1. Severe Hypotension With Concomitant Sodium-Glucose Co-Transporter-2 Inhibitor and Angiotensin Receptor-Neprilysin Inhibitor Therapy in a Patient With Heart Failure Reduced Ejection Fraction: A Case Report.
- Author
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Schumacher C
- Subjects
- Humans, Female, Neprilysin pharmacology, Neprilysin therapeutic use, Tetrazoles adverse effects, Angiotensin Receptor Antagonists adverse effects, Stroke Volume, Valsartan adverse effects, Aminobutyrates adverse effects, Drug Combinations, Diuretics pharmacology, Diuretics therapeutic use, Receptors, Angiotensin therapeutic use, Glucose therapeutic use, Sodium pharmacology, Sodium therapeutic use, Treatment Outcome, Heart Failure complications, Heart Failure drug therapy, Heart Failure chemically induced, Sodium-Glucose Transporter 2 Inhibitors, Diabetes Mellitus, Type 2 complications, Diabetes Mellitus, Type 2 drug therapy, Hypotension chemically induced, Hypotension drug therapy, Symporters pharmacology, Symporters therapeutic use, Benzhydryl Compounds, Biphenyl Compounds, Glucosides
- Abstract
Background: Large cardiovascular outcomes trials in individuals with heart failure, with and without diabetes, have demonstrated a significant risk reduction in the composite outcome of cardiovascular death or hospitalizations for heart failure with SGLT2 inhibitor therapy. These positive outcomes have led to the recommendation that SGLT2 inhibitors serve as backbone therapy in patients with heart failure reduced ejection fraction (HFrEF). To date, there has not been enough participants in clinical trials on concomitant SGLT2 inhibitor and angiotensin receptor-neprilysin inhibitor therapy to evaluate the benefits and risks of combination therapy with these two agents outside of smaller subgroup analyses. Case Summary: This case describes a Black female with diabetes meeting her glycemic targets and concomitant stable NYHA FC II HFrEF on guideline-directed medical therapy (GDMT) with sacubitril/valsartan, spironolactone and metoprolol succinate who developed severe hypotension and dehydration requiring hospitalization after initiation of SGLT2 inhibitor therapy. Practice Implications: This case report raises the question of whether those with type 2 diabetes, and/or those on background angiotensin receptor-neprilysin inhibitor therapy, who are euvolemic or sensitive to diuretic therapy should be started on lower dose dapagliflozin and titrated to 10 mg daily based on response. It also raises awareness to the potential increased diuretic effect produced with concomitant use of sacubitril/valsartan and dapagliflozin. Caution and education to mitigate the risk for volume depletion should be provided to those patients who are euvolemic and initiated on a SGLT2 inhibitor, regardless of their background diuretic and GDMT. Conclusion: Future research should focus on the benefits and safety considerations and provide education on how to best initiate and adjust SGLT2 inhibitors in the setting of sacubitril/valsartan use in diverse heart failure patient populations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Christine Schumacher is on the Speakers Bureau for Abbott and participated on an Advisory Board for Dexcom.
- Published
- 2024
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