SGLT-2 Inhibitors for Heart Failure
An estimated 63 million people worldwide experience heart failure during their lifetime, of whom many are treated using sodium-glucose cotransporter-2 (SGLT-2) inhibitors. As the prevalence of heart failure is projected to rise, understanding the role of SGLT-2 inhibitors in the management of heart failure is crucial for addressing the unmet needs in treatment of this condition.
To learn more about the use of SGLT-2 inhibitors in this patient population, Consultant360 reached out to Jennifer Clements, PharmD, who is a clinical pharmacy specialist in diabetes transition in the Spartanburg Regional Healthcare System in South Carolina. She recently presented on this topic at the Association of Diabetes Care & Education Specialists (ADCES) 2021 conference.
Consultant360: To begin, could you give us a brief overview of your session?
Jennifer Clements: My session focused on the role and clinical evidence for SGLT-2 inhibitors. The risk of heart failure and recommendations in the American Diabetes Association 2021 Standards of Medical Care were summarized. Evidence-based guidelines were translated regarding the care of people with diabetes and heart failure. Lastly, challenges and strategies to overcome challenges were identified regarding the use of SGLT-2 inhibitors in clinical practice. During the session, case studies were presented and reviewed to evaluate factors for a therapeutic plan and transitional care management of people with heart failure, regardless of diabetes status.
C360: SGLT-2 inhibitors are currently recommended for the treatment of diabetes. Are there any patient-specific contraindications that would impact how you prescribe SGLT-2 inhibitors in people with heart failure?
JC: Per the package insert, the contraindications are history of serious hypersensitivity to the medications or people who are on dialysis. When evaluating the trials with SGLT-2 inhibitors for heart failure, there were some exclusion criteria, which generally included prior use of SGLT-2 inhibitors with unacceptable adverse events, diagnosis of type 1 diabetes, hypotension (systolic blood pressure, < 95 mm Hg), an estimated glomerular filtration rate (GFR) of less than 25 mL/min/1.73 m2, current use of an SGLT-2 inhibitor, pregnancy, and lactation. There may be some additional exclusions when evaluating this class of medications for chronic kidney disease.
C360: Could you discuss how the 2021 Standards of Medical Care differs from the previous Standards of Medical Care regarding SGLT-2 inhibitors?
JC: Without going too far back, the 2020 Standards of Medical Care stated that an SGLT-2 inhibitor could be considered for people with type 2 diabetes who also had cardiovascular or renal disease. Specifically, this class could be considered for those with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease regardless of baseline A1c or desired A1c. This class of medications was preferred over a glucagon-like peptide-1 (GLP-1) receptor agonist for heart failure or chronic kidney disease, as long as the patient had adequate renal function. In the 2021 Standard of Medical Care, an SGLT-2 inhibitor can be considered among people with type 2 diabetes who also have atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. This class of medications can be considered regardless of baseline A1c, desired A1c, or metformin use. However, a majority of individuals from the cardiovascular trials were taking metformin as background therapy. SGLT-2 inhibitors remain to be the preferred option for heart failure in these updated standards, as long as GFR is adequate for clinical use. It is important to remember that the specific agents with clinical cardiovascular benefit and impact people with heart failure include dapagliflozin and empagliflozin.
C360: What are some clinical pearls you would give to your peers regarding treating people with heart failure using SGLT-2 inhibitors?
JC: Develop a monitoring plan for people taking an SGLT-2 inhibitor. Provide adequate counseling on this class of medication and give the patient information, such as risks and benefits. A 1-page handout could include information on the class, along with prescribed therapy and administration instructions. Think about the person when considering adverse events, as the frequency of a specific adverse event may be higher in people with heart failure compared with those with diabetes. Lastly, be creative with cost of the medications. Coverage is increasing for dapagliflozin and empagliflozin for heart failure; however, you can investigate copay cards, patient assistance programs, and other local resources to reduce the economic burden.
C360: What are some common knowledge gaps health care practitioners have about managing people with heart failure using SGLT-2 inhibitors?
JC: There may be some knowledge gaps on the clinical benefit of empagliflozin and dapagliflozin in people with heart failure, regardless of diabetes status, as these agents have been seen as a therapy for people with diabetes. It will be a change in mindset. In addition, monitoring is important with this class of medications. Lastly, who will prescribe this class is a common gap, as people are seeing endocrinology, cardiology, and nephrology (with renal outcomes) benefits. It should not matter who is seeing the patient with heart failure, regardless of diabetes, as long as someone is evaluating the patient to determine whether an SGLT-2 inhibitor is appropriate.
Clements J. The role of SGLT2 inhibitors in the treatment of heart failure. Talk presented at: Association of Diabetes Care & Education Specialists 2021 Conference; August 12-15, 2021; Virtual. https://adcesmeeting.org/2021/ADCES21/agenda.asp?BCFO=&pfp=BrowsebyDay&tn=&cpf2=&cus2=&pta=&all=1&mode=