What is the recommended approach for starting empagliflozin (Empagliflozin) in patients with heart failure with preserved ejection fraction (HFpEF)?

Approach to Starting Empagliflozin in Patients with HFpEF

Empagliflozin is strongly recommended for patients with heart failure with preserved ejection fraction (HFpEF) to reduce hospitalizations for heart failure and cardiovascular mortality, regardless of diabetes status. 1

Patient Selection and Dosing

• Target population: Patients with symptomatic heart failure with LVEF >40% and elevated natriuretic peptides 1
• Dosing: Empagliflozin 10 mg once daily 1, 2
• Timing: Benefits appear early, with significant reduction in heart failure events observed as soon as 18 days after initiation 2

Pre-Initiation Assessment

1. Renal function assessment:

   • Confirm eGFR ≥30 mL/min/1.73m² (empagliflozin should not be initiated if eGFR <30) 3
   • For patients with eGFR 20-30 mL/min/1.73m², consider dapagliflozin as an alternative 3, 4

2. Volume status evaluation:

   • Ensure patient is euvolemic before initiation
   • Consider temporary withholding if patient is volume depleted

3. Medication review:

   • Check for concurrent insulin or sulfonylureas (increased hypoglycemia risk) 3
   • Assess diuretic regimen (may need adjustment due to empagliflozin's diuretic effect)

Monitoring After Initiation

1. Short-term follow-up (2-4 weeks):

   • Assess for volume depletion/hypotension
   • Monitor renal function
   • Evaluate for genital mycotic infections

2. Long-term monitoring:

   • Regular assessment of renal function
   • Monitor for symptoms of euglycemic diabetic ketoacidosis (rare but serious) 3
   • Evaluate functional status improvement (NYHA class often improves within 12 weeks) 2

Expected Benefits

• 21% reduction in composite of cardiovascular death or hospitalization for heart failure 1
• 29% reduction in time to heart failure hospitalization 1
• Significant reduction in total heart failure hospitalizations 2
• Decreased slope of eGFR decline 1, 5
• Modest improvement in quality of life 1
• Benefits observed regardless of diabetes status 5
• Improvement in NYHA functional class (20-50% more likely to improve) 2

Special Populations

1. Patients with diabetes:

   • Benefits are similar regardless of diabetes status 5
   • No dose adjustment needed for patients with diabetes 3
   • Monitor for hypoglycemia if on insulin or sulfonylureas 3

2. Patients with atrial fibrillation:

   • Empagliflozin provides similar benefits in patients with and without atrial fibrillation 6

3. Patients with varying LVEF ranges:

   • Benefits are consistent across LVEF ranges of 41-49%, 50-60% 1
   • Benefits may be attenuated at higher LVEFs >62.5% 1

Common Pitfalls and How to Avoid Them

1. Genital mycotic infections:

   • Counsel patients about proper hygiene
   • Monitor for symptoms, especially in women and uncircumcised men

2. Volume depletion/hypotension:

   • Consider reducing diuretic dose when initiating empagliflozin
   • Educate patients about symptoms of hypotension
   • Ensure adequate hydration

3. Euglycemic diabetic ketoacidosis:

   • Educate patients about symptoms (nausea, vomiting, abdominal pain)
   • Advise temporary discontinuation during acute illness or fasting

4. Delayed recognition of benefits:

   • Inform patients that while some benefits appear early (within weeks), the full range of benefits may take time to manifest
   • Encourage adherence even if symptomatic improvement isn't immediately apparent

Integration with Other Heart Failure Therapies

For patients with HFpEF (LVEF >40%), consider the following additional therapies:

• Diuretics as needed for symptom relief 1
• In patients with LVEF 41-49% (HFmrEF), consider adding:
  • ACEi, ARB, or ARNi 1
  • MRAs (particularly with poorly controlled hypertension) 1
  • Evidence-based beta blockers 1

Remember that empagliflozin should be added to, not replace, other guideline-directed medical therapies for heart failure.