From the Guidelines
Using midodrine and Jardiance (empagliflozin) together in acute and chronic congestive heart failure (CHF) generally does not make sense due to their opposing effects on fluid balance. Midodrine is a vasoconstrictor that increases blood pressure, which can be helpful in patients with hypotension but may increase cardiac workload in heart failure. Jardiance, an SGLT2 inhibitor, promotes fluid loss through increased urination and has proven benefits in heart failure by reducing cardiac preload and afterload, as shown in the EMPEROR-Preserved trial 1. The combination could create conflicting physiological effects - midodrine increasing vascular resistance while Jardiance aims to reduce fluid overload. In acute heart failure, this combination is particularly problematic as midodrine could worsen congestion. For chronic heart failure, Jardiance alone is preferred as it has demonstrated benefits in reducing hospitalizations and improving quality of life, with a significant 21% reduction in the primary composite endpoint of time to HF hospitalization or cardiovascular death, as seen in the EMPEROR-Preserved trial 1. If hypotension is a concern with Jardiance, dose adjustment of other medications (like diuretics or ACE inhibitors) would be more appropriate than adding midodrine. Patients with heart failure should have their medication regimen carefully tailored to their specific hemodynamic status under specialist supervision. Some key points to consider when managing CHF include:
- The use of SGLT2 inhibitors, such as Jardiance, has been shown to be beneficial in patients with symptomatic HF, with LVEF >40% and elevated natriuretic peptides 1
- The benefits of SGLT2 inhibitors are seen regardless of the presence or absence of diabetes at baseline 1
- The combination of midodrine and Jardiance may create conflicting physiological effects, and alternative strategies should be considered to manage hypotension in patients with CHF.
From the Research
Combination Therapy in Acute and Chronic CHF
The use of midodrine and Jardiance (empagliflozin) together in acute and chronic heart failure (CHF) can be considered based on the available evidence.
- Midodrine is a peripheral alpha1-adrenergic agonist that may allow for up-titration of neurohormonal antagonist therapy, leading to improved outcomes in patients with heart failure and symptomatic hypotension 2, 3.
- Empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, has been shown to reduce cardiovascular risk in patients with type 2 diabetes mellitus and heart failure with reduced ejection fraction (HFrEF) 4, 5.
- The medical management of acute heart failure involves several aspects, including diagnosis, decongestion, vasoactive therapy, and goal-directed medical therapy initiation, where SGLT2 inhibitors like empagliflozin may play a role 6.
Potential Benefits and Considerations
The combination of midodrine and empagliflozin may offer potential benefits in acute and chronic CHF, including:
- Improved optimization of guideline-directed medical therapy (GDMT) in patients with HFrEF and symptomatic hypotension 2, 3.
- Reduced cardiovascular risk and improved outcomes in patients with type 2 diabetes mellitus and HFrEF 4, 5.
- However, the safety and efficacy of this combination therapy need to be further evaluated, and individual patient factors should be considered when making treatment decisions 4, 5, 6, 2, 3.