More Good News for SGLT2 Inhibitors in Heart Failure

Volume 17, Issue 1

Patients with acute decompensated heart failure (ADHF) suffer from a dearth of effective therapies. Loop diuretics remain the cornerstone of decongestion therapies despite their obvious limitations. These medications can exacerbate renal injury, deplete vital electrolytes like potassium and magnesium, and exacerbate gout attacks by raising serum uric acid levels.

The EMPULSE trial showed that using 10 mg daily of empagliflozin in patients with ADHF reduced the risk of recurrent heart failure events within the first 90 days of hospitalization. While not specifically designed to address the effectiveness of empagliflozin as a decongestant, this trial did report a great drop in weight vs placebo.

In this week’s issue of Talking Therapeutics, we delve into a new trial aimed at assessing the ability of empagliflozin to effectively decongest patients with ADHF.

Point 1: SGLT2 Inhibitors Can Decongest

In a new trial published last week, the authors administered 25 mg daily of empagliflozin, in addition to loop diuretic therapy, to 60 patients with ADHF. Their principal findings were that, compared to placebo, treatment with empagliflozin resulted in: 

• a 25% increase in cumulative urine output over 5 days (median 10.8 vs 8.7 L mL in placebo, group difference estimation 2.2 L [95% CI, 8.4-3.6]; P=0.003);
• increased diuretic efficiency (14.1 mL urine per milligram furosemide equivalent [95% CI, 0.6-27.7]; P=0.041);
• no significant change in renal function (estimated glomerular filtration rate, 51±19 vs 54±17 mL/min per 1.73 m²; P=0.599);
• a more pronounced decrease in NT-proBNP (-1861 vs -727.2 pg/mL after 5 days; quotient in slope, 0.89 [95% CI, 0.83-0.95]; P<0.001);
• a greater change in NYHA class from baseline to day 5 and until hospital discharge; and
• lower levels of serum uric acid.

Point 2: One Step Closer to Standard of Care

While there were no safety concerns noted with empagliflozin in this trial, it was a relatively small study with short-term follow-up. Hence additional studies are needed to fully confirm the clinical benefits of using empagliflozin as a decongestant in ADHF.

However, since SGLT2 inhibitors are part of the standard of care for all patients with heart failure regardless of ejection fraction, they can reasonably be considered for patients admitted to the hospital with ADHF.