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3yr

Case 1: A 68-year-old female patient presents with fatigue, chest pain, palpitations, dyspnea, and syncope while performing normal physical activity. She is comfortable at rest, with limited impairment of functional status. She is categorized as having HFpEF NYHA Class II, with an LVEF of 58% and an eGFR of 61 mL/min/1.73 m2. She is currently taking ACE inhibitors and diuretics.

Case 2: A 65-year-old man is experiencing symptoms fatigue, chest pain, palpitations, dyspnea, and syncope with less than normal physical activity. He is comfortable at rest only, with limitations on functional status. He recently transitioned to HFpEF NYHA Class III, with an LVEF of 35% and eGFR of 58 mL/min/1.73 m2. He is currently taking an ARB, diuretic, and beta blocker.

In both patients, the addition of which agent would result in a relative risk reduction in time to cardiovascular death or hospitalization due to heart failure? Before prescribing this drug, in which patients should renal function and volume status be tested? What are the most common adverse reactions for this drug (i.e., occurring in ≥5% of patients)?

  • 3yr
    Jardiance can be helpful in both patients. I would assure creatinine clearance is above 25 cc/min before prescribing SGLT2 inhibitor like Jardiance. Volume status should be assessed clinically from physical exam and BUN and Cr on blood labs, to assure not volume depleted before initiating. Caution patient about higher risk of genital infection and higher risk for dehydration.
  • 3yr
    I would start with adding spironolactone and empaliflozin in patient 1 and recheck renal function and electrolytes in 1-2 weeks.
    In patient 2, I would change ARB to Entresto and add spironolactone. I would tritrate up the dose of Entresto in follow up appotments as BP allows. I might add empagliflozin in the future if insurance coverage allows. Recheck LV function on future echo, and consider CRM therapy if LVEF< still.
  • 3yr
    For the first patient would add an SGLT2 inhibitor, at present Jardiance for HFPEF but sooner rather than later could also consider Farxiga as well as approval for HFPEF is imminent and Farxiga has an indication for renal protection. Would probably also add Spironolactone and monitor renal function and potassium with that addition. Major side effect from SGLT2 inhibitors would be GU yeast infections.
    For the second patient would also add an SGLT2 inhibitor, preferably Farxiga with additional renal data. I would also change ARB to Entresto with worsening LVEF and strongly consider addition of Spironolactone. Would carefully monitor potassium and renal function in this patient with additional medications. Following three months of GDMT with the above changes, if the LVEF is not improved would recommend placement of an ICD device.
  • 3yr
    For the first case , I would consider the sglt inhibitor - Empa for CHF . The second case, I concur with other posters with the exchange of arb for valsartan /sacubitril.
  • 3yr
    I’m assuming both patients have had eval for aortic valve stenosis and CAD.

    For the 1st patient who had HFpEF, I’d add SGLT2. In addition, Aldactone could have some benefit.

    For the 2nd patient, I’d also add SGLT 2, switch to Entresto, and add Aldactone. All Med changes to be done in stepwise fashion.

    I usually get labs every 2 weeks while making changes. (Chem7 and BNP). Use of SGLTs is associated with increased risk of UTIs.
  • 3yr
    In both patients, I'd encourage transition of each to sacubitril/valsartan (after an appropriate wash out for the first one) and add an SLGT2 inhibitor. For the HFrEF patient, if diabetic, I'd use empagliflozin; otherwise, I'd use dapagliflozin. As others have mentioned, an MRA is also beneficial for the second patient. At initiation and then 2-4 weeks after starting and/or after changing doses, I'd recommend checking a BMP. Each drug is different, but yeast infection for the SLGTs and hypotension/worsening renal function for the MRA & sacubitril/valsartan.
  • 3yr
    For the first patient I would add beta blocker and Jardiance .I am assuming no AS and this has been assessed. The second patient I would consider adding spironolactone and Jardiance. Need to closely watch fluid status with the glycosuria and 2 diuretics.
  • 3yr
    I read it right - both patients presented with syncope . The vignette should include evaluation of the aortic valve. Both are older patients and aortic stenosis could be responsible
  • 3yr
    For the first patient I would add Spironolactone and Jardiance (medication coverage permitting). I would repeat GFR assessment in one month. Most common issues with SGLT2 inhibitors is GU infection which has been more frequent than reported.
    For the second patient I would change the ARB to Entresto hold the diuretic and add Farxiga. Again would repeat GFR assessment in one month and follow closely. IF renal function remains stable would add Spironolactone or Inspra.
  • 3yr
    For the two patients I would add SGLT2 inhibitors Like jardiance And for second one also same plus Entresto aldactone. Volume status is important to reduce renal side effects. And most common side effect of SGLT2 inhibitors is GU tract infection
  • 3yr
    Patients wii be helped by SGLT2 inhibitors like FARXIGA and second patient by ENTRESTO,but they both can be helped by BETA BLOCKERS like CARVEDILOL.



  • 3yr
    What has been your clinical experience with SGLT2 inhibitors? Do you have any useful insights to share?
  • 3yr
    I would start both patients on an SGLT2 inhibitor. For the second patient, I would add spironolactone and consider switching the ARB to Entresto depending on the patient’s blood pressure. SGLT2 inhibitors increase the risk of GU infections.
  • 3yr
    for first case would first add sglt2 inhubitor like empagliflozin, consider spironolactone
    in case 2 would switch to entresto, stop stand alone arb and would add farxiga
  • 3yr
    For case 1, would switch ACEI to Entresto, titrate appropriately, then add beta blocker and titrate. Would add SGLT2I as well. Watch fluid status, BP, electrolytes. Watch for GU infection. For case 2, would switch ARB to Entresto and titrate appropriately, add MRA (spironolactone or epleronone), add SGLT2I. Watch fluid status, electrolytes, BP, monitor for GU infection.
  • 3yr
    Many of my patients encounter high out of pocket cost for SGLT2 inhibitors and cancel their prescription
  • 3yr
    I would start with adding spironolactone in patient 1 and recheck renal function and electrolytes in 2 weeks. Add empagliflozin next.
    In patient 2, I would start by changing ARB to Entresto and adding spironolactone. Titreate up Entresto as BP allows. Due to naturetic effect of neprilisin inhibitor, consider reduction in diuretic dose. . Also, recheck lytes and renal function in 1-2 weeks. Add empagliflozin nextaiming for standard four drug therapy for HFrEF (beta blocker, ARNI, MRA, and SGLT2 inhibitor). Recheck LV function on future echo, and consider CRM therapy if LVEF< still.
  • 3yr
    SGLT inhibitors and Aldactone. Both have great value. Watching K and risk of infection
  • 3yr
    For both patients Entresto (over an ARB) would be a good choice, as well adding an SGLT2. For Patient 2, spironolactone as well.

    Need to make sure patient not volume depleted or has severe Ckd before using ARNI or MRA.

    Need to discuss risk of GU infections with SGLT2s.
  • 3yr
    For case 1, consider Jardiance. Consider Beta BLocker
    For case 2, spironolactone first, with change ARB to Entresto; add Farxiga or Jardiance.
    Jardiance, spironolactone, and Entresto are all impacted by renal fx and potassium level, and needs to be known before starting the medication.
    Volume status needs to be known to avoid hypovolemia and hypotension.
    Discuss risk of GU infections with Jard/Farx
    Barrier to care as always is pre/auth, formulary status, and cost.
  • 3yr
    Case 1: I agree with addition of SGLT2i to decrease risk of mortality and hospitalization.

    Case 2: add SGLT2i for above benefits. In addition I would consider changing from ARB to Entresto and add spironolactone.

    I monitor lytes/cr in a week after starting and often lower the dose of current diuretics to avoid hypovolemia.

    Patients should be made aware of increased risk of GU infections.
  • 3yr
    SGLT2 inhibitor is a great drug. It has shown to improve hospitalizations in patients with reduce ejection fraction. It is not indicate in patients with DKA
  • 3yr
    Would consider SGLT2 inhibitor. GU infection can be an issue given high glucose content in urine.
  • 3yr
    Case 1: Would add SGLT2 inhibitor; and possibly using Entresto
    Case 2: Would consider change to Entresto and add SGLT2 inhibitor
    Cost may be a barrier
    Fluid status should be managed in both patients
    Risk for UTI/infection with SGLT2i
  • 3yr
    What are the barriers to care with SGLT2 inhibitors? Is Prior Authorization an issue? Please explain.
  • 3yr
    Case 1: SGLT2 inhibitor
    Case 2: Change to Entresto and add SGLT2 inhibitor
    Both may be limited by affordability.

    I am more cautious in patients whose glycemic control is very poor as my sense is that this may increase the risk of Fournier's etc. I typically emphasize the data that suggest the SGLPT2 drugs may help with weight loss if people are reluctant.
  • 3yr
    I will start on SGLTi ,Empa or Dapa. In the Case 2, I like to start on Dapa.
  • 3yr
    An SGLT2 inhibitor should be started and has been shown to decrease hospitalization and death from HFpEF as well as HFrEF. The most common side effect is urinary/genital infections.
  • 3yr
    Would consider SGLTi (e.g. Empa or Dapa). With respect to Case 2, I would favor Dapa given the strong results from DAPA-ckd literature. There is some suggestion that this class of agents may help patient with diastolic HF (EMPEROR PRESERVED).
    Notably, for Case 2 would favor the replacement of the ARB for an ARNI.
  • 3yr
    I would definitely consider Dapaglifozin for both the patients. This agent has been shown to reduce the risk of heart failure hospitalization and is safe in patients with CKD. Also may reduce progression of CKD. while of Dapaglifozin may need to consider reducing the dose of diuretics and may need to even consider stopping it al toghther. Genital mycotic infections is of concern
  • 3yr
    In both patients the addition of an STLT2 would be helpful. Based on Paragon trial, one can consider easily moving patients from ARB’s to entresto as well. But, given the question, both the Dapa HF and Emperor-preserved Provide evidence for use in both HFpEF and HFmEF while acceptable with patients with relatively preserved GFR (>30ml/min/ ) as both these patients were—as well to potentially even improve albuminuria and the risk of progression to frank albuminuria. Volume status is important to reduce the chance for hypovolemia. Finally, risks include: genital infections due to glycosuria, possibly osteopenia, rare decrease in GFR and even rare Fournier’s gangrene. Invokana has some risk of lower limb amputation.
  • 3yr
    GU infection
  • 3yr
    SGLT2 inhibitor

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