patients with type 2 diabetes and high cardiovascular risk 1, 5
• Ertugliflozin: More recent SGLT2 inhibitor with similar glycemic efficacy, though with less robust cardiovascular outcomes data compared to empagliflozin 1, 2
• Sotagliflozin: A dual SGLT1/SGLT2 inhibitor approved for reducing cardiovascular death and heart failure in patients with heart failure or type 2 diabetes 3

Comparative Benefits and Efficacy

• All SGLT2 inhibitors provide similar glycemic control, typically reducing HbA1c by approximately 0.7-1.0% when added to metformin 1
• All SGLT2 inhibitors offer additional benefits beyond glycemic control:
  • Weight reduction (2.9-4.7 kg) 6
  • Blood pressure lowering (3-5 mmHg systolic, ~2 mmHg diastolic) 6
  • Cardiovascular risk reduction, particularly for heart failure hospitalization 3
  • Renoprotective effects, especially in patients with albuminuria 7, 5

Cardiovascular Outcomes Comparison

• Empagliflozin (Jardiance): Demonstrated 38% reduction in cardiovascular death and 35% reduction in heart failure hospitalization in EMPA-REG OUTCOME trial 8, 9
• Dapagliflozin (Farxiga): Showed 27% reduction in heart failure hospitalization in DECLARE-TIMI 58 and significant benefits in the DAPA-HF trial for patients with heart failure 3, 10
• Canagliflozin (Invokana): Provided 33% reduction in heart failure hospitalization in CANVAS and 39% reduction in CREDENCE trial 8, 5
• Ertugliflozin: Showed non-inferiority for cardiovascular outcomes but less robust benefits compared to other SGLT2 inhibitors 2, 5

Cost Considerations

• According to 2021 pricing data, the median monthly costs (AWP) for maximum approved daily doses are similar across the class 1:
  • Empagliflozin (25 mg): $627
  • Dapagliflozin (10 mg): $621
  • Canagliflozin (300 mg): $622
  • Ertugliflozin (15 mg): $354 (potentially more cost-effective option)

Special Considerations and Cautions

• All SGLT2 inhibitors share similar adverse effect profiles 2, 11:

  • Genital mycotic infections (most common side effect)
  • Risk of volume depletion and hypotension
  • Rare but serious risk of diabetic ketoacidosis (including euglycemic DKA)
  • Limited efficacy in patients with reduced renal function (eGFR <45 mL/min/1.73m²)

• Important differences to consider:

  • Canagliflozin has been associated with increased risk of amputation and bone fractures, which has not been observed with empagliflozin 12
  • Dapagliflozin has particularly robust data for heart failure with preserved ejection fraction 10
  • Empagliflozin has the most extensive cardiovascular outcomes data 3, 8

Patient Selection Algorithm

1. For patients with established atherosclerotic cardiovascular disease (ASCVD):

   • Empagliflozin or canagliflozin preferred based on strongest outcome data 3, 5

2. For patients with heart failure (regardless of ejection fraction):

   • Dapagliflozin or empagliflozin preferred based on dedicated heart failure trials 3, 10

3. For patients with diabetic kidney disease:

   • Canagliflozin has the strongest dedicated renal outcomes data (CREDENCE trial) 5

4. For patients with cost concerns:

   • Ertugliflozin offers the lowest cost option with similar glycemic efficacy 1

5. For patients at higher risk of amputation:

   • Avoid canagliflozin; prefer empagliflozin or dapagliflozin 12

Remember that all SGLT2 inhibitors are recommended as part of glucose-lowering regimens for patients with established ASCVD, heart failure, or chronic kidney disease, independent of A1C and metformin use 1, 3.