SGLT2 inhibitors in cardiological practice

Modern antidiabetics, such as SGLT2 inhibitors, have shown positive effects on cardiovascular risks or kidney function for diabetics. However, recent study results show an equal benefit for heart failure patients regardless of their diabetes status.

Guidelines and their implementation in everyday life

Some modern antidiabetics, such as SGLT2 inhibitors, have shown positive effects on cardiovascular risks or kidney function for diabetics over numerous studies. Several international clinical guidelines now address these effects and recommend the use of SGLT2 inhibitors in high-risk cardiovascular patients with type-2 diabetes. However, recent study results show that there is an equal benefit in patients with heart failure regardless of their diabetes status.

The most proactive guideline on this topic so far is the European Society of Cardiology (ESC) treatment guide on diabetes, pre-diabetes, and cardiovascular disease published in 2019. It recommends that patients with diabetes who are at high risk of cardiovascular disease or arteriosclerosis should preferably use drugs with a cardioprotective effect. These can be the so-called SGLT2 (sodium-dependent glucose co-transporter 2) inhibitors or GLP-1 receptor agonists.

SGLT2 inhibitors act independently of diabetes status

The heart failure with reduced ejection fraction (HFrEF) guideline update, also published at the end of 2019, now also recommends the use of SGLT2 inhibitors in patients with mild to moderate heart failure and reduced left ventricular ejection fraction with and without diabetes mellitus.

Recent studies had previously shown that the cardioprotective effect of SGLT2 inhibitors also occurs in non-diabetics and significantly reduces the risk of death or hospitalization.

How are SGLT2 inhibitors used in cardiology?

Prof. Dr. med. Stefan Anker (Charité University Hospital, Berlin, Germany) presented important cornerstones of the practical application of SGLT2 inhibitors in cardiological practice based on the current findings on the occasion of the virtual ESC 2020.

In particular, he said, it is important to point out at the start of therapy for diabetics with heart failure that mild to moderate urinary tract infections can occur very early, which are usually self-limiting. With simple genital hygiene, these initial infections can also be avoided very easily.

SGLT2 inhibitors can also have a diuretic effect, meaning that patients will notice a more or less significant loss of fluid. The cardiologists can measure this as a slight drop in blood pressure. For this reason, treatment with SGLT2 inhibitors should start with a daily dose of 10 mg, especially in older patients > 65 years of age, with regular monitoring of blood pressure, hematocrit, and electrolyte balance. If a fluid loss occurs, the SGLT2 inhibitor administration should be interrupted until the fluid balance has been restored.

Important to keep in mind: In patients with known cardiovascular disease and in those with noted hypotension, a drop in blood pressure after SGLT2 inhibitor administration could well represent a health risk. If SGLT2 inhibitors are given to diabetics together with sulfonylureas, there is also an increased risk of hypoglycemia.

Within the first four weeks after initiation of treatment with an SGLT2 inhibitor, the eGFR (Estimated Glomerular Filtration Rate) may also decrease by about 3 ml/min/1.73 m2 and then quickly stabilize again. For this reason, special attention should be paid to patients with kidney dysfunction.

What comprises optimal patient management?

Industry Q&A session: "Time to Take the Lead - Practical Utilization of SGLT2 Inhibitors", ESC 2020 (virtual), 31st August 2020