What are the alternatives to Jardiance (Empagliflozin) for patients with type 2 diabetes?

Alternatives to Jardiance (Empagliflozin) for Type 2 Diabetes

For patients with type 2 diabetes, the best alternatives to Jardiance (empagliflozin) are other SGLT2 inhibitors such as canagliflozin and dapagliflozin, or GLP-1 receptor agonists like dulaglutide, liraglutide, and semaglutide, depending on the patient's cardiovascular and renal risk profile. 1

SGLT2 Inhibitor Alternatives

Other SGLT2 Inhibitors

• Canagliflozin: Provides similar benefits to empagliflozin with proven cardiovascular and renal benefits 1
• Dapagliflozin: Effective alternative with demonstrated benefits for heart failure and kidney disease 1

These alternatives are particularly appropriate for patients with:

• Established atherosclerotic cardiovascular disease (ASCVD)
• Heart failure (especially with reduced ejection fraction)
• Diabetic kidney disease (DKD)
• High risk for cardiovascular events 1

Efficacy Comparison

• Dapagliflozin shows similar glycemic control but slightly less HbA1c reduction compared to empagliflozin (1.2% vs 1.7% reduction) 2
• All SGLT2 inhibitors provide modest weight loss (2-3 kg) and blood pressure reduction 3

GLP-1 Receptor Agonist Alternatives

GLP-1 receptor agonists are excellent alternatives, particularly for patients with:

• Established ASCVD or high cardiovascular risk
• Need for significant weight loss
• Increased stroke risk 1, 4

Recommended GLP-1 RAs with proven cardiovascular benefits:

• Dulaglutide
• Liraglutide
• Injectable semaglutide 1

These agents provide significant A1C reduction (0.8-1.5%), substantial weight loss, and have a low risk of hypoglycemia 4

Other Alternative Classes

Metformin

• Still considered first-line therapy for most patients with type 2 diabetes
• Can be used in combination with other agents 1, 5

Thiazolidinediones (TZDs)

• Pioglitazone: May have cardiovascular benefits, especially for stroke prevention
• Caution: Risk of fluid retention, weight gain, and heart failure 1

Sulfonylureas

• Lower cost alternative but with higher risk of hypoglycemia and weight gain
• No cardiovascular benefits 4

DPP-4 Inhibitors

• Not recommended as alternatives due to less efficacy and no proven cardiovascular benefits 4

Selection Algorithm Based on Patient Characteristics

1. For patients with established ASCVD, heart failure, or DKD:

   • First choice: Another SGLT2 inhibitor (canagliflozin or dapagliflozin)
   • Second choice: GLP-1 RA with proven CV benefit 1

2. For patients needing significant weight loss:

   • First choice: GLP-1 RA (particularly semaglutide)
   • Second choice: SGLT2 inhibitor 1, 4

3. For patients with increased stroke risk:

   • First choice: GLP-1 RA 4

4. For patients with heart failure:

   • First choice: SGLT2 inhibitor (dapagliflozin has strong evidence) 1

5. For patients with cost concerns:

   • Consider metformin and/or sulfonylurea, recognizing their limitations 4

Important Considerations and Precautions

• Renal function: SGLT2 inhibitors generally require eGFR ≥30 mL/min/1.73m² 1
• Pregnancy/breastfeeding: Neither SGLT2 inhibitors nor GLP-1 RAs should be used 1
• Side effects:
  • SGLT2 inhibitors: Genital infections (empagliflozin has lower risk at 3.1% vs dapagliflozin at 8.66%), urinary tract infections, risk of diabetic ketoacidosis 2
  • GLP-1 RAs: Gastrointestinal side effects (nausea, vomiting, diarrhea) 4

Remember that medication selection should prioritize reduction of cardiovascular and renal risk, as these outcomes have the greatest impact on morbidity, mortality, and quality of life for patients with type 2 diabetes.