Can Farxiga (dapagliflozin) be used in patients with congestive heart failure (CHF) and type 1 diabetes mellitus (DM)?

From the Guidelines

Farxiga (dapagliflozin) should not be used in patients with congestive heart failure (CHF) and type 1 diabetes mellitus (DM) due to the increased risk of diabetic ketoacidosis (DKA). While dapagliflozin has demonstrated significant benefits in reducing hospitalization and mortality in heart failure patients with reduced ejection fraction (HFrEF) 1, it carries an increased risk of DKA in type 1 diabetes patients. This risk occurs because SGLT2 inhibitors like Farxiga alter glucose metabolism and can trigger ketone production, particularly in insulin-dependent patients. Some key points to consider include:

• The DAPA-HF trial specifically evaluated the effects of dapagliflozin on the primary outcome of a composite of worsening heart failure or cardiovascular death in individuals with New York Heart Association (NYHA) class II, III, or IV heart failure and an ejection fraction of 40% or less 1.
• The effect of dapagliflozin on the primary outcome was consistent regardless of the presence or absence of type 2 diabetes 1.
• However, the use of SGLT inhibitors increases the susceptibility to diabetic ketoacidosis, particularly when other risk factors or situations occur, including insulin pump malfunctions, significant reduction in insulin doses, and nutritional intake plans with prolonged periods of fasting or carbohydrate restriction 1.
• To decrease the risk of ketoacidosis when using SGLT inhibition in people with type 1 diabetes, it is recommended to closely monitor patients and adjust treatment plans accordingly 1. Patients with both conditions should discuss alternative treatment options with their healthcare provider, who might consider other heart failure medications that don't carry the same risks in type 1 diabetes, as suggested by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Close monitoring would be essential if, in rare circumstances, a specialist determines the heart failure benefits might outweigh the risks in a specific patient with type 1 diabetes. Key considerations for treatment include:
• The benefits and risks of SGLT2 inhibitors in patients with heart failure and type 1 diabetes
• The importance of close monitoring and adjusting treatment plans to minimize the risk of DKA
• The need to consider alternative treatment options for patients with both conditions.

From the FDA Drug Label

DAPAGLIFLOZIN TABLETS are not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus [see Warnings and Precautions (5.1)]. The FDA drug label does not answer the question about using Farxiga in patients with CHF and type 1 DM, as it only mentions that it is not recommended for improving glycemic control in type 1 diabetes mellitus, but does not provide information about its use in patients with CHF and type 1 DM.

From the Research

Use of Farxiga in Patients with CHF and Type 1 DM

• The use of Farxiga (dapagliflozin) in patients with congestive heart failure (CHF) and type 1 diabetes mellitus (DM) is supported by some studies, although most research has focused on type 2 diabetes.
• A study published in 2022 2 found that dapagliflozin prevented atherosclerotic and cardiac complications in experimental type 1 diabetes, suggesting a potential benefit in this population.
• Another study from 2021 3 explored the effect of dapagliflozin on incident type 2 diabetes in patients with heart failure and reduced ejection fraction, but did not specifically address type 1 diabetes.
• A review of diabetes mellitus and heart failure published in 2021 4 noted that novel medications like sodium glucose cotransporter 2 inhibitors (SGLT-2i) have a favorable metabolic profile and may lower the incidence of cardiogenic diabetes, but did not provide specific guidance on the use of Farxiga in patients with CHF and type 1 DM.
• Earlier research from 2008 5 focused on the effect of strict glycemic control on clinical state and course of disease in patients with chronic heart failure and type 2 diabetes mellitus, and may not be directly applicable to patients with type 1 DM.

Key Findings

• Dapagliflozin may have beneficial effects on cardiac function and diabetes prevention in patients with heart failure and reduced ejection fraction 3, 2.
• The use of SGLT-2i like dapagliflozin may be beneficial in preventing cardiovascular complications in patients with type 1 diabetes 2.
• Strict glycemic control is important in managing patients with CHF and diabetes, but the optimal approach may vary depending on the individual patient and the specific type of diabetes 5.