Importance of sodium-glucose cotransporter 2 inhibitor use in diabetic patients with acute heart failure

The impact of sodium-glucose co-transporter-2 inhibitors on serum sodium and potassium in patients with Heart Failure: a systematic review and meta-analysis

BACKGROUND

Managing electrolyte abnormalities, particularly sodium and potassium, in patients with heart failure (HF) remains a concern. A novel anti-diabetic drug, sodium-glucose co-transporter-2 (SGLT2) inhibitors, has become suitable for HF patients, improving cardiovascular outcomes. Therefore, we aimed to conduct a meta-analysis to evaluate the effect of SGLT2 inhibitors on serum sodium and potassium.

METHODS

We systematically searched five databases, identifying randomized clinical trials (RCTs) reporting changes in serum sodium and potassium levels with SGLT2 inhibitors compared to comparator groups. Outcomes were presented as weighted mean differences (WMD) and standardized MD (SMD) with 95% confidence intervals (CI). Subgroup and sensitivity analyses were also conducted.

RESULTS

13 studies were included, with 13 studies with 10,617 participants reporting on serum sodium and nine studies with 9877 participants on serum potassium. In acute HF, SGLT2 inhibitors did not significantly affect serum sodium (WMD: 1.21 mmol/L; 95% CI: - 0.79, 3.21) or potassium levels (WMD: 0.11 mEq/L; 95% CI: - 0.20, 0.42). Subgroup analyses suggested possible variations by follow-up duration (< 7 days vs. ≥ 30 days) and drug type, but findings remained non-significant. Sensitivity analysis using the leave-one-out method and risk of bias assessment results showed no considerable changes in the statistical significance of the pooled results. Similarly, in chronic HF, no significant differences were observed for serum sodium (WMD: 0.23 mmol/L; 95% CI: - 0.45, 0.91) or potassium (WMD: 0.07 mEq/L; 95% CI: - 0.29, 0.44). Sensitivity and subgroup analyses based on duration, drug type, diabetes status, renal function, or systolic blood pressure did not reveal clinically meaningful differences across all analyses. For all analyses, Egger's test was non-significant, indicating no strong evidence of small-study effects. Moreover, the trim-and-fill method combined with the funnel plot did not identify any missing studies, and the recalculated effect size remained unchanged.

CONCLUSIONS

SGLT2 inhibitors did not significantly alter serum sodium or potassium levels in acute or chronic HF, suggesting that these drugs can be safe regarding electrolyte disturbances. Additional RCTs are warranted to enhance the robustness of evidence regarding the mechanisms and effects of SGLT2 inhibitors on serum electrolyte levels, considering variations across different types of SGLT2 inhibitors.

Effect of dapagliflozin on readmission and loop diuretics use in patients with acute heart failure: a retrospective propensity score-matched cohort study

BACKGROUND

The efficacy of dapagliflozin in patients with acute heart failure remains unclear.

OBJECTIVE

To investigate the impact of dapagliflozin (DAPA) on loop diuretics use and 90-day readmission in patients with acute heart failure.

METHODS

In a retrospective cohort study, patients diagnosed with acute heart failure or chronic heart failure with acute exacerbation admitted to Fuyang People's Hospital from January 2021 to April 2023, this study used DAPA (at a dose of 10 mg once daily) in combination with standard treatment. The patients were divided into DAPA group and DAPA-Free group based on whether they used DAPA in acute heart failure. To minimize the influence of confounding factors and ensure comparability between groups, we used propensity score matching (PSM).

RESULTS

A total of 399 patients were included, with 206 patients (51.63%) in the DAPA group and 193 patients (48.37%) in the DAPA-Free group. PSM produced 160 pairs. After PSM, there were no statistically significant differences between the DAPA and DAPA-Free groups in terms of readmission of all causes (16.88% vs. 18.12%, OR 0.9141, 95% CI 0.5385-1.552, log rank P = 0.739) or readmission for heart failure (11.88% vs. 15.0%, OR 0.9077, 95% CI 0.4441-1.469, log rank P = 0.484) after 90-day follow-up. Patients in the DAPA group had a lower mean daily dose of intravenous loop diuretics compared to the DAPA-Free group (20 mg/d vs. 30.00 mg/d, P<0.001), lower total loop diuretic dose during hospitalization (106.06 ± 31.23 mg vs. 144.50 ± 45.39 mg, P = 0.038) and a decreased number of diuretic types used (11.88% vs. 23.12%, P = 0.008).

CONCLUSIONS

DAPA reduced the dose of intravenous loop diuretics. However, it did not improve all-cause readmission for 90 days or readmission for heart failure after discharge.

Strategies for the Management of Cardiorenal Syndrome in the Acute Hospital Setting

Cardiorenal syndrome (CRS) is a life-threatening disorder that involves a complex interplay between the two organs. Managing this multifaceted syndrome is challenging in the hospital and requires a multidisciplinary approach to tackle the many manifestations and complications. There is no universally accepted algorithm to treat patients, and therapeutic options vary from one patient to another. The mainstays of therapy involve the stabilization of hemodynamics, decongestion using diuretics or renal replacement therapy, improvement of cardiac output with inotropes, and goal-directed medical treatment with renin–angiotensin–aldosterone system inhibitors, beta-blockers, and other medications. Mechanical circulatory support is another viable option in the armamentarium of agents that improve symptoms in select patients.

The safety of sodium-glucose co-transporter 2 inhibitors in patients with left ventricular assist device - a single center experience

AIMS

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are used increasingly for patients with heart failure or chronic kidney disease to improve cardiac and renal outcomes. The use of these medications in patients with left ventricular assist devices (LVAD) is still limited and lacks evidence regarding the safety profile. In this study, we aimed to report our experience in treating 20 patients, supported by LVAD, with SGLT2 inhibitors.

METHODS

We studied the safety profile of SGLT2 inhibitors (dapagliflozin and empagliflozin) in 20 patients (mean age 64.7 ± 12.2 years, 75% male) supported by LVAD as destination therapy. All patients have diabetes mellitus and were prescribed SGLT2 inhibitors for glycemic control.

RESULTS

SGLT2 inhibitors were well tolerated with no major adverse events. Few suction events were reported in three patients without the need for pump speed adjustment. There was no change in mean arterial pressure (71.1 ± 5.6 vs. 70.1 ± 4.8 mmHg, P  = 0.063). Modest decline in renal function was observed in six patients within the first weeks after drug initiation. There were no events of diabetic ketoacidosis or limb amputation.

CONCLUSION

SGLT2 inhibitors are safe in patients with LVAD and may potentially improve cardiovascular and renal outcomes in this special population.

Evaluation of sodium-glucose cotransporter 2 inhibitors for renal prognosis and mortality in diabetes patients with heart failure on diuretics

Previous studies about renal protection of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2DM) patients with heart failure (HF) on diuretics were still limited. The goal of the study is to survey the efficacy of SGLT2i to reduce all-cause mortality and renal impairments in patients with T2DM and HF using diuretics. The retrospective cohort study was analyzed from Kaohsiung Medical University Hospital Research Database (KMUHRD) in Taiwan. Adults with T2DM and HF using any diuretics at least 28 days during 2016-2018 were enrolled and then divided into the SGLT2i group and the non-SGLT2i group. Propensity score matching was used to balance baseline characteristics between the two groups. The primary outcome was all-cause mortality. Secondary outcomes contained dialysis occurrence, renal progression, and acute kidney injury (AKI). After 1:1 matching, there were 183 patients in each group respectively. When compared with the non-SGLT2i group, the SGLT2i group had significantly lower all-cause mortality (hazard ratios [HR]: 0.49, 95% CI 0.29-0.83, p = 0.008) and reduction of renal progression (HR: 0.30, 95% CI 0.12-0.75, p = 0.010). SGLT2i showed the trend to decrease dialysis occurrence (HR: 0.83, 95% CI 0.20-3.47, p = 0.797) and an increase in AKI (HR: 1.38, 95% CI 0.67-2.87, p = 0.383) but without significance. SGLT2 inhibitors were associated with reduced all-cause mortality and less renal progression with significance in T2DM patients with HF on diuretics.

A New Chapter in the Treatment of Patients with Heart Failure. The Role of Sodium-Glucose Co-transporter Type 2 Inhibitors

Heart failure (HF) remains one of the major social and medical public health problems worldwide. Despite new advances in the treatment of patients with HF, the prognosis is still poor. According to the European Cardiology Society guidelines for the diagnosis and treatment of acute and chronic heart failure (CHF) 2021, a new class of drugs related to hypoglycemic has been confirmed to be effective in influencing the survival of patients with heart failure with low ejection fraction (HFpEF), regardless of the presence of disorders of carbohydrate metabolism. We are talking about inhibitors of the sodium-glucose co-transporter type 2 (iSGLT-2) or gliflozins. The article presents the results of the latest large clinical trials on the effective use of SGLT-2 in patients with HF, not only with low, but also with intact ejection fraction (HFpEF), for which there is no evidence base at the present stage. The review article presents the results of experimental studies that explored the potential mechanisms of action of gliflozins with an emphasis on new ones that are of fundamental importance for patients with heart failure, and also describes controversial and little-studied issues. Currently, there is no therapy that improves outcomes in patients with acute heart failure. The article presents the results of small analyzes of the use of iSGLT-2 in this category of patients, which are the basis for the hypothesis of their potentially effective and safe use in the case of acute decompensation of CHF, however, the role of gliflozins in this category of patients requires further in-depth study.

A review of cardiovascular benefits of SGLT2 inhibitors

Sodium-glucose cotransporter 2 inhibitor (SGLT2I) is a new type of hypoglycemic drug that targets the kidney. As research continues to advance on this topic, it has been found that SGLT2I has multiple protective effects, such as hypoglycemic, cardio-renal protective, antihypertensive, and lipid-lowering effects. This review discusses the current concepts and possible mechanisms of SGLT2I in the treatment of heart failure, myocardial infarction, hypertension, cardiomyopathy and arrhythmia to provide a reference for clinicians to use drugs more reasonably and scientifically.

Impact of dapagliflozin treatment on renal function and diuretics use in acute heart failure: a pilot study

OBJECTIVE

To determine the impact of sodium-dependent glucose type 2 cotransporter inhibitors on the renal function in acute heart failure.

METHODS

In a single-centre, controlled, randomised study, patients were prescribed dapagliflozin in addition to standard therapy, or were in receipt of standard therapy. The prespecified outcome was renal function deterioration; the secondary outcomes were the development of resistance to diuretics, weight loss, death during hospitalisation and the rehospitalisation or death for any reason within 30 days following discharge.

RESULTS

102 patients were included (73.4±11.7 years, 57.8% men). The average left ventricular ejection fraction was 44.9%±14.7%, the average N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was 4706 (1757; 11 244) pg/mL, the average estimated glomerular filtration rate (eGFR) was 51.6±19.5 mL/min. eGFR decreased 48 hours after randomisation in the dapagliflozin group (-4.2 (-11.03; 2.28) mL/min vs 0.3 (-6; 6) mL/min; p=0.04) but did not differ between the groups on discharge (54.71±19.18 mL/min and 58.92±24.65 mL/min; p=0.36). The incidence of worsening renal function did not differ (34.4% vs 15.2%; p=0.07). In the dapagliflozin group, there was less tendency to increase the dose of loop diuretics (14% vs 30%; p=0.048), lower average doses of loop diuretics (78.46±38.95 mg/day vs 102.82±31.26 mg/day; p=0.001) and more significant weight loss (4100 (2950; 5750) g vs 3000 (1380; 4650) g; p=0.02). In-hospital mortality was 7.8% (4(8%) in the dapagliflozin and 4 (7.7%) in the control group (p=0.95). The number of deaths within 30 days following discharge in the dapagliflozin group and in the control group was 9 (19%) and 12 (25%), p=0.55; the number of rehospitalisations was 14 (29%) and 17 (35%), respectively (p=0.51).

CONCLUSION

The use of dapagliflozin was associated with a more pronounced weight loss and less need to increase diuretic therapy without significant deterioration of the renal function. Dapagliflozin did not improve the in-hospital and 30-day prognosis after discharge.

TRIAL REGISTRATION NUMBER

N04778787.

Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Water and Sodium Metabolism

Sodium-glucose cotransporter 2 (SGLT2) inhibitors exert hypoglycemic and diuretic effects by inhibiting the absorption of sodium and glucose from the proximal tubule. Currently available data indicate that SGLT2 inhibitors transiently enhance urinary sodium excretion and urinary volume. When combined with loop diuretics, SGLT2 inhibitors exert a synergistic natriuretic effect. The favorable diuretic profile of SGLT2 inhibitors may confer benefits to volume management in patients with heart failure but this natriuretic effect may not be the dominant mechanism for the superior long-term outcomes observed with these agents in patients with heart failure. The first part of this review explores the causes of transient natriuresis and the diuretic mechanisms of SGLT2 inhibitors. The second part provides an overview of the synergistic effects of combining SGLT2 inhibitors with loop diuretics, and the third part summarizes the mechanisms of cardiovascular protection associated with the diuretic effects of SGLT2 inhibitors.

The role of sodium-glucose co-transporter 2 protein inhibitors in heart failure: more than an antidiabetic drug?

INTRODUCTION

Heart failure (HF) places a great burden on both the patient and on medical facilities worldwide, with admission due to worsening HF being one of the leading causes of hospitalization. Optimizing HF in the community remains a challenge, but with appropriate medications, specialist review, and community support, the number of hospital admissions could be reduced. Sodium glucose co-transporter protein 2 (SGLT2) inhibitors have been shown to play a role in patients with heart failure and reduce adverse cardiovascular outcomes. This article seeks to investigate the existing medical literature to understand the role of SGLT2 inhibitors in patients with heart failure with reduced ejection fraction (HFrEF).

AREAS COVERED

An electronic search was undertaken looking at recent literature studying the outcomes of SGLT2 inhibitors on patients with heart failure. No limits were placed on the timing of the publications or the type of article. Keywords and MeSH terms were used, and the results were summarized in the relevant section.

EXPERT OPINION

This study shows that SGLT2 inhibitors are a safe and effective medication in the setting of HFrEF and has been shown to reduce symptoms of heart failure thus improving quality of life and reducing admissions due to heart failure and cardiovascular mortality.

Evidence-Based Management of Acute Heart Failure

Acute heart failure (AHF) is a complex, heterogeneous, clinical syndrome with high morbidity and mortality, incurring significant health care costs. Patients transition from home to the emergency department, the hospital, and home again and require decisions surrounding diagnosis, treatment, and prognosis at each step of the way. The purpose of this review is to examine the epidemiology, etiology, and classifications of AHF and specifically focus on practical information relevant to the clinician. We examine the mechanisms of decompensation relevant to clinical presentations-including precipitating factors, neuroendocrine interactions, and inflammation-along with how consideration of these factors may help select therapies for an individual patient. The prevalence and significance of end-organ manifestations such as renal, gastrointestinal, respiratory, and neurologic manifestations are discussed. We also highlight how the development of renal dysfunction relates to the choice of a variety of diuretics that may be useful in specific circumstances and review guideline-directed medical therapy. We discuss the practical use (and pitfalls) of a variety of evidence-based clinical scoring criteria available to risk stratify patients with AHF. Finally, evidence-based management of AHF is discussed, including both pharmacologic and nonpharmacologic therapies, including the lack of evidence for using old and new vasodilators and the recent evidence regarding initiation of newer therapies in hospital. Overall, we suggest that clinicians consider implementing the newer data in AHF and subject existing practice patterns and treatments to the same rigour as new therapies.

Glucose-dependent diuresis in relation to improvements in renal-tubular markers of sodium-glucose cotransporter-2 inhibitors in hospitalized heart failure patients with diabetes

Clinical parameters with correlation to diuretic effects after initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors are unclear. We aimed to identify the factors associated with the diuretic effect observed following the initiation of SGLT2 inhibitors in patients with diabetes having an acute heart failure (HF). Fifty-six patients included were hospitalized for acute HF with diabetes and started on SGLT2 inhibitors. Changes in urine volume (ΔUV) and blood/urine laboratory parameters before and during the first 4 days of therapy were evaluated. Data were prospectively obtained under clinically stable conditions after initial HF treatment. UV increased following the initiation of SGLT2 inhibitors [UV at baseline (BL): 1383 ± 479 mL/day; ΔUV over 4 days: + 189 ± 358 mL/day]. Multivariate analysis revealed no association between BL-hemoglobin A1c or BL-estimated glomerular filtration rate and ΔUV. Conversely, higher BL-fasting plasma glucose (FPG) and higher BL-urine N-acetyl-β-D-glucosaminidase (NAG) were associated with a higher ΔUV. ΔUV was inversely associated with ΔFPG and ΔNAG, and positively associated with Δurinary sodium excretion. Elevated FPG and NAG both improved over 4 days of treatment. In conclusion, the diuretic effect of SGLT2 inhibitors was glycemia-dependent, and was associated with a reduction in elevated renal-tubular markers in hospitalized HF complicated with diabetes.

Safety and Efficacy of Adding Dapagliflozin to Furosemide in Type 2 Diabetic Patients With Decompensated Heart Failure and Reduced Ejection Fraction

Background: Heart failure is the most common cause of hospitalization in elderly patients. It is likely that many of the mechanisms that contribute to reductions in systolic and diastolic function, seen in diabetic patients, place them at an increased risk of heart failure. Diuretic therapy, especially loop diuretics, is the usual way of managing congestion, particularly in volume-overloaded patients. Little is known about the beneficial effect of dapagliflozin when added to loop diuretics in managing patients with decompensated heart failure. Aim: To assess the effect of the addition of dapagliflozin to furosemide in managing decompensated patient with heart failure and reduced left ventricular ejection fraction in terms of weight loss and dyspnea improvement. Patients and Methods: The study included 100 type 2 diabetic patients who were admitted with decompensated heart failure. The study population was randomly divided into two arms. Serum electrolytes and kidney functions were followed up during their hospital stay. Results: With dapagliflozin, there was a statistically significant difference between the two groups regarding the change in body weight and body mass index. The diuresis parameters including urine output, total fluid loss, and fluid balance also showed a statistically significant difference in favor of the use of dapagliflozin, with no significant change in serum potassium or kidney functions. There was significant improvement in patient-reported dyspnea scores with the use of dapagliflozin. Conclusions: Dapagliflozin may provide a new drug option in the treatment of heart failure especially among vulnerable group of diabetics. It had no remarkable effects on serum potassium level and kidney functions. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04385589.