Should You Switch from Empagliflozin to Dapagliflozin?
No, you should not routinely switch a patient from empagliflozin 25mg daily to dapagliflozin unless there is a specific clinical indication based on renal function or cardiovascular/renal protection needs. Both medications are SGLT2 inhibitors with proven cardiovascular and renal benefits, and switching between them without a compelling reason disrupts established therapy 1.
Key Decision Points for Switching
When Switching May Be Indicated
Declining renal function is the primary reason to consider switching from empagliflozin to dapagliflozin:
If eGFR falls below 45 mL/min/1.73 m²: Empagliflozin is not recommended for initiation or continuation when eGFR <45 mL/min/1.73 m² 1, 2. In contrast, dapagliflozin can be continued down to eGFR 25 mL/min/1.73 m² for cardiovascular and renal protection 1, 3.
For chronic kidney disease protection: If your patient has CKD with eGFR 25-45 mL/min/1.73 m² and albuminuria, dapagliflozin offers specific FDA-approved benefits for reducing sustained eGFR decline, end-stage kidney disease, cardiovascular death, and heart failure hospitalization 3. Empagliflozin lacks this specific indication in this eGFR range 2.
When Switching Is NOT Indicated
If eGFR ≥45 mL/min/1.73 m², there is no compelling reason to switch:
Both empagliflozin and dapagliflozin demonstrate similar cardiovascular benefits, including reductions in major adverse cardiovascular events, heart failure hospitalizations, and cardiovascular death 1, 4.
Research directly comparing the two agents shows no significant differences in clinical outcomes (composite coronary events, ischemic events, heart failure, or renal outcomes) in patients without prior cardiovascular disease 4.
Some studies suggest empagliflozin may provide slightly greater HbA1c reduction (-1.7% vs -1.1% at 3 years) and body weight reduction (-4.5 kg vs -1.0 kg) compared to dapagliflozin 5, 6, though these differences are modest.
Practical Algorithm for Decision-Making
Step 1: Check current eGFR
- eGFR ≥45 mL/min/1.73 m²: Continue empagliflozin 25mg. No switch needed 1.
- eGFR 25-44 mL/min/1.73 m²: Switch to dapagliflozin 10mg daily for continued cardiovascular and renal protection 1, 3.
- eGFR <25 mL/min/1.73 m²: Do not initiate dapagliflozin, but may continue if already established 1, 3.
Step 2: Assess primary treatment goal
- For glycemic control alone: If eGFR <45 mL/min/1.73 m², neither SGLT2 inhibitor is recommended for glucose lowering due to reduced efficacy 1, 3. Consider GLP-1 receptor agonists instead 1.
- For cardiovascular/renal protection: Dapagliflozin has broader eGFR range approval (down to 25 mL/min/1.73 m²) 3.
Step 3: Consider albuminuria status
- If UACR ≥200 mg/g and eGFR 25-45 mL/min/1.73 m²: Dapagliflozin is specifically indicated to reduce kidney disease progression 7, 3.
Important Safety Considerations When Switching
If you do switch from empagliflozin to dapagliflozin:
Withhold both medications during acute illness (fever, vomiting, diarrhea, reduced oral intake) to prevent diabetic ketoacidosis and volume depletion 7.
Withhold at least 3 days before major surgery or procedures with prolonged fasting 7, 3.
Monitor eGFR within 1-2 weeks after switching: Expect a transient eGFR dip of 3-5 mL/min/1.73 m² in the first 1-4 weeks, which is reversible and associated with better long-term renal outcomes 7.
Assess volume status carefully: Patients on diuretics, elderly patients (≥75 years), or those with low blood pressure are at higher risk for volume depletion 7, 8.
Reduce insulin dose by approximately 20% if HbA1c is well-controlled to prevent hypoglycemia 8.
Common Pitfalls to Avoid
Do not switch based solely on perceived superiority of one agent over another when eGFR ≥45 mL/min/1.73 m². The cardiovascular benefits are a class effect 4.
Do not continue empagliflozin when eGFR persistently falls below 45 mL/min/1.73 m² as per FDA labeling 2. This is when dapagliflozin becomes the preferred option 1, 3.
Do not use either SGLT2 inhibitor primarily for glycemic control when eGFR <45 mL/min/1.73 m² as glucose-lowering efficacy is significantly reduced 1, 3.
Do not forget to educate patients on sick day rules regardless of which SGLT2 inhibitor they are taking 7.