How to manage a patient with uncontrolled diabetes and CHF on insulin degludec, glipizide, and Farxiga (dapagliflozin)?

Management of Uncontrolled Diabetes with CHF

Intensify insulin degludec to 70-100 units daily, discontinue glipizide immediately, continue Farxiga 10 mg, and add metformin if eGFR >30 mL/min/1.73 m².

Immediate Medication Adjustments

Discontinue Glipizide

• Glipizide (sulfonylurea) should be stopped immediately in this patient with CHF, as it provides no cardiovascular or heart failure benefit and increases hypoglycemia risk, which can trigger arrhythmias in heart failure patients 1, 2.
• Sulfonylureas do not reduce mortality or morbidity in patients with diabetes and CHF 1.

Continue and Optimize Farxiga (Dapagliflozin)

• Farxiga 10 mg should be continued as it is the cornerstone therapy for this patient with both diabetes and CHF 1, 2.
• SGLT2 inhibitors reduce heart failure hospitalization by 27-39% and cardiovascular death by 18-31% 1, 2, 3.
• Dapagliflozin specifically demonstrated a 26% reduction in the composite outcome of worsening heart failure or cardiovascular death in the DAPA-HF trial 1.
• The European Society of Cardiology gives SGLT2 inhibitors a Class I, Level A recommendation for patients with diabetes and heart failure 1, 2.

Intensify Insulin Degludec

• Increase insulin degludec from 50 units to 70-100 units daily to address the A1c of 9.3% 4.
• With an A1c of 9.3%, the patient requires approximately 0.7-1.0 units/kg/day of basal insulin, assuming body weight of 70-100 kg 5.
• Insulin may be considered in patients with heart failure, though it should be used cautiously 1, 2.
• Monitor closely for hypoglycemia, as it can trigger arrhythmias in CHF patients 1.

Add Metformin

• Add metformin 500 mg twice daily, titrating to 1000 mg twice daily if the patient's eGFR is >30 mL/min/1.73 m² and CHF is stable 1, 2.
• Metformin is recommended as second-line therapy in stable CHF with normal renal function (Class IIa, Level C recommendation) 1, 2.
• Metformin should be avoided if the patient is unstable or hospitalized with CHF 1.
• Check renal function before initiating and monitor regularly 1.

Alternative Add-On Options if Metformin Contraindicated

GLP-1 Receptor Agonists

• Consider adding liraglutide, semaglutide, or dulaglutide if metformin is contraindicated or not tolerated 1, 2.
• GLP-1 receptor agonists reduce cardiovascular events and have neutral effects on heart failure risk 1, 2.
• Liraglutide specifically reduces cardiovascular death in high-risk patients 1.

DPP-4 Inhibitors (Selected Agents Only)

• Sitagliptin or linagliptin may be considered as they have neutral effects on heart failure hospitalization 1, 2.
• Never use saxagliptin in this patient, as it increases heart failure hospitalization risk (Class III, Level B recommendation) 1, 2.

Critical Medications to Avoid

Thiazolidinediones (TZDs)

• Pioglitazone and rosiglitazone are absolutely contraindicated in patients with symptomatic heart failure (Class III, Level A recommendation) 1, 2.
• TZDs cause fluid retention and can precipitate or worsen CHF 1.
• The hazard ratio for CHF with TZDs is 1.6-1.8 compared to other agents 1.

Monitoring Requirements

Assess CHF Stability

• Evaluate for signs of decompensated heart failure: orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, S3 gallop, pulmonary rales, or worsening pedal edema 1.
• If CHF is unstable or the patient requires hospitalization, hold metformin temporarily 1.

Check Renal Function

• Measure serum creatinine and eGFR before adding metformin 1.
• Metformin requires eGFR >30 mL/min/1.73 m² 1, 2.
• Monitor renal function regularly, especially when using SGLT2 inhibitors, ACE inhibitors, ARBs, or diuretics 1.

Monitor for Hypoglycemia

• Educate patient on hypoglycemia symptoms and avoidance strategies 1.
• Hypoglycemia can trigger arrhythmias in heart failure patients 1.
• With insulin intensification and glipizide discontinuation, hypoglycemia risk should decrease 2.

Weight and Fluid Status

• Monitor body weight weekly for the first month after medication changes 1.
• Assess for new or worsening pedal edema 1.
• SGLT2 inhibitors typically reduce body weight by 2-3 kg 6, 7, 8.

Additional Cardiovascular Risk Management

Ensure Optimal Heart Failure Therapy

• Verify patient is on ACE inhibitor or ARB (or sacubitril/valsartan), beta-blocker, and mineralocorticoid receptor antagonist as appropriate for CHF 1.
• Consider sacubitril/valsartan if patient remains symptomatic despite standard therapy 1, 2.

Statin Therapy

• Ensure patient is on appropriate statin therapy for cardiovascular risk reduction 1.
• This 53-year-old with diabetes and CHF qualifies for statin therapy regardless of baseline lipid levels 1.

Aspirin Consideration

• Consider aspirin 75-162 mg daily for primary prevention, as this patient is >50 years old with diabetes and CHF (10-year cardiovascular risk >10%) 1.

Expected Outcomes

Glycemic Control

• Target A1c reduction of 1.5-2.0% with this intensified regimen over 3-6 months 6, 7, 8.
• Insulin intensification should provide 1.0-1.5% A1c reduction 4.
• Metformin addition should provide an additional 0.5-1.0% A1c reduction 9, 6.

Heart Failure Benefits

• Continued SGLT2 inhibitor therapy reduces heart failure hospitalization risk by 27-39% 1, 2, 3.
• Cardiovascular death risk reduced by 18-31% with SGLT2 inhibitors 1, 2, 3.

Weight and Blood Pressure

• Expect 2-4 kg weight loss from SGLT2 inhibitor and metformin combination 6, 7, 8.
• Modest blood pressure reduction (2-5 mmHg systolic) from SGLT2 inhibitor 7, 8.