SGLT2 Inhibitors for Uncontrolled Diabetes with Mild Diastolic Dysfunction
SGLT2 inhibitors should be prescribed for this 53-year-old male with uncontrolled diabetes mellitus and mild diastolic dysfunction, even though he is currently asymptomatic. 1
Rationale for SGLT2 Inhibitor Therapy
- SGLT2 inhibitors are recommended for patients with type 2 diabetes and diastolic dysfunction to reduce the risk of heart failure hospitalization, regardless of baseline HbA1c or individualized HbA1c target 1
- The European Society of Cardiology specifically recommends SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) to lower the risk of heart failure in patients with diabetes 1
- SGLT2 inhibitors can improve diastolic function in patients with type 2 diabetes, as demonstrated by reductions in E/e' ratios, suggesting they directly address the patient's cardiac condition 2
Cardiovascular Benefits in This Patient Population
- SGLT2 inhibitors have demonstrated cardiovascular benefits in patients with diabetes, particularly in those with or at high risk for heart failure 1
- These medications can improve vascular endothelial function and reduce arterial stiffness, which are important mechanisms in diastolic dysfunction 2
- For patients with diastolic dysfunction, SGLT2 inhibitors provide cardioprotection through multiple mechanisms including improved hemodynamics, reduced preload and afterload, and direct effects on cardiac remodeling 3
Specific Recommendations for This Patient
- Begin with an SGLT2 inhibitor (empagliflozin, dapagliflozin, or canagliflozin) in addition to current therapy, with empagliflozin having the strongest evidence for reducing mortality in patients with diabetes and cardiovascular disease 1, 4
- Consider this treatment independent of the patient's current glycemic control, as cardiovascular benefits occur regardless of baseline HbA1c 1
- Monitor renal function before initiating therapy and periodically thereafter, as SGLT2 inhibitors are not recommended when eGFR is persistently less than 45 mL/min/1.73 m² 5
Precautions and Monitoring
- Assess for risk factors for diabetic ketoacidosis (DKA) before initiating therapy, as SGLT2 inhibitors may increase susceptibility to DKA 1, 5
- Provide education regarding symptoms of DKA and consider home monitoring supplies for β-hydroxybutyrate if the patient has risk factors 1
- Monitor for genital mycotic infections, which are a common side effect of SGLT2 inhibitors 5
- Consider dose adjustment of other glucose-lowering medications, particularly insulin or sulfonylureas, to reduce the risk of hypoglycemia 5, 6
Additional Considerations
- SGLT2 inhibitors may provide neuroprotective effects, potentially reducing the risk of cognitive decline and dementia in patients with diabetes 7, 1
- These medications have shown benefits beyond glycemic control, including blood pressure reduction, weight loss, and improved renal outcomes 6, 3
- For patients with osteoporosis or at risk for amputation, empagliflozin may be preferred over canagliflozin based on safety data 6
By initiating an SGLT2 inhibitor in this patient with uncontrolled diabetes and mild diastolic dysfunction, you are providing evidence-based therapy that addresses both glycemic control and the underlying cardiac condition, potentially preventing progression to symptomatic heart failure and reducing cardiovascular mortality.