Is Farxiga (dapagliflozin) the only common drug used for patients with any stage of heart failure?

Is Farxiga the Only Common Drug Used for Heart Failure?

No, Farxiga (dapagliflozin) is not the only common drug used for heart failure—it is one component of a comprehensive multi-drug regimen that includes ACE inhibitors/ARBs/ARNIs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and diuretics, all of which are recommended across heart failure stages. 1, 2

Core Guideline-Directed Medical Therapy for Heart Failure

The foundation of heart failure treatment consists of multiple drug classes that work synergistically:

Neurohormonal Antagonists (Foundation Therapy)

• ACE inhibitors or ARBs are indicated in all symptomatic heart failure patients with reduced ejection fraction (HFrEF) to reduce hospitalization and death 1
• Beta-blockers are indicated in symptomatic HFrEF patients with diabetes to reduce heart failure hospitalization and death, and are recommended after acute MI with LVEF <40% to prevent sudden cardiac death 1
• Mineralocorticoid receptor antagonists (MRAs) are indicated in HFrEF patients who remain symptomatic despite ACE inhibitors and beta-blockers to reduce hospitalization and death 1
• Sacubitril/valsartan (ARNI) is indicated instead of ACE inhibitors in HFrEF patients with diabetes who remain symptomatic despite treatment with ACE inhibitors, beta-blockers, and MRAs 1

SGLT2 Inhibitors (Including Farxiga)

• SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) are recommended for all patients with symptomatic heart failure regardless of ejection fraction or diabetes status 2
• The American College of Cardiology gives SGLT2 inhibitors a Class I recommendation for HFrEF and recommends them for HFmrEF (LVEF 41-49%) with Class 2a strength 2, 3
• Dapagliflozin provides incremental benefit even when patients are already on optimal guideline-directed medical therapy (ACE inhibitor/ARB, beta-blocker, and MRA), reducing the primary outcome by 26% 2
• Both empagliflozin and dapagliflozin are effective across the ejection fraction spectrum (HFrEF and HFpEF) 2

Symptomatic Relief

• Diuretics are recommended in patients with HFpEF, HFmrEF, or HFrEF with signs and/or symptoms of fluid congestion to improve symptoms 1, 3
• Digoxin may be used in symptomatic patients who have not responded to diuretics, ACE inhibitors, and beta-blockers, though it is not first-line therapy 1

Additional Therapies for Specific Populations

Finerenone (Nonsteroidal MRA)

• Finerenone is recommended in patients with type 2 diabetes and chronic kidney disease to reduce progression from stage A heart failure to symptomatic incident heart failure, reducing heart failure hospitalization by 29% in FIDELIO-DKD 1

Device Therapy

• ICD, CRT, or CRT-D device therapy is recommended in patients with diabetes as in the general heart failure population 1

Clinical Implementation Algorithm

For newly diagnosed symptomatic HFrEF:

1. Initiate ACE inhibitor/ARB (or ARNI if already on ACE inhibitor) + beta-blocker + MRA + SGLT2 inhibitor as foundational "quadruple therapy" 2
2. Add diuretics for volume management if congestion present 1
3. Consider digoxin only if symptoms persist despite neurohormonal antagonists 1

For HFmrEF (LVEF 41-49%):

1. Initiate SGLT2 inhibitor (dapagliflozin 10mg or empagliflozin 10mg daily) 3
2. Add/optimize ACE inhibitors/ARBs, beta-blockers, or MRAs 3
3. Use diuretics for congestion 3

For HFpEF (LVEF ≥50%):

1. Initiate SGLT2 inhibitor (dapagliflozin or empagliflozin) 2
2. Manage comorbidities and use diuretics for symptoms 1

Critical Pitfalls to Avoid

• Do not use dapagliflozin as monotherapy—it provides additive benefit to existing guideline-directed medical therapy and should be part of comprehensive treatment 2
• Do not discontinue ACE inhibitors, beta-blockers, or MRAs when starting SGLT2 inhibitors—these medications work synergistically 2
• Avoid thiazolidinediones and saxagliptin in patients at risk for heart failure due to increased heart failure hospitalization risk 1
• Do not use aliskiren (direct renin inhibitor) in HFrEF with diabetes due to higher risk of hypotension, worsening renal function, hyperkalemia, and stroke 1
• Dapagliflozin should be used with caution when combined with high-dose loop diuretics and is contraindicated in patients with eGFR <25 mL/min/1.73 m² 2

Safety Monitoring for SGLT2 Inhibitors

• Monitor for euglycemic ketoacidosis, particularly in patients with poor food intake 1, 2
• Assess for genital and soft tissue infections 2
• Monitor volume status due to diuretic effects, though symptomatic hypotension is rare (0.3% vs 0.5% placebo) 2
• Regular renal function monitoring is recommended, though dapagliflozin preserves kidney function even with eGFR as low as 25 mL/min/1.73 m² 2, 3