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3yr
Clinical trials show additional benefits of SGLT2 inhibitors

Results from randomized controlled trials have indicated that sodium glucose cotransporter 2 (SGLT2) inhibitors lower the chances of major adverse cardiovascular events (MACE). In the trials, MACE was defined as a composite of mortality due to cardiovascular causes, non-fatal MI, or non-fatal stroke. SGLT2 inhibitors also decreased the risk of all-cause mortality and heart failure compared with dipeptidyl peptidase-4 (DPP-4) inhibitors.

These studies have led to the use of select SGLT2 inhibitors as a means to treat heart failure regardless of type 2-diabetes or ejection-fraction status. SGLT2 inhibitors can be used in patients with heart failure with reduced or preserved ejection fraction (i.e., HFrEF, HFpEF). Mechanistically, these agents inhibit the reabsorption of filtered glucose, thus decreasing the risk of future heart-failure decompensation. 

What has been your clinical experience with SGLT2 inhibitors in heart failure patients? How does this class compare with other HF agents? Which HF patients are particularly responsive to SGLT2 inhibitors in your experience?

  • 3yr
    Thanks, All, for your wonderful responses! How do you compare SGLT2 inhibitors to other treatments for HF? How do you advise your patients on these drugs? Do your patients encounter any challenges with this therapy?
  • 3yr
    SGLT2 inhibitor is gaining a huge momentum of my practice ,
    I usually bring patients to office , to discuss the indication , start them on a sample , while trying to get it approved
    mostly HFrPF for now , but more & more start using it in HFpEF
    agree that we cardiologist are taking the lead now ,& feel comfortable using it regardless of diabetic state
    the studies supporting it's use are powerful
    I suspect the indication will expand to more that CHF patients later . ie high risk , low grade cardiomyopathy with no prior CHF yet . ect .
  • 3yr
    SGLT-2 are now part of standard Rx for HFrEF, along with BB, ACE/ARB, Entresto, ICD. I generally try to titrated BB/ACE first due to cost as much as tolerated then shortly after add Entresto and SGLT-2, although difficult for some patients due to cost.
  • 3yr
    SGLT-2 inhibitors are now a standard heart failure drug independent of DM in patients with HFpEF and HFrEF. However, costs are an issue for many of my patients.
  • 3yr
    I use SGLT2 agents predominantly in my HFrEF patients, both with and without DM2. It is suppoorted by guidelines, which helps with payor issues.
    While I have not been as aggressive with HPpEF and CKD patients, there is benefit here too.
    Some of the initial issues of who should start this class of medication (PCP vs Cardiology vs. Endo vs Nephro) have subsided as Cardiologists have become more comfortable prescribing what has traditionally been viewed as a class of diabetes medications.
    The other issue is cost. We tend to use Entresto in most of our CHF patients (HFrEF> HFpEF, though data supports both) and that can be expensive for patients. When you then add branded SGLT2 meds, this can be prohibitively expensive for some patients.
  • 3yr
    I use SGLT2i for nearly all HFrEF with or without DM2 as these are now indicated by most recent consensus update. In light of recent data, HFpEF is now also an option. Finally in those with concomitant DM2 or CKD or both these drugs are helpful. Most insurance covers Jardiance or Farxiga.
  • 3yr
    This drug class has become an addition to ACC/AHA-accepted therapy for HFrEF and now HFpEF, regardless of diabetic state. Seems to be a class effect, not specific to one or another drug. While I observe with gimlet eye the addition of yet another layered-on class of drug for the Rx of HF, there does seem to be something useful here, as this class is supported by trial data, is gaining acceptance (by cardiologists and PCPs) and is well-tolerated. Not terribly expensive for the patient, a major concern for me in this age of polypharmacy.
  • 3yr
    This class increasingly used for HF and has been easy to use re: DM or no DM, renal fxn, effect in HFREF as well as HFPEF but less experience with the latter thus far.
  • 3yr
    Part of guideline for DM and non-DM and those with HFrEF/HFpEF and also HFmEF. And why we all know this, the problem about adding yet another agent to their already growing our emterium is set between cost and a diet of pills is becoming increasingly burdensome for our patients. Yet, of course we know that intellectually patient should take mouthfuls of pills in the live Clearly longer. One can imagine in 10 years they’ll be another series of three or four additional classes of meds for this pt population!
  • 3yr
    The SGLT2 inhibitors have been used much more fequently over the past 6 months and the response has been very favorable. Patients tolerate these well and side effect profile is favorable. Predominant outcomes data most favorable for HFrEF.
  • 3yr
    studies have shown that patient with heart failure and reduced ejection fraction benefit most from SGLT2 inhibitors. These medications are still new. I was working at a small hospital last week and intended to start a STEMI patient with DM and EF 30% on this med but the hospital did not have the medication. The more date become published the wider the will be accessible. Contraindications/cautions should be placed into consideration: genital fungal infections, genital hygiene
  • 3yr
    The data on SGLT2 is very impressive, especially since it was in the context of use of all the other proven classes of medicines for systolic CHF. Would use it without regard to diabetes. Since it tends to have a diuretic effect, it can be used early on in a patient's care (not as an add-on), whereas beta blockers for example are best used once the patient is euvolemic. In fact, the opposite is true - to try not to use if the patient may be dehydrated.
  • 3yr
    This medication class has become one of the required parts of GDMT in HEFrEF and one of the few medications that may be beneficial in HEFpEF (aside of optimal HTN control)
  • 3yr
    I have been adding a slgt2 inhibitor to virtually all my patients with HFref. -- especially those with diabetes. It is well tolerated and I havent seen any adverse reactions in my patients. What I cant tell is personally how effective it is since I use it as add on the other agents ( particularly entresto and fine if pts are compliance and follow diet they do well- how much of it is due to SLGT2 -- I cant evaluate
  • 3yr
    This class of drug indeed reduce CHF. We have had a very favorable response. Agree with previous post that initiation as soon as possible is in the best interest of the patient.
  • 3yr
    We know from several clinical trials that we have improvements in outcomes for patients regardless of ejection fraction with both empagliflozin and dapagliflozin; I have begun to initiate SLGT2 inhibitors (preferencing dapa in reduced EF and empa in preserved EF, based on trial data) in symptomatic heart failure patients without diabetes and then strongly recommending to PCPs that they start one or the other in patients with diabetes. As one of the four "pillars" of heart failure treatment, I think it's important that patients with rEF be started ASAP, and then pEF be started, as said, if symptomatic (in conjunction with afterload reducers, including MRAs). We have now started initiating in the hospital when stable, based on EMPULSE.
  • 3yr
    Those with diabetes
  • 3yr
    Thanks, All, for your wonderful contributions! How do you advise your patients on the use of SGLT2 inhibitors? What are your patients' questions/expectations?
  • 3yr
    I have increased my use if these medications for treating my heart failure patients. I consider it an add on therapy. I do have some concerns over side effects ( infections, and potential DKA). Previously I would have considered this in the area of my colleagues who are either endocrinologist or PCP’s. I am increasingly becoming more comfortable
  • 3yr
    I have significantly increased my use of SGLT2 inhibitors in patients with CHF regardless of diabetes status. I use empagliflozin in patients with HFpEF and use dapagliflozin in patients with HFrEF and renal insufficiency. I frequently am able to decrease dosage of diuretics. I am seeing symptomatic improvement in my CHF patients.
  • 3yr
    Having a 4th class of medication to treat chf is great because on occasion a patient has a comorbidity that precludes dosing with an ARNI or MRA or a beta blocker and being able to offer an effective agent for HFPEF patients has been long awaited and is certainly appreciated.
  • 3yr
    I consider these agents are my primary choice for newly diagnosed HF patients with reduced ejection fraction those with and without diabetes, especially if they have underlying CKD as well. Also my use of Dapaglifozin is steadily increasing in patients with HFpEF. I have not tried Canaglifozin so far, don't find the need as we already have two of these agents well shown in clinical trials to be beneficial.
  • 3yr
    Have been using SGLT2 inhibitors for all CHF including HFPEF since the trials have shown promise. Probably these medications work the best in patients with mid-range EF and HFPEF, particularly in patients with CKD. There are few other medications that work well and have clinical data for HFPEF with LVEF >55%. I have been changing Rx for diabetics from DDP4 inhibitors to SGLT2 inhibitors for over one year now due to the CV survival data. My choice of SGLT2 inhibitors is limited to Farxiga and/or Jardiance, as others have limited data (or negative data in patients with PAD)
  • 3yr
    The SGLT-2 inhibitors have now become heart failure drugs that can be given in patients even without diabetes mellitus. They are useful in patients with HF with reduced and preserved EF and are very useful in patients with underlying CKD as shown by DAPA-HF study results. The use of these drugs are steadily increasing in my practice
  • 3yr
    As seen in the most recent heart failure guidelines released only a few days ago, SLG T-2 inhibitors have become one of the 4 pillars of the management of heart failure with reduced ejection fraction. Additionally, patients with midrange and preserved ejection fraction also have demonstrated a clinical benefit in clinical trials. For nondiabetic patients, I have been initiating empagliflozin for patients with preserved ejection fraction and dapagliflozin for patients with reduced ejection fraction. I think that my experience is too new in order to determine which subgroups of patient's most benefit beyond that. For the diabetic patient, I strongly recommend to the primary provider that the consider initiation of SLG T-2 inhibitors as long as there is no concern for hypoglycemia. Given that this may require adjustment of other antihyperglycemic medications, I personally do not prescribe for this patient population at this point... though with more experience, that may change.

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