A 74-year-old man with HFpEF (ejection fraction 60%), hypertension, and chronic kidney disease (CKD) on hemodialysis presents for hospital follow-up.
He was recently admitted to the hospital for heart failure (HF) and is following up after discharge. He is doing well overall.
Your patient should not be considered for a Sodium-glucose cotransporter-2 inhibitor (SGLT2i) at this time.
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The correct answer is: Fact
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have not been adequately studied in dialysis; they should be discontinued at dialysis initiation and not initiated in patients already on dialysis.
In the EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Reduced Ejection Fraction) trial, individuals with estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2 were initiated on empagliflozin. The annual rate of decline in the eGFR was slower in the empagliflozin group than in the placebo group (-0.55 vs. -2.28 mL/min/1.73 m2 of body surface area per year; p < 0.001), and empagliflozin-treated patients had a lower risk of serious renal outcomes.1
In the DAPA-CKD (Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease) trial, individuals with eGFR ≥25 mL/min/1.73 m2 were initiated on dapagliflozin. The hazard ratio for the composite endpoint of a sustained decline in eGFR of ≥50%, end-stage kidney disease, or death from renal causes was 0.56 (95% confidence interval, 0.45-0.68; p < 0.001).2
In trials of SGLT2i and HF, if the eGFR fell <20-25 mL/min/1.73 m2, the drugs were continued. Thus, if eGFR declines in a patient taking an SGLT2i who has CKD, but not yet on renal replacement therapy, it is reasonable to consider continuing the drug, even if below these eGFR thresholds.1,2
Educational grant support provided by: Boehringer Ingelheim Pharmaceuticals Inc. (BIPI) and Lilly USA, LLC (Lilly). To visit the course page for the Heart Failure & SGLT2is: The New Pillar in Care grant, click here!
References
Packer M, Anker SD, Butler J, et al.; EMPEROR-Reduced Trial Investigators. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med 2020;383:1413-24.
Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al.; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med 2020;383:1436-46.
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