Cleveland Clinic Journal of MedicineShould I Start an SGLT-2 Inhibitor in my Patient with Heart Failure and Chronic Kidney Disease?

Transforming Cardio-Renal Outcomes: The Potential of SGLT-2 Inhibitors

In the evolving landscape of cardiology and nephrology, the advent of sodium-glucose cotransporter 2 (SGLT-2) inhibitors marks a significant stride in the concomitant management of heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD). This article looks into the nuanced efficacy and recommended clinical applications of SGLT-2 inhibitors, underscoring their dual benefits in renal protection and cardiovascular risk reduction, particularly in the context of emerging data from recent trials.

Key Points:

• SGLT-2 inhibitors are increasingly recognized for their benefits in patients with both CKD and heart failure, offering renoprotective and cardiovascular advantages.
• Initial studies highlighted SGLT-2 inhibitors’ ability to reduce hospitalizations for heart failure in type 2 diabetes patients, with further research extending these findings to HFrEF patients, regardless of diabetic status.
• The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial demonstrated a significant reduction in cardiovascular death or heart failure exacerbations in patients with HFrEF using dapagliflozin.
• The EMPA-KIDNEY trial showed that empagliflozin reduces the risk of kidney disease progression or cardiovascular death in CKD patients, supporting its use in individuals with an eGFR as low as 20 mL/min/1.73m2.
• SGLT-2 inhibitors operate by inhibiting glucose and sodium reabsorption in the kidneys, which leads to beneficial effects on the renin-angiotensin-aldosterone system and tubuloglomerular feedback.
• Despite their benefits, clinicians must be vigilant for possible side effects of SGLT-2 inhibitors, including acute kidney injury and euglycemic ketoacidosis, and monitor renal function post-initiation.
• The initiation of SGLT-2 inhibitors is now considered in the inpatient setting for acute heart failure based on evidence showing significant benefits post-hospitalization.

A meta-analysis of 10 high-quality randomized clinical trials (71,553 participants) found that use of SGLT-2 inhibitors was associated with lower occurrence of cardiovascular death or HHF by 33% in high-risk patients.

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