What are alternative medications to Jardiance (Empagliflozin) 10 mg for a patient with type 2 diabetes?

Alternative Medications to Jardiance (Empagliflozin) 10 mg

For patients requiring an alternative to Jardiance 10 mg, the best options within the same SGLT2 inhibitor class are canagliflozin 100 mg daily or dapagliflozin 10 mg daily, both of which provide equivalent cardiovascular and renal protection at their starting doses. 1, 2, 3

Within-Class SGLT2 Inhibitor Alternatives

Canagliflozin

• Start at 100 mg orally once daily for full cardiovascular benefit, with no need for dose escalation specifically for cardiovascular risk reduction 1, 2
• Provides a 39% reduction in heart failure hospitalization and 31% reduction in cardiovascular death or heart failure hospitalization 1
• Can be initiated in patients with eGFR as low as 30 mL/min/1.73 m² for cardiovascular and renal protection 2
• Important safety consideration: Unlike empagliflozin, canagliflozin has been associated with increased risk of amputation and bone fractures, which should factor into your decision 4

Dapagliflozin

• Fixed dose of 10 mg orally once daily with no titration needed 2, 3
• Reduces cardiovascular death, heart failure hospitalization, and urgent heart failure visits 3
• Can be initiated down to eGFR 30 mL/min/1.73 m² 2
• Has demonstrated benefits in heart failure with preserved ejection fraction (HFpEF) 1
• Carries a low risk of hypoglycemia as monotherapy 3

Different-Class Alternative: GLP-1 Receptor Agonists

Liraglutide (Preferred GLP-1RA)

• The American College of Cardiology identifies liraglutide as the preferred GLP-1RA based on the most convincing cardiovascular benefit data 1
• Start at the lowest dose and titrate slowly to the goal dose of 1.8 mg daily subcutaneously for cardiovascular risk reduction 1
• Provides MACE reduction but does not reduce heart failure hospitalization like SGLT2 inhibitors 1
• Key difference from SGLT2 inhibitors: Associated with transient nausea and vomiting, especially during initiation and dose escalation 1
• Requires subcutaneous injection versus oral administration 1

Decision Algorithm for Selecting an Alternative

Choose Another SGLT2 Inhibitor (Canagliflozin or Dapagliflozin) If:

• Patient specifically needs heart failure hospitalization reduction (all SGLT2 inhibitors provide this benefit) 1
• Patient has heart failure with preserved ejection fraction (consider dapagliflozin based on EMPEROR-Preserved data) 1
• Patient prefers oral administration 1
• Patient has diabetic kidney disease with albuminuria (canagliflozin has specific FDA approval for this indication) 2
• Avoid canagliflozin if patient has peripheral vascular disease or high amputation risk 4

Choose a GLP-1RA (Liraglutide) If:

• Patient has contraindication to SGLT2 inhibitors (severe renal impairment below eGFR 30, history of recurrent genital infections, or prior euglycemic DKA) 2
• Primary goal is MACE reduction without concern for heart failure 1
• Patient can tolerate subcutaneous injections and gastrointestinal side effects 1
• Patient needs greater weight loss (GLP-1RAs typically provide more weight reduction than SGLT2 inhibitors) 1

Critical Safety Adjustments When Switching

For All SGLT2 Inhibitor Alternatives:

• Assess eGFR before initiation: empagliflozin requires eGFR ≥45, while canagliflozin and dapagliflozin can be started at eGFR ≥30 2
• Reduce loop diuretic dose by 50% in patients on high-dose diuretics to prevent symptomatic hypotension 2
• Reduce insulin dose by approximately 20% and consider reducing or discontinuing sulfonylureas to prevent hypoglycemia 2
• Counsel about genital yeast infection risk and proper hygiene 2
• Warn about euglycemic diabetic ketoacidosis risk and advise temporary discontinuation during acute illness or surgery 2

For GLP-1RA (Liraglutide):

• Start low and titrate slowly to minimize gastrointestinal side effects 1
• No increased hypoglycemia risk when used with metformin, but adjust insulin secretagogues if used concomitantly 1
• No specific diuretic dose adjustment needed (unlike SGLT2 inhibitors) 1

Common Pitfalls to Avoid

• Do not uptitrate SGLT2 inhibitors for cardiovascular benefit: The lowest doses provide full cardioprotection; any dose increase should be for glycemic control only 1, 2
• Do not assume all SGLT2 inhibitors have identical safety profiles: Canagliflozin carries unique amputation and fracture risks not seen with empagliflozin 4
• Do not forget to temporarily discontinue SGLT2 inhibitors at least 3 days before major surgery or prolonged fasting 3
• Do not overlook cost considerations: Both SGLT2 inhibitors and GLP-1RAs are expensive, and out-of-pocket costs may be substantial 1