What if empagliflozin (SGLT2 inhibitor) isn't tolerated due to dizziness?

Managing Dizziness with SGLT2 Inhibitors

If empagliflozin isn't tolerated due to dizziness, consider switching to another class of medication for cardiovascular and renal protection, such as a GLP-1 receptor agonist, or try reducing the diuretic dose if the patient is on concurrent diuretic therapy.

Understanding the Cause of Dizziness with SGLT2 Inhibitors

Dizziness with empagliflozin is typically related to:

1. Volume depletion: SGLT2 inhibitors cause osmotic diuresis, which can lead to dehydration and orthostatic hypotension 1
2. Blood pressure reduction: These medications inherently lower blood pressure by 4-5 mmHg systolic and 2 mmHg diastolic 1
3. Interaction with other medications: Particularly when combined with diuretics or other antihypertensive agents

Management Algorithm for Dizziness with SGLT2 Inhibitors

Step 1: Assess for Dehydration and Hypotension

• Check for orthostatic hypotension (drop in BP upon standing)
• Evaluate for clinical signs of dehydration
• Measure blood pressure (concerning if SBP <80 mmHg) 1

Step 2: Modify Current Therapy

1. If on concurrent diuretic therapy:

   • Reduce or temporarily discontinue diuretic dose 1
   • Monitor for congestion signs if heart failure is present

2. If blood pressure is low but asymptomatic:

   • Continue SGLT2i and add mineralocorticoid receptor antagonist (MRA) which has less BP-lowering effect 1
   • Consider reducing doses of other antihypertensive medications

3. If blood pressure is low with significant symptoms:

   • Temporarily discontinue empagliflozin
   • Ensure adequate hydration
   • Consider referral to heart failure specialist if patient has heart failure 1

Step 3: Consider Alternative Options

For patients with Type 2 Diabetes:

• Switch to a GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) which provides cardiovascular benefits without causing volume depletion 1
• Consider DPP-4 inhibitors (except saxagliptin) which have neutral effects on heart failure risk 1

For patients with Heart Failure:

• Ensure other guideline-directed medical therapy is optimized (ACEi/ARB/ARNI, beta-blockers, MRAs) 2
• Consider ivabradine if in sinus rhythm with heart rate ≥70 bpm 1

Special Considerations

High-Risk Patients for SGLT2i-Related Dizziness

• Elderly patients 3
• Patients with neurological deficits affecting fluid intake 3
• Patients on multiple antihypertensive medications
• Those with baseline low blood pressure (SBP <110 mmHg)

Prevention Strategies if Rechallenge is Attempted

1. Ensure adequate fluid intake (preventive water intake) 3
2. Monitor blood pressure regularly, especially when standing
3. Start with the lowest dose and titrate slowly 1
4. Educate patient about symptoms of dehydration and when to seek help

Important Caveats

• Do not discontinue all heart failure medications: If the patient has heart failure, maintaining other guideline-directed therapies is crucial for mortality benefit 2
• Avoid thiazolidinediones as alternative in heart failure patients 1
• Monitor renal function: Especially if changing medication regimens, as worsening kidney function can contribute to symptoms
• Consider timing of administration: Taking the medication at bedtime might reduce symptomatic hypotension during daytime activities

Remember that while dizziness is an important side effect to address, the cardiovascular and renal benefits of SGLT2 inhibitors are substantial, so alternative strategies to maintain these benefits should be pursued whenever possible.