From the Guidelines
SGLT2 inhibitors are recommended to help with decongestion in acute heart failure, as they promote diuresis and natriuresis, leading to effective volume reduction and improved decongestion. These medications, including empagliflozin (Jardiance), dapagliflozin (Farxiga), and canagliflozin (Invokana), work by inhibiting sodium and glucose reabsorption in the proximal tubule of the kidney, resulting in increased urinary sodium and glucose excretion 1. In acute heart failure settings, SGLT2 inhibitors are typically started at standard doses (empagliflozin 10mg daily, dapagliflozin 10mg daily, or canagliflozin 100mg daily) alongside conventional therapies like loop diuretics. The decongestion effect occurs through a mechanism different from traditional diuretics, as SGLT2 inhibitors work in the proximal tubule rather than the loop of Henle, which helps reduce pulmonary congestion, peripheral edema, and may decrease heart failure hospitalization rates 1.
The use of SGLT2 inhibitors in acute heart failure is supported by recent guidelines, which recommend their use in patients with heart failure, independent of left ventricular ejection fraction (LVEF), in the absence of contraindications 1. An algorithm to optimize decongestion in decompensated heart failure suggests initiating or optimizing SGLT2 inhibitors alongside loop diuretics and other guideline-directed medical therapies 1. The osmotic diuresis produced by SGLT2 inhibitors is generally well-tolerated and doesn't cause the same electrolyte disturbances often seen with loop diuretics. However, patients should be monitored for potential side effects including genital mycotic infections, volume depletion, and hypotension, particularly when used alongside other diuretics.
Key points to consider when using SGLT2 inhibitors for decongestion in acute heart failure include:
- Starting at standard doses (empagliflozin 10mg daily, dapagliflozin 10mg daily, or canagliflozin 100mg daily)
- Using alongside conventional therapies like loop diuretics
- Monitoring for potential side effects, including genital mycotic infections, volume depletion, and hypotension
- Considering the use of SGLT2 inhibitors in patients with heart failure, independent of LVEF, in the absence of contraindications 1.
From the Research
SGLT2 Inhibitors and Decongestion in Acute Heart Failure
- SGLT2 inhibitors have been shown to promote natriuresis and diuresis, which can be beneficial in acute heart failure 2.
- A narrative review of randomized controlled trials found that SGLT2 inhibitors may have a role in inpatient management of acute heart failure, with benefits in cardiovascular outcomes and no significant increase in adverse effects such as hypotension, hypokalemia, and acute renal failure 2.
- Another study found that SGLT2 inhibitors induce significant osmotic diuresis and natriuresis, decrease interstitial fluid volume and blood pressure, and improve left ventricular function, which can be beneficial in acute heart failure 3.
Clinical Evidence
- A retrospective evaluation of patients with heart failure found that most patients did not require a change in loop diuretic dose after initiation of SGLT2 inhibitors, but some patients did have a reduction in loop diuretic dose within 6 months of starting SGLT2 inhibitors 4.
- A case series found that SGLT2 inhibitors improved weight loss, urine output, and diuretic efficiency in patients with acute decompensated heart failure, without worsening creatinine, potassium, or blood pressure 5.
- A review of the current evidence suggests that early administration of SGLT2 inhibitors in hospitalized patients with acute heart failure may be beneficial, with a proposed practical flowchart for early administration of SGLT2 inhibitors in the acute setting 6.
Safety and Efficacy
- The safety and efficacy of SGLT2 inhibitors in acute heart failure have been demonstrated in several studies, with benefits in cardiovascular outcomes and no significant increase in adverse effects 2, 3, 5.
- However, further trials are required to shed more light on the issue of SGLT2 inhibitors in acute heart failure, particularly with regards to the optimal timing of initiation and the potential risks and benefits in different patient populations 3.