Add SGLT2 inhibitors to your HF patients

It’s partly because guidelines for heart failure with reduced ejection fraction now recommend “quad therapy” adding an SGLT2i to triple therapy....

As a clinical pharmacist, you will need to ensure appropriate use of SGLT2 inhibitors (empagliflozin, etc), as more hospitals add these medications to formulary. It’s partly because guidelines for heart failure with reduced ejection fraction (HFrEF) now recommend “quad therapy” adding an SGLT2 inhibitor (SGLT2i) to triple therapy, regardless of diabetes.

Plus, guidelines suggest an SGLT2i for patients with heart failure with mildly reduced EF (HFmrEF) or preserved EF (HFpEF). Expect hospitals that add an SGLT2i to choose dapagliflozin or empagliflozin. These have the most data so far.

Continuation. It’s okay to hold a patient’s home SGLT2i during admission if your hospital doesn’t have one on formulary. If you do stock an SGLT2i, continue it in most stable patients.

Consider creating a therapeutic interchange, such as switching canagliflozin 100 mg/day to empagliflozin 10 mg/day.

But hold the SGLT2i for acute kidney injury, or in patients with volume depletion due to vomiting, excess diuresis, etc.
And hold an SGLT2i if there are risks for ketoacidosis, NPO, within 3 days of surgery, etc. Risk is mainly in diabetes, but it might be practical to standardize to any patient taking an SGLT2i.

Initiation. Think about ADDING an SGLT2i for some patients, such as those with symptomatic HFrEF despite optimized triple therapy. Data reinforce that this can be safely done during admission. But check renal cutoffs, they vary by drug and indication. For example, avoid empagliflozin for heart failure if eGFR is under 20 mL/min/1.73 m², or under 30 mL/min/1.73 m² if treating diabetes. Defer initiation in some patients, such as those with symptomatic hypotension, or unstable heart failure requiring escalating diuretic doses. Monitor fluid status when adding an SGLT2i. If patients take a diuretic, a lower dose may be needed.

Discharge. Restart a patient’s home SGLT2i if needed. If an SGLT2i is added, ensure the patient can afford it. Educate about side effects (genitourinary infections, etc). For more data, read our note "Keep NEW heart failure guidelines in mind".

NPS-adv

References

Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-e1032.
Anker SD, Usman MS, Butler J. SGLT2 Inhibitors: From Antihyperglycemic Agents to All-Around Heart Failure Therapy. Circulation. 2022 Jul 26;146(4):299-302.
Voors AA, Angermann CE, Teerlink JR, et al. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med. 2022 Mar;28(3):568-574.
Schulze PC, Bogoviku J, Westphal J, Aftanski P, et al. Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF). Circulation. 2022 Jul 26;146(4):289-298.
Solomon SD, McMurray JJV, Claggett B, de Boer RA, et al. Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. N Engl J Med. 2022 Aug 27.