Sodium glucose cotransporter-2 (SGLT2) inhibitors have been considered revolutionary advances in the treatment of patients with Typ 2 Diabetes, especially in patients with comorbid cardiovascular and kidney disease.
But this relatively new class of drugs recently made the leap into cardiac practice, with Food and Drug Administration (FDA) approvals from Dapagliflozin (Farxiga) and empagliflozin (Jardiance) for Heart failure with reduced ejection fraction (HFrEF).
With several proven benefits in often overlapping diseases, SGLT2 inhibitors are now important tools for both general practitioners and specialists. However, implementing it consistently in heart failure remains a challenge, and it can be difficult to know which provider should initiate therapy for suitable patients.
Experts said Medical news from Medscape that GPs can take the lead in identifying heart failure patients who would benefit from an SGLT2 inhibitor or otherwise support the multidisciplinary care supported by the up to 22% of people with type 2 diabetes who develop heart failure.
PCPs: The front line in heart failure
SGLT2 inhibitors lower blood sugar levels by blocking the reabsorption of glucose by the kidneys. They also increase urinary sodium excretion, at least temporarily, which along with a number of other mechanisms can be beneficial in heart failure
Mikhail Kosiborod, MD, director of cardiometabolic research at Saint Luke’s Mid America Heart Institute, professor of medicine at the University of Missouri-Kansas City, and co-author of the DAPA-HF study that led to FDA approval of dapagliflozin for HFrEF, said primary care was “absolutely critical” to the effective introduction of SGLT2 inhibitors in heart failure, which affects up to one in five people in their lifetime.
Family doctors are the key to effective prevention. They really are the first line of defense in heart failure, diabetes, and chronic kidney disease.
“General practitioners are the key to effective prevention,” said Kosiborod. “You see most patients who have never had a cardiovascular or kidney event or who do not have access to special care. They really are the first line of defense for prevention and, in many cases, for the treatment of the heart chronic kidney disease.”
Implementation of the standard of care remains an important unmet need for patients with HFrEF. Now known as “quadruple therapy” with the addition of SGLT2 inhibitors – which reduce the risk of death by 73% over 2 years – the standard of care was previously known as “triple therapy”, a combination of an angiotensin receptor neprilysin inhibitor (ARNI) . , a beta blocker and a mineralocorticoid receptor antagonist (MRA). Previous research has shown that less than 25% of patients eligible for triple therapy received it.
It often takes years for effective new therapies to reach the patient after positive results from clinical studies and inclusion in practice guidelines. To overcome the clinical sluggishness in heart failure, Dr recommended on deck ”.
“Every encounter with a patient, be it a GP, a cardiologist, or an endocrinologist, is an opportunity to improve care,” Inzucchi said. “If you see a patient with heart failure who is not receiving an SGLT2 inhibitor, it is imperative that you start, as long as there are no contraindications, and keep their specialists informed.”
Kenny Lin, MD, MPH, professor of family clinical medicine at Georgetown University School of Medicine, Washington, DC, said PCPs are well equipped to prescribe SGLT2 inhibitors for heart failure in appropriate cases based on the severity of the disease.
“PCPs have the ability to prescribe SGLT2 inhibitors to patients with stable heart failure who visit a cardiologist once or twice a year – or not at all,” said Lin. “On the other hand, for patients with unstable heart failure who experience frequent exacerbations and hospital admissions, I would probably be more comfortable if this therapy was administered by cardiology, as it is a relatively new addition to the standard treatment for heart failure.”
Teamwork, communication key
Both generalists and specialists may have practical and safety concerns about initiating an SGLT2 inhibitor in heart failure patients with and without type 2 diabetes. Experts agreed that these concerns can be allayed through good communication between the providers.
A recent survey by the American College of Cardiology showed that the most common barriers cardiologists face when prescribing an SGLT2 inhibitor (29.8%), the risk of Hypoglycemia which can occur in patients with diabetes that too Insulin or sulfonylurea. In this scenario, cardiologists and diabetes specialists can work together to adjust the dose of a patient’s existing diabetes therapy if necessary.
“Just keep everyone posted,” Inzucchi said. “For patients on insulin who are being followed up by an endocrinologist, you may want to give an advance warning so that the insulin dose can be adjusted for those who are already closely monitored. If a cardiologist or endocrinologist is involved in your treatment, at least copy them into your review. ”
Family doctors may also be better equipped to educate patients about genital hygiene to prevent genital yeast infections – a common side effect of SGLT2 inhibitors that usually occurs during early treatment – or to treat it when it occurs.
Despite these safety issues and less often potential complications such as Diabetic Ketoazidosis“Family doctors should know that SGLT2 inhibitors are generally well tolerated and easy to prescribe,” Kosiborod said.
“It’s one pill a day, no dose titration is required, there aren’t many drug interactions to worry about, and they’re usually well tolerated,” Kosiborod said. “So they’re about as easy to use as anything we’ve ever had in the Heart Failure Armamentarium.”
Given the speed at which SGLT2 inhibitors work and the benefits of heart failure in randomized trials within weeks, Kosiborod said lost time is a major consequence of any missed opportunity to initiate these therapies in suitable patients to keep the disease from progressing impede.
“Heart failure patients will seek out various generalists and specialists. So the doctor who should prescribe SGLT2 inhibitors is the one who has the option, ”said Kosiborod. “Especially in the case of heart failure, these active ingredients have shown that patients live longer, feel better and cannot leave the hospital. A chance is lost if we wait unnecessarily to initiate these effective therapies. “
While continuing medical education, focused on SGLT2 inhibitors for heart failure, is just beginning to appeal to the primary care audience, Lin expects general practitioners to play a growing role in their adoption.
“I think general practitioners will have questions about the selection and dosage of SGLT2 inhibitors for heart failure in patients without diabetes,” he said. “But I expect that as we prescribe these drugs, we will become more and more important and just as comfortable with them as prescribing diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, and other commonly used drugs for heart failure.”
Kosiborod and Inzucchi reported relationships between several pharmaceutical companies. Lin did not report any relevant financial conflicts of interest.
Adam Leitenberger is a medical journalist in the Philadelphia area and covers a wide range of fields. Follow him on Twitter @adamleitenberg..