Can a patient with diabetes and potential cardiovascular risk factors replace empagliflozin (SGLT2 inhibitor) 10 mg with dapagliflozin (SGLT2 inhibitor) 10 mg?

Can Empagliflozin 10 mg Be Replaced with Dapagliflozin 10 mg?

Yes, empagliflozin 10 mg can generally be replaced with dapagliflozin 10 mg in patients with diabetes and cardiovascular risk factors, as both SGLT2 inhibitors demonstrate cardiovascular and renal protection at these doses, though empagliflozin has superior evidence for cardiovascular mortality reduction. 1, 2

Key Considerations for Switching

Cardiovascular Outcomes: Empagliflozin Has Stronger Mortality Data

Empagliflozin demonstrates superior cardiovascular mortality reduction compared to dapagliflozin. 2

• Empagliflozin reduces cardiovascular death by 38% (HR 0.62,95% CI 0.49-0.77) and all-cause mortality by 32% (HR 0.68,95% CI 0.57-0.82) 1, 2
• Dapagliflozin shows no significant reduction in cardiovascular death (HR 0.98,95% CI 0.82-1.17) 1, 3
• For MACE outcomes, empagliflozin achieves superiority (HR 0.86,95% CI 0.74-0.99, p=0.04), while dapagliflozin shows only non-inferiority (HR 0.93,95% CI 0.84-1.03, p=0.17) 1, 3

Heart Failure Outcomes: Both Are Effective

Both medications significantly reduce heart failure hospitalization, with dapagliflozin showing slightly better performance in this specific outcome 1:

• Empagliflozin reduces HF hospitalization by 35% (HR 0.65,95% CI 0.50-0.85) 1
• Dapagliflozin reduces HF hospitalization by 27% (HR 0.73,95% CI 0.61-0.88) 1
• For the composite of cardiovascular death or HF hospitalization, empagliflozin shows HR 0.66 (95% CI 0.55-0.79) versus dapagliflozin HR 0.83 (95% CI 0.73-0.95) 1

Renal Protection: Empagliflozin Shows Superior Benefit

Empagliflozin demonstrates stronger renal protection than dapagliflozin 1, 2:

• Empagliflozin reduces renal composite endpoints by 46% (HR 0.54,95% CI 0.40-0.75) 1
• Dapagliflozin reduces renal composite endpoints by 47% (HR 0.53,95% CI 0.43-0.66) 1
• Both can be initiated at eGFR ≥25 mL/min/1.73 m² for cardiovascular and renal protection 4, 5

Clinical Algorithm for Switching Decision

When Empagliflozin Should NOT Be Replaced:

1. Established cardiovascular disease with high mortality risk: Empagliflozin's proven 38% cardiovascular mortality reduction makes it the preferred agent 2
2. History of myocardial infarction or stroke: Empagliflozin has superior MACE reduction 1, 2
3. Advanced chronic kidney disease (eGFR 25-45 mL/min/1.73 m²): Empagliflozin shows 50% renal risk reduction in this population 2

When Switching to Dapagliflozin Is Reasonable:

1. Primary indication is heart failure: Dapagliflozin has robust HF hospitalization data (HR 0.73) and is FDA-approved for HFrEF and HFpEF 1, 4
2. Cost or formulary restrictions: If empagliflozin is not accessible and cardiovascular mortality is not the primary concern 1
3. Patient already stable on dapagliflozin: No need to switch to empagliflozin if achieving therapeutic goals 4

Practical Switching Protocol

If Proceeding with Switch:

• Stop empagliflozin 10 mg and start dapagliflozin 10 mg the next day—no washout period required 4, 5
• No dose titration needed: Both use fixed 10 mg daily dosing for cardiovascular/renal protection 1, 4
• Recheck eGFR within 1-2 weeks: Expect transient 3-5 mL/min/1.73 m² dip, which is hemodynamic and reversible 5
• Monitor for volume depletion: Consider reducing concurrent diuretic doses by 20-50% if patient is on loop diuretics 4, 5

Safety Profile Comparison

Adverse Events:

• Genital mycotic infections: Slightly higher with dapagliflozin (8.66%) versus empagliflozin (3.1%, p=0.005) 6
• Urinary tract infections: Higher with dapagliflozin (7.08%) versus empagliflozin (2.34%, p=0.003) 6
• Diabetic ketoacidosis: Similar low risk with both agents (0.3% with dapagliflozin) 3
• Hypoglycemia: Both have low risk when not combined with insulin or sulfonylureas 4, 6

Common Pitfalls to Avoid

1. Do not switch solely for cost if patient has established ASCVD: Empagliflozin's mortality benefit is clinically significant and not replicated by dapagliflozin 2
2. Do not discontinue either drug if eGFR falls below 45 mL/min/1.73 m²: Cardiovascular and renal benefits persist even when glycemic efficacy is lost 4, 5
3. Do not reduce insulin doses by more than 20% when switching: Risk of rebound hyperglycemia 4
4. Educate patients to hold medication during acute illness: Both drugs should be withheld during fever, vomiting, diarrhea, or reduced oral intake to prevent ketoacidosis 5

Bottom Line

For patients with established cardiovascular disease or high cardiovascular mortality risk, empagliflozin 10 mg should be maintained due to its proven 38% cardiovascular mortality reduction. 2 For patients whose primary indication is heart failure or chronic kidney disease without established ASCVD, dapagliflozin 10 mg is an acceptable alternative with comparable heart failure and renal protection. 1, 4