What is the role of Jardiance (Empagliflozin) in the management of heart failure?

Role of Jardiance (Empagliflozin) in Heart Failure Management

Empagliflozin is strongly recommended for all patients with symptomatic chronic heart failure regardless of ejection fraction or diabetes status, as it significantly reduces cardiovascular mortality, heart failure hospitalizations, and improves quality of life. 1

Efficacy Across Heart Failure Spectrum

• Empagliflozin reduces the risk of hospitalization for heart failure by 35% compared to placebo in patients with type 2 diabetes and high cardiovascular risk 1
• Benefits are consistent across heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) populations 1
• In EMPEROR-Reduced trial, empagliflozin reduced the composite outcome of cardiovascular death or hospitalization for heart failure by 21% (HR 0.79 [95% CI 0.69–0.90]; P < 0.001) in patients with HFrEF (LVEF ≤40%) 1, 2
• In EMPEROR-Preserved trial, empagliflozin reduced the same composite outcome by 21% in patients with HFpEF (LVEF >40%) 1
• Benefits are observed regardless of diabetes status, with similar efficacy in patients with and without diabetes 1, 3

Clinical Benefits Beyond Hospitalization Reduction

• Empagliflozin improves symptoms, physical limitations, and quality of life in heart failure patients 1, 4
• Treatment reduces the need for intensification of diuretics by 33% (HR 0.67; 95% CI 0.56-0.78; P<0.0001) 2
• Patients on empagliflozin are 20-40% more likely to experience improvement in NYHA functional class 2
• Benefits appear early after treatment initiation (as soon as 12 days) and are sustained long-term 2
• Reduces total number of heart failure hospitalizations requiring intensive care (HR 0.67; 95% CI 0.50-0.90) 2

Recent Evidence for Post-Myocardial Infarction

• The EMPACT-MI trial showed empagliflozin reduces the risk of first heart failure hospitalization (HR 0.77 [95% CI 0.60-0.98]) and total heart failure hospitalizations (rate ratio 0.67 [95% CI 0.51-0.89]) in patients with left ventricular dysfunction after acute myocardial infarction 5
• Patients treated with empagliflozin after MI had reduced need for new diuretics, renin-angiotensin modulators, or mineralocorticoid receptor antagonists 5

Dosing and Administration

• FDA-approved dose is 10 mg once daily in the morning, with or without food 6
• Dose may be increased to 25 mg daily if tolerated 6
• Should not be initiated in patients with eGFR less than 45 mL/min/1.73 m² 6
• Assess volume status before initiation and correct volume depletion if present 6

Safety Considerations

• Monitor for symptomatic hypotension, particularly in patients with renal impairment, elderly patients, those with low systolic blood pressure, or patients on diuretics 6
• Risk of diabetic ketoacidosis exists, including euglycemic ketoacidosis, requiring monitoring especially in susceptible patients 1
• Empagliflozin does not lower HbA1c in patients without diabetes and is not associated with increased hypoglycemia risk in non-diabetic heart failure patients 3
• Discontinue if eGFR persistently falls below 45 mL/min/1.73 m² 6

Clinical Implementation Algorithm

1. Patient Selection: Consider empagliflozin for all patients with symptomatic heart failure (NYHA class II-IV) regardless of ejection fraction or diabetes status 1
2. Pre-initiation Assessment:
   • Check eGFR (must be ≥45 mL/min/1.73 m²) 6
   • Assess volume status and correct depletion if present 6
   • Review current medications, especially diuretics 6
3. Initiation: Start with 10 mg once daily in the morning 6
4. Monitoring:
   • Watch for hypotension, especially in first weeks of treatment 6
   • Monitor renal function periodically 6
   • Assess for signs/symptoms of ketoacidosis, particularly during illness or fasting 1
5. Dose Adjustment: Consider increasing to 25 mg daily if well-tolerated 6
6. Long-term Follow-up: Continue indefinitely as benefits persist over time 2

Empagliflozin represents a significant advancement in heart failure management, with consistent benefits across the spectrum of heart failure patients, regardless of ejection fraction or diabetes status. Its ability to reduce mortality, hospitalizations, and improve quality of life makes it a cornerstone therapy in contemporary heart failure management.