Is dapagliflozin (Dapagliflozin) effective in treating myocarditis secondary to tropical fever?

Dapagliflozin in Myocarditis Secondary to Tropical Fever

Dapagliflozin is not recommended as a specific treatment for myocarditis secondary to tropical fever, as there is insufficient evidence supporting its use in this specific condition. While dapagliflozin has proven cardiovascular benefits in heart failure and diabetes, its role in acute inflammatory cardiac conditions like myocarditis has not been established in major clinical guidelines.

Current Evidence on Myocarditis Management

Acute myocarditis, regardless of etiology, requires management based on:

1. Hemodynamic stability assessment
2. Presence of heart failure symptoms
3. Underlying cause (viral, autoimmune, etc.)

Treatment Approach for Myocarditis:

• First-line therapy: Supportive care based on clinical presentation, severity, and etiology 1
• For hemodynamic instability: Inotropic agents or mechanical circulatory support may be required
• For specific forms: Immunosuppression (e.g., corticosteroids) is appropriate for eosinophilic or giant cell myocarditis or cases due to systemic autoimmune disorders 1

Potential Role of Dapagliflozin

While not specifically indicated for myocarditis, dapagliflozin might have theoretical benefits:

1. Anti-inflammatory effects: One preclinical study showed that dapagliflozin alleviated Coxsackievirus B3-induced viral myocarditis in mice by regulating macrophage polarization through STAT3-related pathways 2. However, this is experimental evidence only and cannot be directly translated to clinical practice.

2. Heart failure benefits: If myocarditis progresses to heart failure with reduced ejection fraction (HFrEF), SGLT2 inhibitors like dapagliflozin are recommended as part of guideline-directed medical therapy 3.

Guidelines on SGLT2 Inhibitors in Cardiovascular Disease

The 2021 ACC Expert Consensus states that SGLT2 inhibitors (including dapagliflozin):

• Are established, evidence-based therapies for patients with HFrEF 3
• Reduce the risk of cardiovascular death or worsening heart failure regardless of diabetes status 3
• Should be included among standard therapies for HFrEF 3

The ESC guidelines (2020) recommend dapagliflozin in patients with T2DM and cardiovascular disease to reduce cardiovascular events 3.

Clinical Decision Algorithm

For patients with myocarditis secondary to tropical fever:

1. Acute phase management:

   • Focus on standard supportive care and treating the underlying tropical fever
   • Monitor for and manage complications (heart failure, arrhythmias)
   • Consider immunosuppression only for specific forms of myocarditis 1

2. If heart failure develops:

   • For patients who develop HFrEF (LVEF ≤40%): Consider adding dapagliflozin as it reduces the risk of cardiovascular death and hospitalization for heart failure 3
   • For patients with HFpEF (LVEF >40%): Dapagliflozin may still be beneficial as it reduces heart failure hospitalizations across the LVEF spectrum 3

3. Monitoring considerations:

   • Watch for volume depletion, especially if the patient is already receiving diuretics
   • Monitor renal function and electrolytes 4
   • Be alert for genital mycotic infections, a common side effect 4

Important Caveats

• No direct evidence: There are no clinical trials specifically evaluating dapagliflozin in myocarditis secondary to tropical fever
• Potential benefit in post-myocarditis heart failure: If the patient develops heart failure after myocarditis, dapagliflozin would be appropriate based on heart failure guidelines 3
• Recent MI data: The DAPA-MI trial showed benefits of dapagliflozin in patients with acute myocardial infarction without diabetes or heart failure, but these were primarily cardiometabolic benefits rather than reduction in cardiovascular death or hospitalization for heart failure 5

In summary, while dapagliflozin has established cardiovascular benefits in heart failure and diabetes, it should not be used as a primary treatment for myocarditis secondary to tropical fever unless heart failure develops as a complication.