Which SGLT2 (sodium-glucose cotransporter 2) inhibitor, dapagliflozin (Farxiga) or empagliflozin (Jardiance), is more suitable for a teenager with type 2 diabetes?

Which SGLT2 Inhibitor for a Teenager with Type 2 Diabetes?

Empagliflozin is the only SGLT2 inhibitor with FDA approval and clinical trial evidence for use in adolescents with type 2 diabetes, making it the clear choice over dapagliflozin for teenagers. 1

Evidence Supporting Empagliflozin in Adolescents

The 2024 American Diabetes Association guidelines explicitly state that empagliflozin is the only SGLT2 inhibitor approved for youth-onset type 2 diabetes 1. This recommendation is based on a multicenter, double-blind, placebo-controlled trial in 158 children aged 10-17 years with type 2 diabetes, where empagliflozin 10 mg demonstrated:

• Significant A1C reduction of 0.84% from baseline compared to placebo (p=0.012) 1
• No episodes of severe hypoglycemia during the study period 1
• Well-tolerated safety profile in this age group 1

Why Not Dapagliflozin?

Dapagliflozin lacks dedicated clinical trial data in pediatric populations with type 2 diabetes. While a 2024 systematic review found some case reports and observational data on dapagliflozin use in children, these were primarily for off-label indications like chronic kidney disease and heart failure, not for glycemic control in type 2 diabetes 2. The review identified only 189 diabetic pediatric patients exposed to either SGLT2 inhibitor across all studies, with empagliflozin being the primary agent studied in controlled trials 2.

Clinical Implementation Algorithm

For teenagers aged 10-17 years with type 2 diabetes:

1. Start empagliflozin 10 mg once daily as the evidence-based SGLT2 inhibitor choice 1
2. Combine with metformin unless contraindicated, as metformin remains first-line therapy and the TODAY study showed approximately 50% of youth achieved durable glycemic control with metformin alone 1
3. Consider adding a GLP-1 receptor agonist if glycemic targets are not met, as randomized controlled trials in youth have shown these agents safely and effectively decrease A1C 1

Safety Considerations Specific to Adolescents

Monitor for the same adverse effects seen in adults, though the risk profile may differ slightly:

• Genital mycotic infections occur more frequently with SGLT2 inhibitors but were manageable in pediatric trials 1, 2
• Diabetic ketoacidosis risk appears rare in children but requires education, especially in those on insulin 2, 3
• Hypoglycemia risk is low with empagliflozin monotherapy but increases when combined with insulin or sulfonylureas 1
• Volume depletion should be monitored, particularly in adolescents on concurrent diuretics 1

Common Pitfall to Avoid

Do not assume class effect equivalence in pediatric populations. While dapagliflozin and empagliflozin show similar efficacy in adults 4, 5, only empagliflozin has undergone rigorous testing in adolescents with type 2 diabetes 1. Using dapagliflozin in this population would be off-label without supporting pediatric trial data.

Contraindications Apply Regardless of Age

• Severe renal impairment (eGFR <30 mL/min/1.73 m² for glycemic control) 1
• History of serious hypersensitivity to the drug 1
• Personal or family history of medullary thyroid carcinoma (contraindication for GLP-1 RAs if considering combination therapy) 1