What are the alternatives to Jardiance (empagliflozin) for type 2 diabetes management if it is too expensive?

Alternatives to Jardiance (Empagliflozin) for Type 2 Diabetes When Cost is a Concern

For patients who cannot afford Jardiance (empagliflozin), metformin combined with a sulfonylurea (such as glimepiride) is the most cost-effective alternative treatment for type 2 diabetes management. 1

Cost Comparison of Diabetes Medications

Medication costs are a major source of stress for patients with diabetes and can significantly impact medication adherence. Here's how the costs compare:

• Metformin: $2-3 per month (immediate release)
• Sulfonylureas (e.g., glimepiride): $3-4 per month
• SGLT2 inhibitors:
  • Empagliflozin (Jardiance): $526-658 per month
  • Dapagliflozin: $511-639 per month
  • Canagliflozin: $521-652 per month
  • Ertugliflozin: $297-372 per month (lowest cost SGLT2 inhibitor)

Step-by-Step Approach When Jardiance is Too Expensive

1. Optimize Metformin First

• Ensure patient is on maximum tolerated dose of metformin (up to 2000-2550 mg daily)
• Metformin remains the first-line agent with proven efficacy, safety, and cardiovascular benefits at minimal cost 1

2. Add a Low-Cost Second Agent

• Sulfonylureas (particularly glimepiride): Most cost-effective second-line option at $3-4 per month 1
  • Caution: Monitor for hypoglycemia, especially in elderly or those with irregular eating habits
  • Consider lower starting doses in these populations

3. Consider Other Cost-Effective Options

• Pioglitazone: $5 per month (generic)
  • Caution: May cause fluid retention, weight gain, and heart failure exacerbation
• DPP-4 inhibitors: Higher cost than sulfonylureas but lower than SGLT2 inhibitors
  • Alogliptin is the lowest cost option in this class ($166-234 per month)

4. Explore Cost-Reduction Strategies

• Discount programs: GoodRx, CostPlus, SingleCare may provide lower-cost alternatives 1
• Pharmaceutical assistance programs: Many manufacturers offer savings cards or patient assistance programs
• Consider ertugliflozin: If an SGLT2 inhibitor is strongly indicated, ertugliflozin is the lowest-cost option in this class 1

Special Considerations

For Patients with Established Cardiovascular Disease

• While SGLT2 inhibitors like empagliflozin offer cardiovascular benefits, metformin also provides cardiovascular protection at a fraction of the cost 1
• If cardiovascular risk is high, consider adding a GLP-1 RA once finances allow, as these also demonstrate cardiovascular benefits 1

For Patients with Chronic Kidney Disease

• In patients with CKD, SGLT2 inhibitors provide significant benefits
• If cost prohibits SGLT2 inhibitor use, ensure optimal blood pressure control with ACE inhibitors or ARBs, which are available as low-cost generics 1

For Patients with Heart Failure

• While SGLT2 inhibitors reduce heart failure hospitalizations, proper management of heart failure with standard therapies (ACE inhibitors/ARBs, beta-blockers, and diuretics) should be prioritized when cost is a barrier 1

Monitoring and Follow-up

• Monitor HbA1c every 3 months until target is achieved
• Watch for hypoglycemia if using sulfonylureas, especially when combined with other agents
• Assess for adverse effects specific to each medication class
• Reassess treatment plan if glycemic targets are not met within 3 months

Common Pitfalls to Avoid

• Don't discontinue metformin when adding other agents unless contraindicated
• Don't ignore financial toxicity - medication non-adherence due to cost leads to worse outcomes
• Don't overlook potential drug interactions between diabetes medications and other drugs
• Don't forget to reassess kidney function regularly, as this may affect medication choices and dosing

Remember that achieving glycemic control with affordable medications is better than non-adherence to expensive medications. The goal is to find a sustainable treatment plan that the patient can afford long-term.