Recommended Diabetes Medications for Patients with Congestive Heart Failure
SGLT2 inhibitors (empagliflozin, canagliflozin, and dapagliflozin) are strongly recommended as first-line diabetes medications for patients with congestive heart failure (CHF) due to their proven ability to reduce heart failure hospitalizations and mortality. 1
First-Line Therapy
- SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) are recommended with the highest level of evidence (Class I, Level A) for patients with diabetes and CHF 1
- These medications reduce heart failure hospitalization risk by 32-35% and provide mortality benefits 1, 2
- Empagliflozin specifically is recommended to reduce the risk of death in patients with type 2 diabetes and cardiovascular disease 1
- SGLT2 inhibitors provide cardiovascular benefits through hemodynamic effects including blood pressure reduction and decreased extracellular volume, beyond their glucose-lowering effects 3, 4
Second-Line Options
- Metformin should be considered for diabetes treatment in patients with heart failure if eGFR is stable and >30 mL/min/1.73 m² (Class IIa, Level C) 1
- GLP-1 receptor agonists (lixisenatide, liraglutide, semaglutide, exenatide, dulaglutide) have a neutral effect on heart failure risk and may be considered (Class IIb, Level A) 1
- The DPP4 inhibitors sitagliptin and linagliptin have a neutral effect on heart failure hospitalization risk and may be considered (Class IIb, Level B) 1
Medications to Consider with Caution
- Insulin may be considered in patients with advanced systolic heart failure with reduced ejection fraction (HFrEF), but should be used cautiously (Class IIb, Level C) 1
- Hypoglycemia should be avoided as it can trigger arrhythmias in patients with heart failure 1
Medications to Avoid
- Thiazolidinediones (pioglitazone, rosiglitazone) are contraindicated in patients with diabetes and symptomatic heart failure due to increased risk of heart failure exacerbation (Class III, Level A) 1
- The DPP4 inhibitor saxagliptin is associated with increased risk of heart failure hospitalization and is not recommended for patients with diabetes and heart failure (Class III, Level B) 1
Additional Considerations for Heart Failure Management
- Sacubitril/valsartan is recommended instead of ACE inhibitors in patients with HFrEF and diabetes who remain symptomatic despite treatment with ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists 1
- Ivabradine should be considered in patients with heart failure and diabetes in sinus rhythm with resting heart rate ≥70 bpm who remain symptomatic despite optimal heart failure treatment 1
- Cardiac revascularization with CABG surgery is recommended for patients with HFrEF, diabetes, and two or three-vessel coronary artery disease 1
- Aliskiren (direct renin inhibitor) is not recommended for patients with HFrEF and diabetes due to higher risk of hypotension, worsening renal function, hyperkalemia, and stroke 1
Special Considerations
- Recent evidence from meta-analysis of the EMPEROR-Reduced and DAPA-HF trials shows that SGLT2 inhibitors reduce all-cause mortality by 13% and cardiovascular death by 14% in patients with HFrEF regardless of diabetes status 5
- SGLT2 inhibitors also reduce the risk of the composite renal endpoint by 38% 5
- Regular monitoring of renal function is essential when using SGLT2 inhibitors, particularly in patients with baseline renal impairment 2
By following these evidence-based recommendations, clinicians can optimize glycemic control while simultaneously improving cardiovascular outcomes in patients with both diabetes and heart failure.