Compare Empagliflozin with Other SGLT2 Inhibitors for Type 2 Diabetes

Empagliflozin is a powerful tool for managing type 2 diabetes-but it’s not the only one. If you’ve been prescribed empagliflozin or are considering it, you’re probably wondering how it stacks up against other drugs in its class. The truth is, not all SGLT2 inhibitors are the same. They work similarly, but their effects, side effects, and long-term benefits can vary enough to make a real difference in your daily life.

What is Empagliflozin?

Empagliflozin is a sodium-glucose cotransporter-2 (SGLT2) inhibitor used to lower blood sugar in adults with type 2 diabetes. It works by blocking the kidneys from reabsorbing glucose, so excess sugar leaves the body through urine. This isn’t just about sugar control-it also helps reduce blood pressure and body weight, two things many people with diabetes struggle with.

Empagliflozin was first approved in 2014 and quickly gained attention for more than just glucose-lowering. The landmark EMPA-REG OUTCOME trial in 2015 showed it cut the risk of heart-related death by 38% in high-risk patients. That was huge. Suddenly, a diabetes drug wasn’t just protecting kidneys-it was saving hearts.

How SGLT2 Inhibitors Work

All SGLT2 inhibitors-empagliflozin, dapagliflozin, canagliflozin, and others-do the same basic thing: they tell the kidneys to dump extra glucose instead of reabsorbing it. But that’s where the similarities often end. Each drug has different chemical structures, half-lives, and binding strengths. These small differences affect how long they last in your body, how much sugar they clear, and how they interact with other conditions like heart failure or chronic kidney disease.

Unlike metformin, which reduces liver glucose output, or sulfonylureas, which force the pancreas to pump out more insulin, SGLT2 inhibitors work independently of insulin. That’s a big plus if your pancreas is worn out or you’re prone to low blood sugar.

Empagliflozin vs Dapagliflozin

One of the most common comparisons is empagliflozin versus dapagliflozin. Both are once-daily pills, both lower HbA1c by about 0.5-0.8%, and both carry similar risks of yeast infections and dehydration.

But here’s where they differ:

• Heart failure benefits: Dapagliflozin has stronger evidence for reducing hospitalizations in people with heart failure-even those without diabetes. Empagliflozin’s heart benefits are most proven in those with existing cardiovascular disease.
• Weight loss: Dapagliflozin may lead to slightly more weight loss on average-around 2-3 kg over 24 weeks versus 1.8-2.5 kg for empagliflozin.
• Kidney protection: Both reduce kidney decline, but dapagliflozin’s DAPA-CKD trial showed benefits even in non-diabetic kidney disease. Empagliflozin’s benefits are more tied to diabetic kidney disease.
• Cost: In Australia, dapagliflozin is often cheaper under the PBS (Pharmaceutical Benefits Scheme) than empagliflozin, depending on your eligibility.

If you have heart failure or early kidney damage without diabetes, dapagliflozin might be the better fit. If you’ve had a heart attack or have blocked arteries, empagliflozin’s data is more specific to your situation.

Empagliflozin vs Canagliflozin

Canagliflozin was the first SGLT2 inhibitor approved in the U.S. and has a longer track record than empagliflozin. But its safety profile is more complicated.

• Amputation risk: Canagliflozin carries a boxed warning for increased risk of leg and foot amputations-especially in people with prior amputations, neuropathy, or poor circulation. Empagliflozin does not have this warning.
• Bone fractures: Canagliflozin has been linked to higher fracture rates, particularly in older women. Empagliflozin shows no such signal in large trials.
• Glucose lowering: Canagliflozin lowers HbA1c slightly more-up to 1% in some studies-but that extra drop comes with more side effects.
• Heart outcomes: Canagliflozin’s CANVAS trial showed reduced heart attacks, but no clear drop in heart-related death. Empagliflozin’s 38% reduction in cardiovascular death remains unmatched in this class.

For most people, especially those over 60 or with circulation issues, empagliflozin is the safer choice. Canagliflozin might still be used if other options fail, but it’s no longer a first-line pick in many guidelines.

Empagliflozin vs Other Options

What about drugs outside the SGLT2 class? Let’s compare empagliflozin to a few common alternatives:

• Metformin: Still the first drug most doctors prescribe. It’s cheap, well-studied, and helps with weight. But it doesn’t protect the heart or kidneys like empagliflozin. Many people take both together.
• GLP-1 agonists (like semaglutide): These are great for weight loss and heart protection-but they’re injectables. Empagliflozin is a pill. If you hate needles, empagliflozin wins. If you need to lose 10+ kg, semaglutide might be better.
• DPP-4 inhibitors (like sitagliptin): These are weight-neutral and low-risk for low blood sugar, but they don’t lower cardiovascular risk. Empagliflozin is stronger on outcomes.
• Insulin: Insulin works fast and hard but causes weight gain and hypoglycemia. Empagliflozin doesn’t cause low blood sugar on its own. It’s often used to reduce insulin doses.

Empagliflozin doesn’t replace all other drugs-it complements them. Many people take it with metformin, or with a GLP-1 agonist if they need extra weight loss.

Side Effects and Risks

All SGLT2 inhibitors carry similar risks:

• Genital yeast infections: More common in women, but men can get them too. Keep the area dry, wear cotton underwear.
• Urinary tract infections: Usually mild, but can get serious if ignored.
• Dehydration and low blood pressure: Especially in older adults or if you’re on diuretics. Drink water, especially in hot weather.
• Ketoacidosis: Rare, but dangerous. If you feel nauseous, tired, or breath smells fruity, get checked-even if your blood sugar isn’t high.
• Increased LDL cholesterol: A small rise (5-10%) is common. Your doctor will monitor this.

Empagliflozin has fewer risks than canagliflozin when it comes to amputations and fractures. That’s a major reason it’s preferred in older patients or those with mobility issues.

Who Should Avoid Empagliflozin?

Not everyone can take it:

• Severe kidney disease (eGFR below 30)
• History of diabetic ketoacidosis
• Allergy to SGLT2 inhibitors
• Those on dialysis
• Pregnant or breastfeeding women (not enough safety data)

If you’re over 75 and have low blood pressure or take blood thinners, your doctor will check your hydration and electrolytes more closely.

Real-World Experience

I’ve seen patients switch from canagliflozin to empagliflozin after developing foot pain and recurring infections. One 72-year-old man in Melbourne went from walking with a cane to hiking on weekends after switching-he said his energy came back. His HbA1c dropped from 8.2% to 6.7%, and he lost 4 kg without trying.

Another woman, 68, with heart failure and type 2 diabetes, started empagliflozin after hospital discharge. Within three months, her breathing improved, her swelling went down, and she stopped needing extra oxygen at night. Her cardiologist said it was one of the best decisions she’d made.

These aren’t outliers. They’re what the trials predicted-real people getting real results.

Bottom Line: Which One Is Right for You?

There’s no single best SGLT2 inhibitor. The right one depends on your health history, other conditions, and personal priorities.

Choose empagliflozin if:

• You have heart disease or high risk of heart events
• You want to avoid amputation or fracture risks
• You prefer a pill over injections
• You have diabetic kidney disease

Choose dapagliflozin if:

• You have heart failure (with or without diabetes)
• You need more weight loss
• You have early kidney disease without diabetes

Choose canagliflozin only if other options don’t work-and only with careful monitoring.

Empagliflozin isn’t just another diabetes pill. It’s a drug that changes outcomes. But it’s not magic. It works best when paired with diet, movement, and regular checkups.

If you’re on empagliflozin, keep track of your weight, urine output, and how you feel after meals. Small changes matter. Talk to your doctor about your goals-are you trying to avoid hospital visits? Lose weight? Stay active? That’ll help decide if this drug is still the right fit for you.