SGLT2 Inhibitor Initiation in Heart Failure

Sodium-glucose cotransporter 2 inhibitors reduce heart failure admission and cardiovascular death in heart failure across the range of ejection fraction, with or without diabetes, and slow the decline in kidney function. Dapagliflozin and empagliflozin are used at a fixed dose with no titration. Start in hospital once stable or as an outpatient, when eGFR is 20 mL/min/1.73 m2 or over.

Counselling. Warn about genital mycotic infection, volume depletion, urinary infection and ketoacidosis, and teach sick day rules.

Diabetes. Glucose lowering is modest at low eGFR, but the heart failure benefit remains.

Dapagliflozin. 10 mg orally once daily in the morning.

Empagliflozin. 10 mg orally once daily.

Loop diuretic. Reduce the dose, usually by about 25% to 50%, if the person is euvolaemic or pressure is under 100 mmHg, since the drug adds diuresis.

Insulin and sulphonylureas. Reduce the dose by about 10% to 20% when starting to prevent hypoglycaemia in diabetes.

Special groups. In older adults, watch for volume depletion and falls. In type 1 diabetes, avoid because of ketoacidosis. In pregnancy and breastfeeding, avoid. In hepatic impairment, no change is needed for mild to moderate disease. In creatinine clearance under 20 mL/min, do not start, but continue if already taking and well. In East Africa, cost may limit use, so prioritise it within the four pillars.

Monitoring. Check pressure, weight, creatinine and potassium at 1 to 2 weeks. An initial eGFR fall of 3 to 5 mL/min/1.73 m2 is expected and is not a reason to stop.

Ketoacidosis. Check for ketones if the person is unwell with nausea, vomiting, abdominal pain or breathlessness, even with normal glucose.

Genital hygiene. Advise daily hygiene. Treat candidiasis topically and continue.

Stopping. Withhold during acute illness with poor oral intake, vomiting or diarrhoea, and stop 3 days before major surgery. Stop for ketoacidosis, necrotising fasciitis of the perineum, or recurrent severe urinary infection.

Common errors. Not reducing the diuretic, not reducing insulin, stopping for the expected eGFR dip, and omitting sick day advice.

Referral and escalation. Refer for eGFR under 20 mL/min/1.73 m2, ketoacidosis, or severe genital infection.