What is a comparable medication to Farxiga (dapagliflozin) for a patient with type 2 diabetes and heart failure?

Comparable Medications to Farxiga (Dapagliflozin)

Empagliflozin (Jardiance) and canagliflozin (Invokana) are the most comparable medications to Farxiga, with empagliflozin being the preferred alternative based on the most robust cardiovascular and heart failure outcomes data. 1, 2

SGLT2 Inhibitor Class Equivalence

All three FDA-approved SGLT2 inhibitors—empagliflozin, canagliflozin, and dapagliflozin—share the same mechanism of action by inhibiting sodium-glucose reabsorption in the proximal renal tubule, leading to glucosuria and natriuresis. 3

Cardiovascular Outcomes Comparison

• Empagliflozin demonstrates equivalent cardiovascular efficacy to dapagliflozin, reducing hospitalization for heart failure by 35% in patients with type 2 diabetes and high cardiovascular risk. 2

• Both empagliflozin and dapagliflozin show comparable effectiveness across the ejection fraction spectrum (HFrEF and HFpEF), with empagliflozin reducing the composite outcome of cardiovascular death or hospitalization for heart failure by 21% (HR 0.79,95% CI 0.69-0.90). 1, 2

• A 2025 comparative effectiveness study found no significant difference between canagliflozin, dapagliflozin, and empagliflozin for MI/stroke risk (canagliflozin HR 0.98,95% CI 0.91-1.05; dapagliflozin HR 0.95% CI 0.89-1.03 compared to empagliflozin). 4

Heart Failure Specific Considerations

• For heart failure hospitalization, empagliflozin may have a slight advantage over low-dose dapagliflozin (5mg), as the 2025 comparative study showed dapagliflozin 5mg had higher risk of heart failure hospitalization (HR 1.30,95% CI 1.12-1.50) compared to empagliflozin. 4

• Standard dose dapagliflozin (10mg) and empagliflozin (10mg) show comparable heart failure benefits, with both reducing cardiovascular death or hospitalization for heart failure by approximately 21% in HFpEF populations. 1, 2

• Both medications provide benefits regardless of diabetes status, with consistent efficacy in patients with and without type 2 diabetes across the glycemic spectrum. 1, 2, 5

Renal Protection Profile

• Dapagliflozin provides robust renal protection, reducing composite renal outcomes by 44% (HR 0.56,95% CI 0.45-0.68), with benefits observed even in patients with eGFR as low as 25 mL/min/1.73 m². 1

• Both empagliflozin and dapagliflozin demonstrate renoprotective effects independent of diabetes status, making them interchangeable for patients requiring kidney protection. 1

Safety Profile Differences

• Empagliflozin has a slightly lower risk of diabetic ketoacidosis compared to dapagliflozin (dapagliflozin HR 0.78,95% CI 0.68-0.90 compared to empagliflozin). 4

• Canagliflozin carries a higher risk of severe urinary tract infections (HR 1.13,95% CI 1.03-1.24 compared to empagliflozin) but lower risk of genital infections (HR 0.94,95% CI 0.91-0.97). 4

• Both empagliflozin and dapagliflozin have lower rates of genital infections compared to canagliflozin, with dapagliflozin showing HR 0.92 (95% CI 0.89-0.95) compared to empagliflozin. 4

• All SGLT2 inhibitors require monitoring for euglycemic ketoacidosis, volume depletion, and genital/urinary tract infections, particularly when combined with diuretics. 1, 2

Clinical Implementation Algorithm

For patients with heart failure (any ejection fraction):

• Use empagliflozin 10mg daily OR dapagliflozin 10mg daily (avoid dapagliflozin 5mg for heart failure). 1, 4

For patients with diabetic kidney disease:

• Dapagliflozin may offer slightly superior renal protection based on DAPA-CKD data. 1

For patients with history of recurrent UTIs:

• Prefer empagliflozin or dapagliflozin over canagliflozin. 4

For patients at high risk of diabetic ketoacidosis:

• Prefer dapagliflozin over empagliflozin based on comparative safety data. 4

Guideline Recommendations

• The American College of Cardiology strongly recommends SGLT2 inhibitors (empagliflozin or dapagliflozin) for all patients with symptomatic heart failure regardless of ejection fraction or diabetes status (Class I recommendation). 1, 2

• Both medications can be initiated during heart failure hospitalization in stabilized patients, as deferring initiation results in many eligible patients never receiving therapy within one year. 1

• Continue existing guideline-directed medical therapy (ACE inhibitors, ARBs, beta-blockers, MRAs) when adding either empagliflozin or dapagliflozin, as they provide additive benefit. 1