From the Guidelines
The use of SGLT2 inhibitors for heart failure in hemodialysis patients is not routinely recommended due to limited evidence and potential risks. Currently, there is insufficient data to support their efficacy and safety in this specific population. SGLT2 inhibitors like dapagliflozin or empagliflozin, which have shown benefits in heart failure with reduced ejection fraction in patients with normal kidney function, may not provide the same advantages in hemodialysis patients. For hemodialysis patients with heart failure, standard heart failure therapies should be prioritized. These include:
- Beta-blockers (e.g., carvedilol 3.125-25 mg twice daily)
- ACE inhibitors or ARBs if tolerated
- Aldosterone antagonists with careful monitoring Fluid management through appropriate dialysis prescription is crucial. The primary mechanism of SGLT2 inhibitors – increased urinary glucose excretion – is not applicable in anuric hemodialysis patients. However, these drugs may have other potential benefits such as reducing inflammation or improving cardiac metabolism. Despite this, the altered pharmacokinetics and potential for adverse effects in hemodialysis patients make their use challenging without specific studies in this population 1. If considering SGLT2 inhibitors in a hemodialysis patient with heart failure, it should only be done under close supervision and as part of a clinical trial. Careful monitoring for hypotension, electrolyte imbalances, and other adverse effects is essential. Until more data is available, the risks may outweigh the potential benefits in this vulnerable population. Recent guidelines suggest that SGLT2 inhibitors can reduce the risk of heart failure hospitalization in patients with type 2 diabetes and established cardiovascular disease or at high risk for cardiovascular disease 1. However, these guidelines do not specifically address the use of SGLT2 inhibitors in hemodialysis patients. In the absence of specific studies, the use of SGLT2 inhibitors in hemodialysis patients with heart failure should be approached with caution, and alternative therapies should be prioritized. The American College of Cardiology expert consensus decision pathway for optimization of heart failure treatment recommends that SGLT2 inhibitors should not be used in patients on dialysis due to the lack of data on their safety and efficacy in this population 1. Therefore, standard heart failure therapies should be prioritized in hemodialysis patients with heart failure, and the use of SGLT2 inhibitors should only be considered in the context of a clinical trial or with close supervision and careful monitoring.
From the FDA Drug Label
JARDIANCE is contraindicated in patients on dialysis [see Contraindications (4)]. The FDA drug label does not answer the question about the role of Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors in heart failure patients undergoing Hemodialysis (HD), as it only states that JARDIANCE is contraindicated in patients on dialysis, without providing information on its use in heart failure patients undergoing HD 2.
From the Research
Role of SGLT2 Inhibitors in Heart Failure Patients
- SGLT2 inhibitors have been shown to have a significant impact on patients with heart failure and a reduced ejection fraction (HFrEF), with benefits including reduced heart failure hospitalizations and cardiovascular mortality 3, 4.
- The mechanisms of action of SGLT2 inhibitors are not fully understood, but proposed hypotheses include reduction of preload via osmotic diuresis, lowering of afterload, reduction in myocardial mass, and alteration of myocardial energy substrate toward a more efficient glucose metabolism 3.
- SGLT2 inhibitors have also been found to have a nephroprotective effect, with empagliflozin and dapagliflozin recently approved for the treatment of adults with symptomatic chronic heart failure with reduced ejection fraction 4.
SGLT2 Inhibitors in Patients Undergoing Hemodialysis
- There is limited direct evidence on the role of SGLT2 inhibitors in heart failure patients undergoing hemodialysis (HD).
- However, studies have shown that SGLT2 inhibitors can slow kidney disease progression and reduce the need for renal replacement therapy in patients with diabetes and established atherosclerosis 5.
- Additionally, SGLT2 inhibitors have been found to be safe and effective in patients with heart failure and chronic kidney disease, regardless of diabetes status and left ventricular ejection fraction (LVEF) 6, 7.
Safety and Efficacy of SGLT2 Inhibitors
- Early initiation of SGLT2 inhibitors in patients hospitalized for acute heart failure has been found to be safe and effective, with reduced risk of heart failure hospitalizations and acute kidney injury (AKI) 7.
- SGLT2 inhibitors have also been found to have a favorable safety profile, with no significant increase in adverse events such as volume depletion, hypoglycemia, and ketoacidosis 3, 7.