From the Guidelines
Empagliflozin and dapagliflozin are both effective SGLT2 inhibitors for treating type 2 diabetes, but dapagliflozin may be preferred for patients with heart failure with reduced ejection fraction or chronic kidney disease due to its additional FDA approvals and stronger evidence in these areas, as shown in the DAPA-HF trial 1. When choosing between empagliflozin and dapagliflozin, several factors should be considered:
- Both medications have similar efficacy in reducing A1C levels (0.5-0.8%) and weight loss benefits (2-3kg), as well as modest blood pressure reductions.
- Empagliflozin may be preferred for patients with established cardiovascular disease due to its stronger evidence for cardiovascular mortality reduction, typically dosed at 10mg daily initially, increasing to 25mg if needed.
- Dapagliflozin offers similar glycemic control and has additional FDA approvals for heart failure with reduced ejection fraction regardless of diabetes status and for chronic kidney disease, usually dosed at 5mg daily initially, increasing to 10mg.
- Both medications work by preventing glucose reabsorption in the kidneys, leading to increased glucose excretion in urine and lowered blood sugar levels.
- Side effects for both include genital mycotic infections, urinary tract infections, and volume depletion, with rare cases of diabetic ketoacidosis.
- Neither should be used in patients with type 1 diabetes or severe renal impairment (eGFR <30 ml/min for dapagliflozin, <20 ml/min for empagliflozin) 1. The most recent and highest quality study, the DAPA-HF trial 1, demonstrated the benefits of dapagliflozin in patients with heart failure with reduced ejection fraction, regardless of diabetes status. Key differences between the two medications include:
- FDA approvals: dapagliflozin has additional approvals for heart failure with reduced ejection fraction and chronic kidney disease.
- Dosage: empagliflozin is typically dosed at 10mg daily initially, increasing to 25mg, while dapagliflozin is usually dosed at 5mg daily initially, increasing to 10mg.
- Indications: empagliflozin is indicated for patients with established cardiovascular disease, while dapagliflozin is indicated for patients with heart failure with reduced ejection fraction or chronic kidney disease.
From the Research
Comparison of Empagliflozin and Dapagliflozin
- Empagliflozin and dapagliflozin are both Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors used in the treatment of type 2 diabetes mellitus (T2DM) [ 2, 3 ].
- Studies have shown that both empagliflozin and dapagliflozin have beneficial effects on cardiovascular outcomes, including reduced risk of major adverse cardiovascular events (MACE), cardiovascular death, and hospitalization for heart failure (HHF) [ 2, 4, 5, 6 ].
Cardiovascular Outcomes
- A meta-analysis found no significant difference in the incidence of myocardial infarction, heart failure, cardiovascular mortality, and stroke between dapagliflozin and empagliflozin [ 5 ].
- Another study found that dapagliflozin demonstrated superior efficacy in preventing atrial fibrillation compared to empagliflozin, but no significant differences were observed in terms of MACE, cardiovascular mortality, hospitalization for heart failure, or myocardial infarction [ 6 ].
Cost-Effectiveness
- A cost-effectiveness analysis found that empagliflozin dominated canagliflozin and was highly cost-effective compared to dapagliflozin and standard of care in patients with T2DM and established cardiovascular disease [ 2 ].
Clinical Implications
- Both dapagliflozin and empagliflozin have been shown to be effective in preventing adverse cardiovascular outcomes in patients with T2DM, and clinicians have flexibility in prescribing either of these SGLT2 inhibitors [ 3, 6 ].
- The choice between dapagliflozin and empagliflozin may depend on individual patient factors, such as history of or risk for atrial fibrillation [ 6 ].