Consider heart failure when weighing medications for diabetes
Overview
Heart failure is a frequent and often fatal complication of type 2 diabetes and there will be more focus on how this affects medication choices. Consider whether your patient also has heart failure when evaluating diabetes medications, since some may help or harm.
Management steps
Medications with potential benefit
Continue to recommend metformin first, it's linked to lower mortality in patients with type 2 diabetes and stable heart failure and lactic acidosis is rare. But advise holding metformin during a heart failure exacerbation.
- After metformin, suggest adding an SGLT2 inhibitor either Jardiance (empagliflozin), Invokana (canagliflozin), or Farxiga (dapagliflozin).
- NEW evidence suggests these SGLT2 inhibitors lower risk of heart failure hospitalization in diabetes patients WITH CV disease or CV risks.
- Stay tuned for data to sort out which heart failure patients benefit most. But weigh SGLT2 inhibitor downsides including yeast infections, rare ketoacidosis, and amputation concerns.
- Keep in mind, SGLT2 inhibitors have a diuretic effect. Caution about dizziness, hypotension, etc and expect some patients to need lower doses of their diuretic.
Medications with possible risk
Avoid pioglitazone (Actos) it can cause fluid retention and weight gain and worsen heart failure symptoms. Don't suggest the DPP-4 inhibitors Onglyza (saxagliptin) or Nesina (alogliptin). They're linked to heart failure hospitalizations. Januvia (sitagliptin) or Tradjenta (linagliptin) doesn't seem to increase risk. Other add-ons. Point out the GLP-1 agonists Victoza (liraglutide) or Ozempic (semaglutide) reduce CV risk in diabetes patients WITH CV disease or CV risks and don't seem to increase risk of heart failure hospitalization. But explain evidence in patients with heart failure is limited and some experts are cautious, since these medications modestly increase heart rate. Think about glipizide for a lower-cost option or basal insulin if needed to reach A1C goal. But these don't have much evidence in heart failure and can cause weight gain and hypoglycemia.
References
- Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. (2018). Diabetes Care, 42(Supplement 1), pp.S103–S123.
- Zelniker, T.A., Wiviott, S.D., Raz and Sabatine, M.S. (2019). SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. The Lancet, 393(10166), pp.31–39.
- Das, S.R., Everett, B.M., Birtcher and Sperling, L.S. (2018). 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. Journal of the American College of Cardiology, 72(24), pp.3200–3223.
- Gilbert, R.E. and Krum, H. (2015). Heart failure in diabetes: effects of anti-hyperglycaemic drug therapy. Lancet (London, England), [online] 385(9982), pp.2107–2117.
