Sodium-Glucose Cotransporter 2 Inhibitor Use Among Individuals Age <65 with Type 2 Diabetes and Heart Failure with Reduced Ejection Fraction: A Cost-Benefit Analysis

Sodium-Glucose Cotransporter 2 Inhibitors and Mycotic Genital or Urinary Tract Infections in Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) improve clinical outcomes in persons with heart failure (HF). This class of agents has been consistently associated with an increased risk of mycotic genital infections (MGIs), and in some, but not all trials, urinary tract infections (UTIs). Other medications widely used for cardiac conditions do not cause MGIs and UTIs, so cardiologists and their supporting teams will be encountering clinical questions that they previously did not have to address. This review provides clinicians with practical recommendations about SGLT2i use in individuals with HF as related to the associated MGI and possible UTI risks. Overall, given the benefit of SGLT2is in clinical outcomes, the threshold for not initiating or discontinuing SGLT2is due to concerns for MGIs or UTIs should be high for persons with HF. Likewise, when SGLT2is are discontinued for such concerns, the threshold for reinitiation should be low.

Utilization rates and predictors of sodium glucose cotransporter 2 inhibitor use in patients with heart failure with or without type 2 diabetes

PURPOSE

Sodium glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce cardiovascular deaths and heart failure (HF) hospitalizations in patients with HF. Despite this, utilization remains low. The purpose of this study was to characterize SGLT2 inhibitor utilization rates and predictors of use in a population of patients with or without type 2 diabetes (T2D).

METHODS

This was a retrospective, single-center, descriptive chart review study. Individuals 18 years of age or older with HF were eligible for inclusion. Charts were reviewed between August 2021 and February 2022. The primary objective was to identify rates of SGLT2 inhibitor prescribing for patients with HF within a large academic medical center. Logistic regression analyses were conducted to identify potential SGLT2 inhibitor utilization predictors (demographic characteristics, medical history, laboratory results, specialty provider visits, medication use, and medication coverage).

RESULTS

A total of 800 patients with HF were included: 377 with HF with reduced ejection fraction (HFrEF), 88 with mildly reduced EF, and 335 with preserved EF. Key baseline characteristics were as follows: 43% female; 47% Hispanic; 42% with T2D; 49% with established atherosclerotic cardiovascular disease; and mean age, 65 years. SGLT2 inhibitor utilization was 6.5% overall. Key predictors of utilization were as follows: T2D (odds ratio [OR], 33.4; 95% CI, 8.01-139.55), HFrEF (OR, 2.8; 95% CI, 1.45-5.51), HF clinic visit (OR, 2.5; 95% CI, 1.40-4.60), visit with pharmacist with prescriptive authority (OR, 5.8; 95% CI, 3.14-10.88), and enrollment in the hospital patient assistance program (OR, 2.3; 95% CI, 1.08-4.97).

CONCLUSION

Despite guideline recommendations, SGLT2 inhibitors are underutilized in patients with HF with or without T2D.