Can a patient with hypertension (HTN), diabetes mellitus (DM), and heart failure switch from Farxiga (dapagliflozin) to ramipril due to significant weight loss?

Switching from Farxiga to Ramipril in Heart Failure with HTN and DM

Do not switch from Farxiga (dapagliflozin) to ramipril—instead, continue Farxiga and add ramipril to the regimen, as both medications provide distinct, complementary cardiovascular and mortality benefits in heart failure with reduced ejection fraction (HFrEF). 1

Why Both Medications Should Be Continued

SGLT2 Inhibitors (Farxiga) Are Foundational Therapy

• SGLT2 inhibitors like dapagliflozin are now guideline-directed medical therapy (GDMT) for heart failure, added to beta-blockers, ACE inhibitors/ARBs/ARNIs, and aldosterone antagonists 1
• The weight loss experienced is an expected therapeutic effect, not an adverse reaction requiring discontinuation 1
• SGLT2 inhibitors provide mortality benefit and reduce heart failure hospitalizations independent of blood pressure or glucose effects 1

ACE Inhibitors (Ramipril) Provide Additional Benefits

• Ramipril reduces cardiovascular death by 37%, MI by 22%, and stroke by 33% in diabetic patients with cardiovascular risk factors 2
• In diabetic patients specifically, ramipril reduces diabetic nephropathy, need for dialysis, and retinopathy requiring laser therapy 2
• ACE inhibitors should be first-line therapy for patients with stable CAD and hypertension, targeting BP <130/80 mmHg 2

Optimal Treatment Strategy

Combination Therapy Approach

• Add ramipril to the existing Farxiga regimen rather than substituting one for the other 1
• Both medications work through different mechanisms and provide additive cardiovascular protection 1
• In clinical trials, SGLT2 inhibitors showed consistent benefit even in patients already receiving ACE inhibitors or ARNIs 1

Managing the Weight Loss Concern

• Weight loss from SGLT2 inhibitors is typically modest (2-3 kg) and stabilizes over time 1
• If weight loss is excessive or problematic:
  • Assess for volume depletion and adjust loop diuretic doses downward if needed 1
  • Ensure adequate caloric intake and nutritional status
  • Monitor for signs of sarcopenia or frailty in elderly patients
• Do not discontinue SGLT2 inhibitor therapy solely due to weight loss unless there is clinical evidence of harm 1

Practical Implementation

• Start ramipril at low dose (1.25-2.5 mg daily) and titrate gradually to target dose of 10 mg daily 2, 3
• Monitor renal function and potassium closely when combining these medications 1
• Loop diuretic doses may need reduction to permit optimal titration of ramipril while avoiding hyperkalemia 1
• Coordinate with endocrinology if patient uses insulin or sulfonylureas, as SGLT2 inhibitors may require adjustment of diabetes medications to prevent hypoglycemia 1

Critical Monitoring Parameters

When Adding Ramipril to Farxiga

• Blood pressure: Target <130/80 mmHg in diabetic patients with CAD 2
• Renal function: Creatinine and eGFR at baseline, 1-2 weeks after initiation, and with each dose increase 1
• Potassium levels: Risk of hyperkalemia increases with ACE inhibitors, especially in diabetic patients with renal impairment 1
• Weight and volume status: Adjust diuretics as needed to maintain euvolemia 1

Common Pitfall to Avoid

The most critical error would be discontinuing SGLT2 inhibitor therapy in a heart failure patient due to weight loss, as this removes a medication with proven mortality benefit 1. Weight loss is an expected pharmacologic effect and typically does not require discontinuation unless accompanied by volume depletion, malnutrition, or other clinical harm.