What are alternative treatments to Jardiance (empagliflozin) for heart failure?

Alternatives to Jardiance (Empagliflozin) for Heart Failure Treatment

For patients with heart failure, SGLT2 inhibitors including dapagliflozin (Farxiga) are the best alternative to empagliflozin (Jardiance), as they provide similar benefits in reducing hospitalization for heart failure and cardiovascular death across the spectrum of heart failure with reduced or preserved ejection fraction. 1, 2

SGLT2 Inhibitor Alternatives

First-Line Alternatives to Jardiance

• Dapagliflozin (Farxiga):

  • Reduces risk of cardiovascular death and hospitalization for heart failure by 26% (HR 0.74,95% CI 0.65-0.85) in HFrEF 1
  • Reduces primary composite endpoint by 18% (HR 0.82,95% CI 0.73-0.92) in HFpEF 1
  • Benefits are consistent regardless of diabetes status 3
  • FDA-approved for both HFrEF and HFpEF 2

• Sotagliflozin:

  • Dual SGLT1 and SGLT2 inhibitor 1
  • FDA-approved to reduce cardiovascular death, hospitalization for heart failure, and urgent heart failure visits 1
  • Particularly beneficial for patients recently hospitalized for heart failure 1

Other Heart Failure Medications (Standard of Care)

For Heart Failure with Reduced Ejection Fraction (HFrEF)

1. ACE Inhibitors/ARBs:

   • Recommended as foundational therapy 1
   • Consider switching to sacubitril/valsartan (ARNI) in patients who remain symptomatic 1

2. Beta-blockers:

   • Essential component of HFrEF therapy 1
   • Should be used in stable patients 1

3. Mineralocorticoid Receptor Antagonists (MRAs):

   • Recommended to reduce mortality and hospitalization 1
   • Examples: spironolactone, eplerenone

4. Finerenone:

   • Non-steroidal MRA that reduces heart failure hospitalization 1
   • Also provides renal protection in diabetic patients 1

For Heart Failure with Preserved Ejection Fraction (HFpEF)

1. SGLT2 inhibitors (as mentioned above)
2. Diuretics:
   • Recommended for symptom relief and to reduce congestion 1
   • Not shown to improve mortality but improve quality of life

Important Considerations When Switching

Efficacy Comparison

• The benefits of SGLT2 inhibitors appear to be a class effect, with similar outcomes across different agents 1
• Benefits are seen regardless of diabetes status 1, 3
• Effects appear early (as soon as 12 days after initiation with empagliflozin) 4

Safety Considerations

• Monitor for ketoacidosis: Risk exists even with normal blood glucose levels 3
• Volume depletion: Consider reducing diuretic doses when initiating SGLT2 inhibitors 3
• Genital mycotic infections: More common with SGLT2 inhibitors 3
• Contraindications: Severe renal impairment, end-stage renal disease, or dialysis 3

Medications to Avoid

• Thiazolidinediones (pioglitazone, rosiglitazone): Strong and consistent relationship with increased risk of heart failure 1
• Saxagliptin (DPP-4 inhibitor): Associated with increased risk of heart failure hospitalization 1

Practical Implementation

1. Start with dapagliflozin 10 mg daily as the most evidence-supported alternative to empagliflozin
2. No dose titration is required (unlike many other heart failure medications) 5
3. Continue standard heart failure therapy (ACEIs/ARBs/ARNIs, beta-blockers, MRAs)
4. Consider reducing diuretic doses to prevent volume depletion
5. Monitor for side effects, particularly genital infections and signs of ketoacidosis

Special Populations

• Patients with renal impairment: SGLT2 inhibitors provide renal protection, but use is limited in severe renal impairment 3
• Post-myocardial infarction: Empagliflozin reduces heart failure hospitalizations in patients after acute MI 6, suggesting other SGLT2 inhibitors may have similar benefits

The evidence strongly supports SGLT2 inhibitors as the cornerstone of modern heart failure management across the spectrum of ejection fractions, with dapagliflozin being the most well-studied alternative to empagliflozin.