Home
August 1, 2023
Known for their role in managing diabetes, sodium-glucose cotransporter 2 (SGLT2) inhibitors like Farxiga (dapagliflozin) and Jardiance (empagliflozin) also improve symptoms, function, and quality of life in patients with heart failure (HF).1 So it’s no surprise that they were added to the latest HF guidelines, even for patients without diabetes.1 The 2022 American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) HF guidelines give SGLT2 inhibitors a Class 1A recommendation (strong recommendation based on high quality evidence) in heart failure with reduced ejection fraction (HFrEF) and a Class 2A recommendation (moderate recommendation based on high quality evidence) in heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF).1
Originally, the U.S. Food and Drug Administration (FDA) only approved Jardiance and Farxiga for use in HFrEF.2-4 They’ve since broadened each drug’s labeling to include all HF patients, regardless of ejection fraction, based on results from the EMPEROR-Preserved and DELIVER trials.3-5 Shortly after announcing the change to Farxiga’s labeling, the FDA approved Inpefa (sotagliflozin), a dual SGLT1 / SGLT2 inhibitor, for use in all patients with HF based on evidence from the SOLOIST-WHF and SCORED trials.6,7 The average wholesale price (AWP) for these drugs is around $700 per month. 8
The three other SGLT2 inhibitors, Brenzavvy (bexagliflozin), Invokana (canagliflozin), and Steglatro (ertugliflozin), aren’t currently approved for HF treatment.9
Bottom Line
Considering SGLT2 inhibitors’ new place in heart failure treatment, community-based prescribing is bound to increase. Accordingly, hospice admission teams are going to start running into them too. A key pitfall to avoid is considering them solely as antidiabetic drugs without recognition of their beneficial effects in HF. When managing type 2 diabetes in hospice, these drugs would typically be prioritized for deprescribing as treatment goals are liberalized. In contrast, available data indicates that their use in HF is palliative, making them less suitable for deprescribing. Despite their high cost, when HF is contributing to a patient’s terminal prognosis, SGLT2 inhibitors are clearly related, making them the financial responsibility of hospice. Deprescribing should be considered if patients are volume-depleted, hypotensive, or actively dying.10
Written by:
OnePoint Patient Care Clinical Team
Joseph Solien, PharmD, BCGP, BCPP – Vice President of Clinical Services
Melissa Corak, PharmD, BCGP – Senior Clinical Pharmacist
John Corrigan, PharmD, BCGP – Clinical Pharmacist
References