SGLT2 Inhibitors — Empagliflozin, Dapagliflozin, Canagliflozin Guide (2026)
- SGLT2 inhibitors reduce heart failure hospitalisation by 35% — independent of blood sugar
- Empagliflozin (Jardiance) and dapagliflozin (Forxiga) are now standard of care for heart failure
- These drugs cause glucose to be excreted in urine — lowering blood sugar without insulin
- DKA risk (diabetic ketoacidosis) — always stop before surgery or prolonged fasting
- UTI and genital infections are the most common side effects due to glucose in urine
What Are SGLT2 Inhibitors?
Sodium-glucose cotransporter-2 (SGLT2) inhibitors work by blocking the SGLT2 protein in the kidney tubules — preventing glucose reabsorption back into the bloodstream. This causes excess glucose to be excreted in the urine, lowering blood sugar. Beyond diabetes, they have remarkable heart and kidney protective effects that are independent of their glucose-lowering action.
All SGLT2 Inhibitors Compared
| Drug (Brand) | T2D approved | Heart Failure | CKD | Dose |
|---|---|---|---|---|
| Empagliflozin (Jardiance) | Yes | HFrEF + HFpEF | Yes | 10–25mg daily |
| Dapagliflozin (Forxiga) | Yes | HFrEF + HFpEF | Yes | 10mg daily |
| Canagliflozin (Invokana) | Yes | Limited data | Yes | 100–300mg daily |
| Ertugliflozin (Steglatro) | Yes | Less data | Limited | 5–15mg daily |
The Heart Failure Revolution
The landmark EMPEROR-Reduced and EMPEROR-Preserved trials (empagliflozin) and DAPA-HF trial (dapagliflozin) showed these drugs reduce heart failure hospitalisation and cardiovascular death in patients with heart failure — regardless of whether they have diabetes. This was a paradigm shift: SGLT2 inhibitors are now core heart failure medications, not just diabetes drugs.
Kidney Protection
The DAPA-CKD and EMPA-KIDNEY trials showed SGLT2 inhibitors slow CKD progression by approximately 40% — independent of blood sugar control. Dapagliflozin is now approved for CKD even in patients without diabetes. This represents one of the most significant advances in nephrology in decades.
Side Effects
- Genital mycotic infections: Most common — 10–15% of women, 5% of men. Glucose in urine creates ideal conditions for yeast. Good genital hygiene, cotton underwear, and antifungal treatment if needed.
- UTIs: Slightly increased risk — more urine glucose provides bacterial substrate
- Diabetic Ketoacidosis (DKA): Rare but serious — particularly in Type 1 (if used off-label), and during illness, surgery, or prolonged fasting. The SGLT2 inhibitor 'sick day rules' require stopping the drug during illness or before surgery.
- Volume depletion/hypotension: Mild diuretic effect — monitor BP, especially in elderly or those on diuretics