How does Jardiance (Empagliflozin) work best for acute congestive heart failure (CHF)?

From the Guidelines

Jardiance (empagliflozin) works best for acute congestive heart failure (CHF) when added to standard heart failure therapy at a dose of 10 mg once daily, as evidenced by the EMPEROR-Reduced trial 1. For patients with acute CHF, Jardiance should be initiated once the patient is hemodynamically stable, typically after the acute decompensation has been addressed with diuretics and other standard treatments. The medication works by inhibiting sodium-glucose cotransporter-2 (SGLT2) in the kidneys, which increases glucose excretion in urine and reduces sodium reabsorption. This dual action creates both an osmotic diuresis and natriuresis effect, reducing preload and afterload on the heart. Additionally, Jardiance shifts cardiac metabolism toward ketone utilization, which is more energy-efficient for the failing heart. Some key points to consider when using Jardiance for acute CHF include:

• Monitoring for potential side effects including genital mycotic infections, urinary tract infections, and volume depletion, especially during acute illness 1.
• Using Jardiance cautiously in patients with reduced kidney function and avoiding its use when eGFR falls below 20 mL/min/1.73m².
• Implementing blood glucose monitoring, even in non-diabetic patients, as Jardiance can cause modest reductions in blood glucose levels. The EMPEROR-Reduced trial demonstrated a 21% reduction in the primary composite outcome of cardiovascular death or hospitalization for worsening heart failure with empagliflozin compared to placebo 1. This trial, along with other studies such as DAPA-HF and DELIVER, supports the use of SGLT2 inhibitors like Jardiance in patients with heart failure, regardless of the presence of type 2 diabetes 1. Overall, Jardiance is a valuable addition to standard heart failure therapy for patients with acute CHF, offering benefits in reducing worsening heart failure and cardiovascular death.

From the Research

Mechanism of Action

• Jardiance (empagliflozin) is a sodium-glucose cotransporter 2 inhibitor (SGLT2i) that has been approved for the treatment of symptomatic chronic heart failure (CHF) regardless of left ventricular ejection fraction (LVEF) 2.
• The addition of empagliflozin to standard of care has been shown to significantly reduce the risk of cardiovascular death or hospitalization for heart failure (HHF) in patients with symptomatic CHF 2.

Efficacy in Acute CHF

• Empagliflozin has been shown to improve health-related quality of life (HRQOL) and is generally well tolerated in patients with symptomatic CHF 2.
• The beneficial effect of empagliflozin on CV death/HHF was seen irrespective of the presence or absence of type 2 diabetes and regardless of background HF therapies 2.
• However, there is limited information on the use of Jardiance in acute CHF, and more research is needed to fully understand its effects in this setting.

Combination Therapy

• The combination of sacubitril/valsartan and dapagliflozin has been shown to improve cardiac function in patients with heart failure with reduced ejection fraction (HFrEF) compared to sacubitril/valsartan monotherapy 3.
• The co-administration of sacubitril/valsartan and empagliflozin in patients with HFrEF and concomitant type 2 diabetes appears to be safe in terms of renal function 4.
• However, the efficacy and safety of combination therapy with Jardiance and other heart failure medications in acute CHF is not well established and requires further study.

Cost-Effectiveness

• Empagliflozin has been shown to be a cost-effective strategy for the management of heart failure with preserved ejection fraction (HFpEF) in France, with an incremental cost-effectiveness ratio of €18,597 per life year gained and €13,980 per quality-adjusted life year (QALY) gained 5.
• However, the cost-effectiveness of Jardiance in acute CHF is not well established and requires further study.