Is there evidence for the use of Jardiance (empagliflozin) in treating central apnea related to heart failure?

Empagliflozin for Central Sleep Apnea in Heart Failure

Empagliflozin is recommended for patients with heart failure who have central sleep apnea, as it reduces heart failure hospitalizations and improves clinical outcomes regardless of diabetes status. 1

Mechanism and Evidence

SGLT2 inhibitors like empagliflozin have demonstrated significant benefits in heart failure management that may address central sleep apnea through several mechanisms:

• In the EMPEROR-Reduced trial, empagliflozin reduced the composite of cardiovascular death or heart failure hospitalization by approximately 25% in patients with HFrEF 1
• Empagliflozin significantly reduces heart failure hospitalizations by 30%, which is particularly relevant as central sleep apnea is common in heart failure patients 1
• The EMPEROR-Preserved trial showed that empagliflozin reduced the primary composite endpoint of cardiovascular death or heart failure hospitalization by 21% in patients with HFpEF 1, 2

Dosing Recommendations

• Standard dose: Empagliflozin 10 mg once daily 1, 3
• No dose adjustment is needed based on sleep apnea status
• For patients with eGFR ≥20 mL/min/1.73 m², empagliflozin can be initiated and maintained 1

Important Considerations for Central Sleep Apnea

1. Avoid adaptive servo-ventilation: The 2017 ACC/AHA/HFSA guidelines explicitly state that adaptive servo-ventilation causes harm in patients with NYHA class II-IV HFrEF and central sleep apnea (Class III: Harm recommendation) 1

2. Distinguish from obstructive sleep apnea: It's crucial to differentiate central from obstructive sleep apnea, as treatment approaches differ significantly 1

3. SGLT2 inhibitors as primary therapy: Both empagliflozin and dapagliflozin are recommended for heart failure patients regardless of diabetes status, and may help address the underlying heart failure that contributes to central sleep apnea 1, 4

Monitoring and Follow-up

• Monitor for common adverse effects:

  • Genital mycotic infections
  • Urinary tract infections
  • Volume depletion/hypotension
  • Euglycemic diabetic ketoacidosis (in diabetic patients) 4

• Assess renal function before initiation and periodically during treatment 4

Additional Benefits in Heart Failure Patients with Central Sleep Apnea

• Empagliflozin reduces the risk of worsening heart failure events by 30% 3
• Improves New York Heart Association functional class within 28 days of treatment initiation 3
• Reduces the need for diuretic intensification, which may help with volume status that can affect central sleep apnea 3
• Benefits are seen early (within 12 days) after treatment initiation 3

Comprehensive Management

While empagliflozin is recommended for heart failure patients with central sleep apnea, a comprehensive approach should include:

• Optimizing guideline-directed medical therapy for heart failure 1
• Addressing contributing comorbidities such as atrial fibrillation 1
• Regular monitoring of sleep parameters and heart failure symptoms

Cautions

• Withhold empagliflozin for at least 3 days before major surgery 4
• Use with caution in patients with severe renal impairment (eGFR <20 mL/min/1.73 m²) 4
• Monitor for volume depletion, especially when initiating therapy 4

By addressing the underlying heart failure pathophysiology, empagliflozin offers a promising approach for managing central sleep apnea in heart failure patients, with strong evidence supporting its use for improving overall heart failure outcomes.