Compare Empagliflozin with Other SGLT2 Inhibitors for Type 2 Diabetes

Empagliflozin isn't just another diabetes pill. It's one of the most studied SGLT2 inhibitors on the market, with real-world data showing it cuts heart failure hospitalizations and kidney disease progression in people with type 2 diabetes. But is it the best choice for you? If you're comparing it to other drugs like dapagliflozin, canagliflozin, or ertugliflozin, you're asking the right question. Not all SGLT2 inhibitors are the same - differences in dosing, side effects, heart and kidney protection, and even cost can change which one works best for your body and lifestyle.

What empagliflozin actually does

Empagliflozin works by blocking a protein in your kidneys called SGLT2. Normally, your kidneys reabsorb sugar back into your blood. Empagliflozin stops that. Instead, excess glucose gets flushed out through urine. That’s why people on this drug often lose a few pounds - they’re literally peeing out sugar. But it’s not just about blood sugar. Large clinical trials like EMPA-REG OUTCOME showed empagliflozin reduces the risk of cardiovascular death by 38% in high-risk patients. That’s not a small number. It’s one of the few diabetes drugs proven to save lives beyond just lowering HbA1c.

How dapagliflozin compares

Dapagliflozin (brand name Farxiga) is the closest direct competitor. Like empagliflozin, it’s once daily, works the same way, and has strong evidence for heart and kidney protection. The DECLARE-TIMI 58 trial showed dapagliflozin reduced hospitalization for heart failure by 27%. That’s solid, but not quite as strong as empagliflozin’s 35% reduction in cardiovascular death. In head-to-head studies, both drugs lower HbA1c by about 0.7% to 0.9%. Side effects are nearly identical: yeast infections, urinary tract infections, and increased urination. One practical difference? Dapagliflozin is available in a combination pill with metformin and also with a GLP-1 agonist (semaglutide). Empagliflozin has combo options too, but fewer. If you’re already on metformin and need more control, dapagliflozin’s combo options might make your pill routine simpler.

Canagliflozin: more risk, less benefit

Canagliflozin (Invokana) was the first SGLT2 inhibitor approved in the U.S. It lowers blood sugar well - about 0.8% on average. But its safety profile is less favorable. The CANVAS trial found a higher risk of leg and foot amputations - about twice as many compared to placebo. The FDA added a black box warning for this. It also increases the risk of bone fractures. While it does reduce heart failure hospitalizations, it doesn’t show the same clear reduction in cardiovascular death as empagliflozin. For most patients today, especially those over 60 or with poor circulation, canagliflozin is rarely the first choice. If your doctor suggests it, ask why - and whether the benefits outweigh the risks in your case.

Ertugliflozin: the quiet option

Ertugliflozin (Steglatro) is the newest SGLT2 inhibitor. It’s effective - lowers HbA1c by 0.7% to 0.8% - and has similar heart and kidney benefits in early trials. But there’s one big catch: there’s no large outcomes trial proving it reduces heart attacks, strokes, or death like empagliflozin and dapagliflozin have. The VERTIS CV trial showed non-inferiority for major heart events, but not superiority. It’s a good option if you need a third-line drug or if you’re allergic to the others, but it doesn’t have the same weight of evidence behind it. Also, it’s not available in as many combo packs. If you’re looking for proven, life-saving benefits, ertugliflozin isn’t the top pick yet.

Other alternatives beyond SGLT2 inhibitors

Empagliflozin isn’t the only class of drug you should consider. If you’re comparing it to other diabetes medications, you’re really asking: what gives me the best protection with the fewest side effects?

• GLP-1 agonists like semaglutide (Wegovy, Ozempic) and liraglutide (Victoza) are often more effective at lowering HbA1c and weight loss. They also reduce heart attacks and strokes. But they’re injectables, and many people struggle with nausea or cost. If you hate pills, you might prefer a weekly shot.
• Metformin is still the first-line drug for most people. It’s cheap, safe, and has 70 years of data. But it doesn’t protect your heart like empagliflozin does. Many people end up on both.
• DPP-4 inhibitors like sitagliptin are weight-neutral and low-risk for infections, but they don’t lower HbA1c as much and offer no heart or kidney protection.
• Insulin works when other drugs fail, but it causes weight gain and low blood sugar. It’s not a substitute for empagliflozin’s protective effects - it’s a backup.

If your goal is to protect your heart and kidneys, empagliflozin and dapagliflozin lead the pack. GLP-1 agonists might beat them on weight loss and HbA1c, but not all patients can tolerate them.

Side effects you need to watch for

All SGLT2 inhibitors carry similar risks:

• Genital yeast infections - more common in women, but men get them too. Keep the area dry, wear cotton underwear.
• Urinary tract infections - drink plenty of water. If you get frequent UTIs, this drug might not be for you.
• Dehydration and low blood pressure - especially if you’re on diuretics or have kidney issues. Watch for dizziness when standing up.
• Ketoacidosis - rare, but dangerous. Symptoms: nausea, vomiting, stomach pain, confusion. This can happen even if your blood sugar isn’t high. Stop the drug and seek help immediately.
• Increased urination - you’ll need to pee more, especially at first. Plan your day around it.

There’s also a small risk of Fournier’s gangrene - a rare but life-threatening genital infection. If you have sudden, severe pain or swelling in the genital area, go to the ER.

Cost and insurance: what really matters

Empagliflozin is available as a generic now in many countries, including New Zealand and the U.S. That’s made a big difference. The brand version (Jardiance) can cost over $500 a month without insurance. Generic empagliflozin? Around $10 to $30 a month. Dapagliflozin is also generic now, and prices are similar. Canagliflozin and ertugliflozin are still mostly brand-name, which makes them much more expensive. If you’re paying out of pocket, cost can decide this for you. Check your pharmacy’s discount programs - many offer $5 to $10 copays for generics.

Who should pick empagliflozin?

Empagliflozin is the top choice if:

• You have type 2 diabetes and heart disease, or are at high risk for it
• You have chronic kidney disease (eGFR above 25)
• You want a once-daily pill with strong evidence for saving your life
• You’re okay with mild side effects like increased urination
• You need a low-cost generic option

It’s less ideal if:

• You’re prone to frequent UTIs or yeast infections
• You’re dehydrated often or have low blood pressure
• You’re on dialysis or have very advanced kidney disease (eGFR below 25)
• You’re pregnant or planning to be

Final decision: what to ask your doctor

Don’t just ask, “Which drug is best?” Ask:

1. “Do I have heart or kidney disease that would make empagliflozin or dapagliflozin the best choice?”
2. “Are there any risks I have that make canagliflozin or ertugliflozin unsafe?”
3. “Can we try a generic version - and will my insurance cover it?”
4. “What happens if I don’t take any of these drugs? What’s the risk to my heart and kidneys?”

The right drug isn’t the one with the fanciest name. It’s the one that fits your body, your life, and your long-term health goals. Empagliflozin has the strongest proof of protecting your heart and kidneys - but dapagliflozin is a very close second. The rest? They’re either less proven, more risky, or more expensive. Choose based on evidence, not marketing.