How to manage a patient with heart failure on dapagliflozin (SGLT2 inhibitor) who also experiences urinary incontinence?

Managing Heart Failure in a Patient on Dapagliflozin with Urinary Incontinence

Dapagliflozin should be continued in patients with heart failure who experience urinary incontinence, as its cardiovascular benefits outweigh the potential exacerbation of urinary symptoms. 1, 2

Benefits of Continuing SGLT2 Inhibitors in Heart Failure

• Dapagliflozin (10 mg daily) is a cornerstone therapy for heart failure with reduced ejection fraction (HFrEF), reducing cardiovascular death and heart failure hospitalizations regardless of diabetes status 1
• SGLT2 inhibitors demonstrate a beneficial class effect in patients with HFrEF, with dapagliflozin showing a 30% decrease in first episodes of worsening heart failure and 18% decrease in cardiovascular death 1
• Unlike other heart failure medications, SGLT2 inhibitors do not require dose adjustment or up-titration and have minimal impact on blood pressure, heart rate, or potassium levels 1
• Benefits of dapagliflozin occur within weeks of initiation and are maintained regardless of age, sex, or background medical therapy 1

Managing Urinary Incontinence in Heart Failure Patients

• Up to 50% of heart failure patients suffer from lower urinary tract symptoms, with incontinence occurring three times more frequently in patients with NYHA Class III and IV symptoms 3
• Heart failure medications, including diuretics, can exacerbate urinary symptoms through increased urine production 3
• Avoid initiating antimuscarinic agents for urinary symptoms as they may worsen heart failure through increased heart rate and decreased cardiac output 3

Practical Management Algorithm

1. Continue dapagliflozin therapy at the standard dose of 10 mg daily 1, 2

   • Benefits for heart failure outcomes are substantial and well-established 1, 2
   • Recent evidence shows dapagliflozin may actually improve diuresis and decongestion 4, 5

2. Optimize diuretic therapy:

   • Titrate loop diuretics to the lowest effective dose to control congestion 3
   • Consider timing diuretic administration earlier in the day to reduce nighttime urination 3
   • Monitor daily weights to guide diuretic adjustments 3

3. Implement non-pharmacological interventions:

   • Recommend pelvic floor muscle exercises to improve urinary control 3
   • Suggest timed voiding schedules to reduce incontinence episodes 3
   • Advise appropriate fluid management with moderate restriction in the evening 3

4. Monitor for complications:

   • Assess for urinary tract infections, which can exacerbate incontinence symptoms 3
   • Monitor renal function periodically, as both heart failure and SGLT2 inhibitors can affect kidney function 2
   • Watch for signs of volume depletion, especially if the patient is on multiple diuretics 2

Important Considerations

• Dapagliflozin has been shown to be effective with an eGFR as low as 20-30 mL/min/1.73m² 1, 2
• A mild, transient decrease in eGFR may occur after initiating SGLT2 inhibitors but does not indicate kidney injury and should not prompt discontinuation 1
• Recent studies demonstrate that early dapagliflozin initiation during acute heart failure hospitalization is safe and may enhance diuresis 5, 6
• The cardiovascular benefits of SGLT2 inhibitors are consistent across heart failure populations and should be prioritized over concerns about mild urinary symptoms 1, 7

Cautions

• Avoid adding antimuscarinic medications for urinary symptoms as they may worsen heart failure 3
• Monitor for genital mycotic infections (1.5-1.7%) and urinary tract infections (2.3-2.7%), which can occur with SGLT2 inhibitor therapy but are generally manageable 2
• Be vigilant for signs of volume depletion if the patient is on multiple diuretics in addition to dapagliflozin 2