Leveraging SGLT2 Inhibitors, GLP-1 RAs in Heart Failure, with Jose Lopez, MD

Once viewed solely as glucose-lowering agents for type 2 diabetes, sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have emerged as powerful tools in the management of heart failure.

Initial skepticism surrounding the cardiovascular safety of these agents limited their early use in this population due to early trials raising concern about potential harm. However, more recent research suggests that these agents are not only safe, but also provide meaningful cardiovascular benefits, marking a turning point in how these therapies are viewed in heart failure care.

“When these trials were first conducted, the main point was to make sure these diabetes medications were not harmful to the heart because of earlier trials that had shown neutral or even harmful effects,” Jose Lopez, MD, a cardiovascular disease fellow at the University of Miami Miller School of Medicine/JFK Medical Center, explained in an interview with HCPLive. “When EMPEROR came out and we showed that there was no harmful effect, but actually a benefit, I think it was a really big turning point and a really big part of that shift because we realized these are not just diabetes medications and they can actually be really big players in the space of heart failure, which they have been.”

Lopez emphasizes that SGLT2 inhibitors and GLP-1 RAs are no longer just diabetes medications, referring to both as being “more heart failure medications than anything” and further suggesting SGLT2 inhibitors should be used in almost every patient with heart failure. For those with persistent symptoms, he says GLP-1 RAs can be added later on.

Acknowledging the lack of data on GLP-1 RAs in patients with heart failure with reduced ejection fraction (HFrEF) compared to heart failure with preserved ejection fraction (HFpEF), Lopez notes that use of these medications in this patient population is controversial. However, he indicates a need for additional research before writing GLP-1 RAs off for HFrEF patients, citing small sample sizes, short follow up, and the use of participants with very advanced heart failure as potential limitations to existing research.

“I feel there's still a lot that we don't know,” Lopez said. “I wouldn't necessarily jump to say that these medications are harmful.”

When confronted with the clinical conundrum of both SGLT2 inhibitors and GLP-1 RAs bring indicated in the same patient—for example, a patient with HFpEF, obesity, and diabetes—Lopez says he prioritizes initiating SGLT2 inhibitors and adding GLP-1 RAs on later if needed, noting that this is “almost an everyday situation nowadays.”

Editors’ note: Lopez has no relevant disclosures to report.

Reference

Lopez J, Makuvire T, Davis JD, Carbone S. The Short and Sweet on Sodium-Glucose Cotransporter Inhibitors and Glucagon-like Peptide-1 Receptor Agonists in Heart Failure. US Cardiol. doi:10.15420/usc.2024.44