SGLT2 Inhibitors: Independent Evidence on Heart, Kidney & Risks

Table of contents

• Evidence summary
• What SGLT2 inhibitors are
• How they work
• What they are prescribed for
• What works and what does not
• Benefits by claim
• Risks and all side effects
• All interactions
• Who should avoid SGLT2 inhibitors
• Dosage and how to take it
• Follow the money: who makes them and who funded the evidence
• Related research
• Frequently asked questions
• Sources and funding notes

Evidence summary

Independent evidence and credibility scorecard

Independence tiers: 1 = regulator or government body; 2 = academic or Cochrane team with no declared commercial funding for the work; 3 = independent authors analysing mostly manufacturer-run trials, or minor declared industry ties; 4 = manufacturer-funded or manufacturer-authored. Credibility runs from A (highest) to D.

Our sources cluster in the UK and US, with the trial sponsors spread across Germany, the UK/Sweden and the US. The strongest signal is convergence: three rival companies, each with an interest in making its own drug look best, found benefits of a similar size for heart failure and kidney disease. Independent reviewers (Cochrane, an unfunded BMJ network meta-analysis) and two regulators reached the same conclusion from the same data. What no one has is a large publicly funded outcome trial, so every efficacy estimate traces back to industry data.

What SGLT2 inhibitors are

SGLT2 inhibitors (also called gliflozins) are prescription tablets that block a transporter called sodium-glucose co-transporter 2 in the kidney. The MHRA lists four available in the UK: canagliflozin, dapagliflozin, empagliflozin and ertugliflozin (MHRA). This review focuses on the first three, which have the large outcome trials.

• Dapagliflozin: brand Forxiga (UK/EU) or Farxiga (US), made by AstraZeneca. Generic versions have been sold in the UK since August 2025 and approved in the US since 7 April 2026 (CPE; FDA).
• Empagliflozin: brand Jardiance, developed by Boehringer Ingelheim with Eli Lilly. The UK product information now lists it as "Empagliflozin 10 mg film-coated tablets (previously known as Jardiance)", with Boehringer Ingelheim as licence holder (SmPC). Lilly's filing lists the compound patent as running to 2029 in the US and major European countries (Lilly 10-K).
• Canagliflozin: brand Invokana, sold in the US by Janssen (Johnson & Johnson). Its initial US approval was in 2013 (Invokana label).

All are prescription-only medicines. Fixed-dose combinations with other diabetes medicines also exist.

How they work

The kidneys filter glucose out of the blood and then pull almost all of it back. SGLT2 does much of that pulling back in the first part of the kidney tubule. Blocking it means glucose and sodium leave in the urine. On dapagliflozin 10 mg, people with type 2 diabetes passed about 70 g of glucose a day (about 280 kcal) and about 375 mL more urine a day at 12 weeks (Forxiga SmPC).

The regulator-approved product information describes the proposed heart and kidney mechanism. More sodium reaches the far end of the tubule, which triggers a feedback loop that lowers pressure inside the kidney's filters. Together with the extra urine, this reduces fluid overload and blood pressure and eases the load on the heart (Forxiga SmPC). What is proven in humans is the outcome: fewer heart-failure admissions and slower kidney decline, in people with and without diabetes. What remains a hypothesis is exactly which mechanism produces it. The SmPC's wording that the benefits "may" come from these effects reflects that uncertainty.

Because glucose removal depends on how much glucose is filtered, the sugar-lowering effect shrinks as kidney function falls. It is reduced below an eGFR of 45 and is likely absent in severe kidney impairment. The heart and kidney benefits persist at lower eGFR (Forxiga SmPC; Nuffield 2022). For the same reason the drugs rarely cause hypoglycaemia on their own: when blood sugar is normal, little glucose is filtered.

What they are prescribed for

Licensed uses

In the UK, dapagliflozin and empagliflozin are licensed for adults and children aged 10 and over with type 2 diabetes, and for adults with symptomatic chronic heart failure or chronic kidney disease (Forxiga SmPC; empagliflozin SmPC). In the US, canagliflozin is approved for glucose control in type 2 diabetes (age 10 and up), to reduce major cardiovascular events in adults with type 2 diabetes and heart disease, and to reduce kidney failure and related outcomes in diabetic kidney disease with albuminuria (Invokana label). None of these drugs is licensed for type 1 diabetes in these labels.

Where guidelines place them

NICE's February 2026 update of NG28 made SGLT2 inhibitors part of first-line treatment. For adults with type 2 diabetes and no relevant comorbidity, NICE now says to offer modified-release metformin and an SGLT2 inhibitor. The same applies to people with heart failure or obesity. For people with artery disease, NICE adds semaglutide (NICE NG28). For eGFR 20–29, NICE recommends dapagliflozin or empagliflozin plus a DPP-4 inhibitor. In frailty, it advises offering an SGLT2 inhibitor only if the frailty does not put the person at risk of volume depletion or low blood pressure (NICE NG28).

Separate NICE technology appraisals cover dapagliflozin and empagliflozin for heart failure with reduced ejection fraction (TA679; TA773), heart failure with preserved or mildly reduced ejection fraction (TA902; TA929) and chronic kidney disease (TA775; TA942). NICE also flags a research gap: SGLT2 inhibitors are prescribed less often to people from the most deprived groups, and it asks why (NICE research recommendations).

What works and what does not

Benefits by claim

Heart failure with reduced ejection fraction

In DAPA-HF (4,744 people, funded by AstraZeneca), worsening heart failure or cardiovascular death occurred in 16.3% on dapagliflozin vs 21.2% on placebo over a median 18 months (HR 0.74, 95% CI 0.65–0.85). That is roughly one event prevented for every 20 people treated over that period. Deaths from any cause were 11.6% vs 13.9% (HR 0.83), and results were similar with and without diabetes (McMurray 2019). EMPEROR-Reduced (3,730 people, funded by Boehringer Ingelheim and Eli Lilly) found 19.4% vs 24.7% for cardiovascular death or heart-failure admission (HR 0.75) and a slower yearly fall in kidney function (Packer 2020).

Heart failure with preserved or mildly reduced ejection fraction

Few drugs had helped this group before. EMPEROR-Preserved (5,988 people, Boehringer Ingelheim/Eli Lilly) found 13.8% vs 17.1% for the primary outcome (HR 0.79), driven mainly by fewer heart-failure admissions (Anker 2021). DELIVER (6,263 people, AstraZeneca) found 16.4% vs 19.5% (HR 0.82). Cardiovascular death alone was not significantly reduced (HR 0.88, 0.74–1.05) (Solomon 2022). In plain terms: fewer hospital stays, with no proven effect on survival in this group.

Chronic kidney disease

DAPA-CKD (4,304 people, AstraZeneca) was stopped early for benefit. The primary kidney-or-death outcome occurred in 9.2% vs 14.5% (HR 0.61); the authors calculated that 19 people needed treatment for 2.4 years to prevent one event. Deaths were 4.7% vs 6.8% (Heerspink 2020). EMPA-KIDNEY (6,609 people with a wider range of kidney function, eGFR 20–90, funded by Boehringer Ingelheim and Eli Lilly) found 13.1% vs 16.9% (HR 0.72). It did not find a significant drop in deaths over two years (Herrington 2023). CREDENCE (canagliflozin, 4,401 people with diabetic kidney disease, Janssen) found a 30% lower risk of the primary outcome and 32% less end-stage kidney disease (Perkovic 2019).

The cleanest summary comes from the Oxford collaborative meta-analysis, paid for by the UK Medical Research Council and Kidney Research UK. Across 13 trials, SGLT2 inhibitors cut kidney disease progression by 37% and acute kidney injury by 23%, with similar effects in people with and without diabetes and across kidney diagnoses (Nuffield 2022). The 2024 Cochrane review, limited to people with diabetes and kidney disease, rated the cut in kidney failure (RR 0.70) and death (RR 0.85) as high-certainty (Natale 2024).

Heart attacks, strokes and cardiovascular death in type 2 diabetes

This is the area where the class was first tested and where the results are least consistent. EMPA-REG OUTCOME (7,020 people with type 2 diabetes and heart disease, Boehringer Ingelheim/Eli Lilly) found a 14% lower rate of cardiovascular death, heart attack or stroke (10.5% vs 12.1%). The gain came from fewer cardiovascular deaths (3.7% vs 5.9%). Heart attacks and strokes did not differ significantly (Zinman 2015). CANVAS (10,142 people, Janssen) also found a 14% reduction (Neal 2017). DECLARE (17,160 people, most without established artery disease, AstraZeneca) found no significant change in heart attacks and strokes (HR 0.93, 0.84–1.03) and no change in cardiovascular death (HR 0.98), but fewer heart-failure admissions (HR 0.73) (Wiviott 2019).

Pooling the three diabetes trials, Zelniker and colleagues found an 11% cut in major cardiovascular events, seen only in people who already had artery disease (HR 0.86) and not in those without (HR 1.00). Benefits for heart failure and kidneys held regardless (Zelniker 2019). That analysis declared no funding, but its authors include DECLARE's lead investigator. The independent BMJ network meta-analysis (764 trials, 421,346 people, no funding) found that SGLT2 inhibitors lowered death, cardiovascular death, non-fatal heart attack and kidney failure with high certainty but appeared to have no effect on stroke. It also found that absolute benefit varies widely: 3 to 40 fewer deaths per 1,000 people over five years, depending on baseline risk (Palmer 2021).

Blood sugar

The glucose effect is moderate. In AstraZeneca's add-on-to-metformin trial summarised in the UK product information, HbA1c fell by 0.78 percentage points on dapagliflozin vs 0.02 on placebo at 102 weeks (Forxiga SmPC). Because the effect fades with kidney function, NICE and the product information say additional glucose-lowering treatment should be considered when eGFR falls below 45 (empagliflozin SmPC).

Weight and blood pressure

Losing around 280 kcal of glucose a day in urine leads to some weight loss, and the extra urine lowers blood pressure slightly (Forxiga SmPC). The independent BMJ review rated the weight effect as low-certainty (Palmer 2021). These drugs are not licensed or marketed as weight-loss treatments.

Risks and all side effects

Diabetic ketoacidosis and sick-day rules

In DECLARE, DKA occurred in 0.3% on dapagliflozin vs 0.1% on placebo (Wiviott 2019). Across 13 trials, the relative risk in people with diabetes was 2.12 (1.49–3.04), but the absolute risk was low, around 0.2 events per 1,000 patient-years on placebo. Only one case occurred among people without diabetes in about 30,000 patient-years (Nuffield 2022). A charity-funded Swedish–Danish registry study (its funders include the Novo Nordisk Foundation) found a similar doubling (HR 2.14, 1.01–4.52) compared with GLP-1 drugs (Ueda 2018).

The danger is that DKA can be missed because blood sugar looks normal. The product information names higher-risk groups: people with low insulin reserve (including latent autoimmune diabetes in adults or past pancreatitis), restricted food intake or severe dehydration, reduced insulin doses, acute illness, surgery or alcohol misuse (Forxiga SmPC). NICE asks prescribers to check for these risks before starting and warns that very low carbohydrate or ketogenic diets raise the risk. It notes "multiple instances of avoidable" DKA admissions in its committee's experience (NICE NG28).

The regulator's rule is to interrupt treatment in people admitted for major surgery or serious acute illness, measure blood ketones (blood is preferred over urine, because these drugs can reduce ketones in urine) and restart only when ketones are normal and the person is stable (MHRA 2020). The US canagliflozin label advises withholding the drug at least 3 days before surgery or procedures with prolonged fasting where possible (Invokana label). At home, the NHS warns that vomiting, diarrhoea or fever while taking dapagliflozin risks dehydration and tells people to get advice from a pharmacist or doctor, or follow the plan they have been given (NHS). Sick-day plans vary by local service; the exact steps should come from the prescriber.

Genital and urinary infections

Genital fungal infections (thrush, balanitis) are the most common side effect. In dapagliflozin's 13-trial safety pool they affected 5.5% vs 0.6% on placebo, and 8.4% vs 1.2% of women. Most were mild and responded to standard treatment (Forxiga SmPC). The independent BMJ review rated this harm as high-certainty (Palmer 2021). Phimosis, sometimes needing circumcision, has been reported. Urinary tract infections are listed as common in the product information. The registry study found no increase in serious urinary infections compared with GLP-1 drugs (HR 0.89) (Ueda 2018).

Fournier's gangrene

FDA staff identified 55 cases of Fournier's gangrene in people taking SGLT2 inhibitors reported between March 2013 and January 2019. All needed surgery, and 3 died. Over a much longer period (1984–2019), they found 19 cases with all other diabetes drugs combined. Reports cannot give a true rate, and people may be more likely to report a newly publicised harm (Bersoff-Matcha 2019). In the randomised DECLARE trial, there was 1 case on dapagliflozin and 5 on placebo (Forxiga SmPC). Both sources point to a rare event that clinicians and patients should recognise early.

Amputation: a canagliflozin signal

CANVAS found 6.3 vs 3.4 amputations per 1,000 patient-years on canagliflozin vs placebo (HR 1.97), mostly at the toe or forefoot (Neal 2017). The European Medicines Agency then told patients on canagliflozin, dapagliflozin and empagliflozin to check their feet and follow preventive foot-care advice (EMA). The FDA added a boxed warning in 2017 and removed it in August 2020 after CREDENCE and other trials. It said the risk "is still increased" but lower than first described, and kept it in the warnings section (FDA 2020). CREDENCE itself found no significant difference (Perkovic 2019).

The independent picture is mixed. In the Oxford meta-analysis, the 12 trials other than CANVAS showed no clear excess (RR 1.06, 0.93–1.21), but across all trials the risk was 15% higher (RR 1.15) (Nuffield 2022). The registry study, where 99% of users took dapagliflozin or empagliflozin, found a higher amputation rate than with GLP-1 drugs (2.7 vs 1.1 per 1,000 person-years; HR 2.32). Observational data cannot exclude that the groups differed in other ways (Ueda 2018). Our reading: the clearest signal is with canagliflozin; a smaller class effect cannot be ruled out, so foot care matters for anyone with diabetes on these drugs.

Fractures

The canagliflozin label warns of a higher fracture risk in CANVAS, appearing as early as 12 weeks (Invokana label). The registry study found no clear excess in fractures for the class as a whole (HR 1.11, 0.93–1.33) (Ueda 2018).

Other side effects

The UK dapagliflozin product information also lists: hypoglycaemia when combined with insulin or sulfonylureas, volume depletion, back pain, dizziness, rash, passing more urine, raised haematocrit, a small early rise in creatinine, thirst, constipation, dry mouth, waking at night to urinate, genital itching, and rarely angioedema and tubulointerstitial nephritis (Forxiga SmPC). In people with eGFR below 60, more had raised parathyroid hormone and low blood pressure. In trials in people with diabetes and kidney disease, hypoglycaemia was slightly less common on SGLT2 inhibitors than on placebo, including episodes needing help from another person (RR 0.75) (Cochrane 2024).

All interactions

Who should avoid SGLT2 inhibitors

Contraindications

The only formal contraindication in the UK and US labels is hypersensitivity to the drug or its ingredients (Forxiga SmPC; Invokana label). Dapagliflozin tablets contain lactose.

Use with care or not at all

• Type 1 diabetes: dapagliflozin and empagliflozin should not be used; DKA was common in type 1 trials of dapagliflozin (Forxiga SmPC; empagliflozin SmPC).
• Previous DKA on an SGLT2 inhibitor: restarting is not recommended unless another clear cause was found and fixed.
• Frailty, dehydration risk or low blood pressure: NICE advises offering the drug only if frailty does not raise the risk of volume depletion or hypotension (NICE NG28).
• Foot ulcers, peripheral artery disease or past amputation: the amputation signal makes careful foot monitoring important, especially with canagliflozin (EMA).
• Recurrent genital infections: people with a past history were more likely to have a recurrence (Forxiga SmPC).

Pregnancy and breastfeeding

There are no human pregnancy data for dapagliflozin. Rat studies showed harm to the developing kidney in the period matching the second and third trimesters, so use is not recommended then and the drug should be stopped when pregnancy is detected. It should not be used while breastfeeding (Forxiga SmPC).

Children and adolescents

Dapagliflozin and empagliflozin are licensed for type 2 diabetes from age 10, but not for heart failure or kidney disease under 18 (empagliflozin SmPC). In a small trial in young people aged 10–24, the HbA1c difference vs placebo did not reach significance (−0.75%, 95% CI −1.65 to 0.15) (Forxiga SmPC).

Kidney and liver disease

Dapagliflozin should not be started below eGFR 15, and empagliflozin not below eGFR 20. In DAPA-CKD, treatment was continued if eGFR fell below 25, and glucose lowering is weak or absent at these levels. No trials included people on dialysis (Forxiga SmPC; empagliflozin SmPC; Cochrane). In severe liver impairment, dapagliflozin starts at 5 mg and empagliflozin is not recommended.

Older adults

No age-based dose change is needed, but people over 75 face a higher risk of volume depletion, and older people are more likely to take diuretics and blood pressure drugs that add to it (empagliflozin SmPC).

Dosage and how to take it

Label doses

These are label doses for information only, not personal advice.

How to take it

Dapagliflozin and empagliflozin are taken once a day, with or without food, swallowed whole (Forxiga SmPC). The NHS advises taking a missed dapagliflozin dose when remembered unless it is less than 12 hours to the next one, and never doubling up (NHS). These are usually long-term medicines; the NHS warns that stopping suddenly can let blood sugar rise, so changes should be agreed with a doctor.

Surgery, illness and fasting

See the sick-day section above. In short: regulators advise pausing for major surgery and serious acute illness, with blood ketone checks before restarting (MHRA), and the US canagliflozin label advises stopping at least 3 days before planned surgery or prolonged fasting where possible (Invokana label).

Product quality and generics

Generic dapagliflozin must meet the same standards as the brand. In the US, the FDA says generic labels carry the same contraindications, warnings and precautions as Farxiga (FDA). The first US generics were approved for glucose control and for reducing heart-failure hospitalisation in type 2 diabetes; the FDA announcement did not list the heart-failure-without-diabetes or kidney-disease uses. We found no recalls or contamination findings specific to SGLT2 inhibitors in the sources we reviewed.

Follow the money: who makes them and who funded the evidence

Who makes them and what they earn

• AstraZeneca (UK licence holder based in Cambridge, UK, per the SmPC) sells dapagliflozin as Forxiga/Farxiga. Its 2025 annual report gives Farxiga revenue of $8,492m, up 10%, making it the company's largest-selling product (AstraZeneca 2025 annual report, SEC filing).
• Boehringer Ingelheim (Ingelheim am Rhein, Germany; licence holder per the SmPC) developed empagliflozin and co-markets it with Eli Lilly (US). Lilly's filing lists Jardiance as "in collaboration with Boehringer Ingelheim" (Lilly 10-K). Trade press reports that the Jardiance family passed $10 billion in sales in 2025 and that Boehringer Ingelheim is not a public company (Contract Pharma).
• Janssen (Johnson & Johnson, US) sells canagliflozin as Invokana (label). Its sales fell after the 2017 amputation warning: trade press reported nine-month sales down by almost a quarter to $653m in 2018 (pharmaphorum).

Prices, generics and public payers

In the UK, generic dapagliflozin launched after the Court of Appeal invalidated AstraZeneca's Forxiga patent. From September 2025, NHS reimbursement for generically written prescriptions fell from £36.59 to £25.89 (5 mg) and £30.15 (10 mg) per pack (Community Pharmacy England). The University of Oxford's Bennett Institute launched an OpenPrescribing measure to track how much SGLT2 prescribing is not generic dapagliflozin, noting NICE's advice to choose the lowest-cost option within a class (Bennett Institute).

In the US, the FDA approved the first generic dapagliflozin tablets on 7 April 2026 (FDA). Both Jardiance and Farxiga were among the first ten drugs in Medicare's price negotiation. From 1 January 2026, the negotiated 30-day price is $197 for Jardiance (2023 list price $573; 66% lower) and $178.50 for Farxiga (list $556; 68% lower). CMS reported about 1.88 million Medicare enrollees using Jardiance and 994,000 using Farxiga (CMS fact sheet).

The money matters for how to read the evidence. Brand makers profit from wider indications (heart failure, kidney disease, first-line diabetes use), which is exactly what the later trials were designed to win. Health systems and generic makers now profit from switching to cheap dapagliflozin. Neither side has much commercial reason to play down the class's benefits; the main pressure is over which SGLT2 inhibitor gets prescribed.

Who funded the evidence

Every large outcome trial was funded by the maker: EMPA-REG OUTCOME, EMPEROR-Reduced and EMPEROR-Preserved by Boehringer Ingelheim and Eli Lilly; EMPA-KIDNEY by Boehringer Ingelheim and Eli Lilly, run by Oxford; DECLARE, DAPA-HF, DAPA-CKD and DELIVER by AstraZeneca; CANVAS and CREDENCE by Janssen (sources in the scorecard above). Company employees co-authored several, for example EMPA-REG's author affiliations include Boehringer Ingelheim staff (Zinman 2015).

The key meta-analyses are cleaner but not untouched. The Oxford meta-analysis was paid for by the Medical Research Council and Kidney Research UK, but many of its authors report institutional grants from Boehringer Ingelheim and Eli Lilly for EMPA-KIDNEY (Nuffield 2022). The BMJ network meta-analysis had no funding; most authors declared no relevant ties, but six reported fees or grants from companies including AstraZeneca, Boehringer Ingelheim, Eli Lilly and Novo Nordisk (Palmer 2021). The Swedish–Danish safety study was funded by Swedish charities and the Novo Nordisk Foundation, and some authors reported fees from AstraZeneca, Boehringer Ingelheim and Eli Lilly outside the work (Ueda 2018).

Documented regulatory events

Regulators acted on safety signals rather than on any misconduct. The EMA's 2017 review added amputation warnings across the class (EMA). The FDA's canagliflozin boxed warning was added in 2017 and removed in 2020 (FDA). The MHRA strengthened ketone-monitoring advice in 2020 after a European review of DKA around surgery (MHRA). The UK patent case ended with AstraZeneca's Forxiga patent invalidated (CPE). We found no warning letters or fraud findings tied to these drugs in the sources reviewed.

Related research

For wider, evidence-graded context, see these Pure City Research guides:

• Type 2 diabetes: prevention and management evidence
• Diabetes and heart disease
• Diabetes supplements: benefits, limits and safety
• Berberine: glucose evidence and safety
• Chronic kidney disease and the heart
• Heart failure
• Heart failure with reduced ejection fraction
• Heart failure with preserved ejection fraction
• Acute decompensated heart failure
• Blood pressure medicines
• Statins and other cholesterol-lowering treatments

Frequently asked questions

Sources and funding notes

What we could not verify: We did not access full trial texts for author-level conflicts beyond the published funding lines. We could not confirm from a primary source Boehringer Ingelheim's ownership structure or its own reported Jardiance revenue, so we cite trade press for those. We did not verify current UK marketing status of canagliflozin, the UK NHS price of empagliflozin, or the origin and licensing history of canagliflozin before Janssen. We found no independent, publicly funded large outcome trial of any SGLT2 inhibitor; every efficacy estimate rests on manufacturer-funded trials.

1. Forxiga 10 mg film-coated tablets, UK SmPC (emc) — MHRA-approved product information; licence holder AstraZeneca UK Ltd.
2. Empagliflozin 10 mg film-coated tablets (previously Jardiance), UK SmPC (emc) — MHRA-approved; licence holder Boehringer Ingelheim International GmbH.
3. Invokana (canagliflozin) prescribing information, DailyMed — FDA-approved label; Janssen Pharmaceuticals.
4. NICE NG28: Initial medicines, How to introduce medicines and Recommendations for research (updated 18 February 2026) — UK public body; DHSC-funded.
5. NICE technology appraisals TA679, TA773, TA902, TA929, TA775, TA942 — UK public body; titles checked, detailed recommendations not summarised here.
6. MHRA Drug Safety Update, 18 March 2020 — UK regulator.
7. EMA referral: SGLT2 inhibitors (previously canagliflozin) — EU regulator, Netherlands.
8. FDA Drug Safety Communication, 26 August 2020 and FDA: first generic dapagliflozin, 7 April 2026 — US regulator.
9. NHS: Dapagliflozin — UK public health service.
10. Nuffield Department of Population Health Renal Studies Group. Impact of diabetes on the effects of SGLT2 inhibitors on kidney outcomes. Lancet 2022 (full text) — meta-analysis; UK MRC and Kidney Research UK; authors with BI/Lilly institutional grants.
11. Natale P et al. SGLT2 inhibitors for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev 2024 (full text) — Cochrane review; no sources of support listed; one author declared AstraZeneca and other industry consultancy.
12. Palmer SC et al. SGLT-2 inhibitors and GLP-1 receptor agonists for type 2 diabetes: network meta-analysis. BMJ 2021 (full text) — no funding.
13. Zelniker TA et al. SGLT2 inhibitors for primary and secondary prevention. Lancet 2019 — meta-analysis; no funding declared; co-authors include DECLARE (AstraZeneca) investigators.
14. Ueda P et al. SGLT2 inhibitors and risk of serious adverse events. BMJ 2018 (full text) — registry cohort; Swedish charities and Novo Nordisk Foundation.
15. Bersoff-Matcha SJ et al. Fournier gangrene associated with SGLT2 inhibitors. Ann Intern Med 2019 — FDA case series; no funding.
16. Zinman B et al. EMPA-REG OUTCOME. NEJM 2015 — RCT; Boehringer Ingelheim and Eli Lilly.
17. Neal B et al. CANVAS Program. NEJM 2017 — RCT; Janssen Research and Development.
18. Perkovic V et al. CREDENCE. NEJM 2019 — RCT; Janssen Research and Development.
19. Wiviott SD et al. DECLARE-TIMI 58. NEJM 2019 — RCT; AstraZeneca.
20. McMurray JJV et al. DAPA-HF. NEJM 2019 — RCT; AstraZeneca.
21. Heerspink HJL et al. DAPA-CKD. NEJM 2020 — RCT; AstraZeneca.
22. Solomon SD et al. DELIVER. NEJM 2022 — RCT; AstraZeneca.
23. Packer M et al. EMPEROR-Reduced. NEJM 2020 — RCT; Boehringer Ingelheim and Eli Lilly.
24. Anker SD et al. EMPEROR-Preserved. NEJM 2021 — RCT; Boehringer Ingelheim and Eli Lilly.
25. EMPA-KIDNEY Collaborative Group (Herrington WG et al.). NEJM 2023 — RCT; Boehringer Ingelheim "and others"; Oxford-run (DCRI announcement).
26. AstraZeneca 2025 annual report (SEC filing) — company document.
27. Eli Lilly 2025 Form 10-K — company document.
28. CMS fact sheet: negotiated prices for 2026 — US government.
29. Community Pharmacy England, 27 August 2025 — pharmacy contractor body.
30. Bennett Institute, University of Oxford, 6 October 2025 — academic.
31. Contract Pharma: Boehringer Ingelheim profile and pharmaphorum: Invokana — trade press, advertising-funded.

Educational research reviewed 9 October 2026. This article is not medical advice; talk to a qualified clinician or pharmacist before starting, stopping or combining treatments.