Expect to See SGLT2 Inhibitors for Some Patients WithOUT Diabetes

You’ll start to see more patients withOUT diabetes using SGLT2 inhibitors (Invokana, etc)…for heart failure or kidney disease.

That’s because growing evidence suggests these meds may improve outcomes when added to standard therapy…and Canadian heart failure guidelines now recommend it.

In heart failure with reduced ejection fraction (HFrEF), adding Jardiance (empagliflozin) over 16 months prevents hospitalization or CV death in about 1 in 14 type 2s…or 1 in 26 patients withOUT diabetes.

In chronic kidney disease (CKD), adding Forxiga (dapagliflozin) over 2.4 years slows CKD progression or reduces the risk of CV or renal death in about 1 in 19 patients with or withOUT type 2 diabetes.

These two new studies add to prior data with Forxiga in HFrEF patients…and Invokana (canagliflozin) in CKD patients.

Forxiga is already approved for treatment of HFrEF. Expect to see more SGLT2 inhibitors get this new indication, since benefits are likely a class effect.

Keep SGLT2 inhibitor risks in mind…especially hypovolemia and acute kidney injury when used with diuretics, in the elderly, etc. Consider lower diuretic doses when patients start an SGLT2 inhibitor.

Concern for genitourinary infections may be less with these meds in patients withOUT diabetes…they spill less glucose into the urine.

For now, continue to avoid SGLT2 inhibitors in severe CKD. See our resource, Stepwise Treatment of Type 2 Diabetes, for renal cutoffs.

Consider these new data as more support for SGLT2 inhibitors in HFrEF or CKD patients WITH type 2 diabetes who need a metformin add-on.

But don’t jump to these meds for patients withOUT diabetes.

Continue to emphasize maximizing standard meds first.

Optimize doses of “triple therapy” for HFrEF…an ACEI, ARB, or Entresto (sacubitril/valsartan) PLUS an evidence-based beta-blocker (carvedilol, etc) AND aldosterone antagonist (spironolactone, etc).

Slow CKD progression by controlling BP with an ACEI or ARB.

Reinforce adherence, since this is a problem for over half of heart failure patients and over 30% of CKD patients.