Some medications may cause or worsen heart failure. Recommend starting with metformin (Glucophage) in most heart failure patients. It improves outcomes and lactic acidosis fears are overblown. Then suggest adding medications that are NOT associated with heart failure such as an SGLT2 inhibitors or "flozin" group (Jardiance, etc), GLP-1 agonist (Byetta, etc), sulfonylurea, or insulin.
Continue to avoid glitazones (pioglitazone [Actos], etc). These can cause fluid retention and may lead to, or exacerbate, heart failure. DPP-4 inhibitors, or "gliptins," are controversial. New labeling will warn about an increased risk of heart failure with saxagliptin (Onglyza, etc) and alogliptin (Inhiglip, etc).. especially in patients who already have heart or kidney disease. Evidence suggests one more heart failure hospitalization for every 150 high-risk patients using saxagliptin or alogliptin for about 2 years.
Lean away from gliptins in heart failure. If one is needed, suggest sitagliptin (Januvia, etc), it seems the least likely to be a problem so far. But explain that gliptins only lower A1C by about 0.5%.
REFERENCES
- Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. (2018). Diabetes Care, 42(Supplement 1), pp.S103–S123. Available at: https://care.diabetesjournals.org/content/42/Supplement_1/S103