From the Guidelines
For a patient with diabetes, heart failure, and a history of UTIs, SGLT-2 inhibitors like empagliflozin or canagliflozin would be excellent choices alongside metformin, as they reduce heart failure hospitalizations and cardiovascular mortality, with a significant 35% reduction in hospitalization for heart failure observed in the EMPA-REG OUTCOME trial 1.
Key Considerations
- The use of thiazolidinediones should be avoided in patients with symptomatic heart failure due to their strong and consistent relationship with increased risk of heart failure 1.
- Metformin may be used for the management of hyperglycemia in patients with stable heart failure as long as kidney function remains within the recommended range for use 1.
- DPP-4 inhibitors have had mixed results in terms of heart failure risk, but SGLT-2 inhibitors have consistently shown benefits in reducing heart failure hospitalizations 1.
Medication Details
- Empagliflozin is typically prescribed at 10mg once daily, which can be increased to 25mg if needed.
- Canagliflozin is typically prescribed at 10mg once daily, but the dose may need to be adjusted based on kidney function.
Additional Benefits and Precautions
- SGLT-2 inhibitors offer additional benefits including weight loss and blood pressure reduction.
- Good hydration and proper genital hygiene should be encouraged to minimize the risk of genital mycotic infections.
- Kidney function should be monitored before and during treatment, as SGLT-2 inhibitors have shown renal protective effects in many patients with diabetes 1.
From the Research
Safe Diabetic Medications for Heart Failure and UTI History
Besides metformin, the following diabetic medications may be considered safe for someone with heart failure and a history of UTI:
- SGLT2 inhibitors: These medications have been shown to have additional benefits such as weight loss, blood pressure reduction, cardiovascular risk reduction, and renoprotective effects 2. However, they may increase the risk of urogenital infections, which could be a concern for someone with a history of UTI.
- DPP-4 inhibitors: These medications are weight neutral and have few adverse effects, making them a potential option for someone with heart failure and a history of UTI 2.
Comparison of Metformin and Sulfonylureas
Studies have compared the effects of metformin and sulfonylureas on heart failure outcomes in patients with diabetes:
- Metformin has been associated with reduced heart failure hospitalization compared to sulfonylureas 3, 4.
- Sulfonylureas have been associated with increased risk of mortality and heart failure hospitalization compared to metformin 4.
Considerations for Patients with Heart Failure and Diabetes
When selecting a diabetic medication for someone with heart failure and a history of UTI, the following factors should be considered:
- The patient's ejection fraction (EF) phenotype: Metformin may be more beneficial for patients with EF >40% 4.
- The risk of urogenital infections: SGLT2 inhibitors may increase this risk, which could be a concern for someone with a history of UTI 2.
- The patient's renal function: Metformin may be more suitable for patients with reduced kidney function 3.