Can non-diabetic patients over 55 years old with at least 2 cardiovascular risk factors take Empagliflozin (Empagliflozin)

Empagliflozin Use in Non-Diabetic Patients Over 55 with Cardiovascular Risk Factors

Non-diabetic patients over 55 years old with at least 2 cardiovascular risk factors should take empagliflozin as it reduces the risk of cardiovascular death and heart failure hospitalization regardless of diabetes status.

Mechanism and Evidence Base

Empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, has demonstrated significant cardiovascular benefits beyond its glucose-lowering effects. The strongest evidence comes from:

• The EMPEROR-Preserved trial showed empagliflozin reduced the combined risk of cardiovascular death or hospitalization for heart failure in patients with preserved ejection fraction, regardless of diabetes status (HR 0.79; 95% CI 0.69-0.90; P<0.001) 1
• The American College of Cardiology and European Society of Cardiology recommend SGLT2 inhibitors for patients with heart failure, with benefits seen regardless of diabetes status 2

Cardiovascular Benefits in High-Risk Populations

Empagliflozin provides several cardiovascular benefits that are particularly relevant for non-diabetic patients with cardiovascular risk factors:

• Reduction in heart failure hospitalization: 35% relative risk reduction (2.7% vs 4.1% in placebo) 3
• Reduction in cardiovascular death: 38% relative risk reduction (3.7% vs 5.9% in placebo) 3
• Reduction in all-cause mortality: 32% relative risk reduction (5.7% vs 8.3% in placebo) 3
• Consistent benefits across the spectrum of heart failure risk: Benefits observed in patients with low-to-average, high, and very high 5-year heart failure risk (HR 0.71,0.52, and 0.55 respectively) 4

Cardiac Remodeling Effects

Empagliflozin has demonstrated favorable effects on cardiac structure:

• Reduces left ventricular end-systolic volume index by 6.0 mL/m² (95% CI, -10.8 to -1.2; P=0.015) 5
• Reduces left ventricular end-diastolic volume index by 8.2 mL/m² (95% CI, -13.7 to -2.6; P=0.0042) 5
• These remodeling effects may explain the mechanism by which empagliflozin reduces heart failure hospitalization and mortality 5

Dosing and Administration

• Recommended dose: 10 mg once daily 2, 6
• Renal function considerations:
  • Do not initiate if eGFR <25 mL/min/1.73 m² 2
  • Withhold for at least 3 days before major surgery or procedures requiring prolonged fasting 2

Monitoring and Adverse Effects

Common adverse effects to monitor include:

• Genital mycotic infections (more common with empagliflozin than placebo) 1
• Urinary tract infections (increased risk in patients ≥75 years) 6
• Volume depletion/hypotension (risk increases in patients ≥75 years) 6
• Euglycemic diabetic ketoacidosis (rare but serious) 2

Clinical Application

For non-diabetic patients over 55 years with at least 2 cardiovascular risk factors:

1. Assess baseline renal function: Ensure eGFR ≥25 mL/min/1.73 m²
2. Start empagliflozin 10 mg daily
3. Monitor for:
   • Volume status and blood pressure
   • Genital and urinary tract infections
   • Renal function

Important Caveats

• Benefits appear early (within weeks) after initiation 2
• Continue indefinitely as part of cardiovascular risk management 2
• The FDA label for empagliflozin currently focuses on its use in diabetic patients, but clinical evidence supports its use in non-diabetics with cardiovascular risk factors 6, 1
• Patients should be educated about potential side effects and when to seek medical attention

By implementing empagliflozin in non-diabetic patients over 55 with cardiovascular risk factors, clinicians can significantly reduce the risk of cardiovascular death and heart failure hospitalization in this high-risk population.