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

SGLT2 Inhibitor Alternatives

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

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) 3
  • Blood pressure lowering (3-5 mmHg systolic, ~2 mmHg diastolic) 3
  • Cardiovascular risk reduction, particularly for heart failure hospitalization 1
  • Renoprotective effects, especially in patients with albuminuria 1

Cardiovascular Outcomes Comparison

• Empagliflozin (Jardiance): Demonstrated 38% reduction in cardiovascular death and 35% reduction in heart failure hospitalization in EMPA-REG OUTCOME trial 1, 4
• 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 1
• Canagliflozin (Invokana): Provided 33% reduction in heart failure hospitalization in CANVAS and 39% reduction in CREDENCE trial 1
• Ertugliflozin: Showed non-inferiority for cardiovascular outcomes but less robust benefits compared to other SGLT2 inhibitors 1

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 1, 5:

  • 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 6
  • Dapagliflozin has particularly robust data for heart failure with preserved ejection fraction 1
  • Empagliflozin has the most extensive cardiovascular outcomes data 1

Patient Selection Algorithm

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

   • Empagliflozin or canagliflozin preferred based on strongest outcome data 1

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

   • Dapagliflozin or empagliflozin preferred based on dedicated heart failure trials 1

3. For patients with diabetic kidney disease:

   • Canagliflozin has the strongest dedicated renal outcomes data (CREDENCE trial) 1

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 6

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.