Investigational and emerging treatments are attempting to achieve certain outcomes in order to have a “place at the table” in the management of type 2 diabetes. Some of these desired characteristics include minimal to no risk of hypoglycemia and weight loss with an effective A1C reduction.
In August 2014, a new drug was approved for the management of type 2 diabetes. Empagliflozin, also known as JARDIANCE, is the third FDA-approved agent sodium glucose co-transporter 2 (SGLT2) inhibitors. In healthy individuals, approximately 90 percent of the filtered glucose is reabsorbed by SGLT2 in the proximal renal tubule. The kidney desires to excrete excessive, filtered glucose in order to restore normal levels of glucose in the blood. In a patient with type 2 diabetes, the kidney is dysfunctional and responds to hyperglycemia through glucose reabsorption. (Defronzo RA, Diabetes 2009)
Empagliflozin is a selective SGLT2 inhibitor, which will decrease blood glucose levels secondary to the process of glucosuria in which glucose is excreted in the urine. It is similar to the other SGLT2 inhibitors – INVOKANA (canagliflozin) and FARXIGA (dapagliflozin). Empagliflozin lowers A1C by 0.7 to 1%; reduces weight by 4 to 7 pounds; and lowers blood pressure by 3 to 5 mm Hg. However, it is expensive – estimated to be $10 per day. Other disadvantages include genital yeast infections and urinary tract infections. Empagliflozin should be started as a second or third agent with other oral agents. As a certified diabetes educator, you can educate patients to take the medication in the morning due to a possible diuretic effect.
To me, this agent provides another option in this therapeutic class. However, this class may become “me-too” class as there may be minimal differences between agents. In addition, there are several emerging SGLT2 inhibitors in clinical trials. These agents will not become a common first-line agent for type 2 diabetes, as metformin remains the superior agent. However, these agents could be used as combination therapy. Remember that diabetes management should be individualized and take into consideration the drug’s efficacy, safety, cost, as well as the patient’s preference and tolerance.