Summary: SGLT2 Inhibitors for Nondiabetic Heart Failure – Equipping PCPs for Success
Despite strong evidence and guideline recommendations, primary care physicians (PCPs) remain slow to prescribe SGLT2 inhibitors for heart failure patients without diabetes, creating a significant gap between evidence and practice.
Guideline Changes
Major heart failure guidelines have undergone a significant shift: SGLT2 inhibitors are now considered foundational therapy for patients with reduced or preserved ejection fraction regardless of diabetes status, according to the 2022 heart failure guideline from the American College of Cardiology/American Heart Association and the 2023 focused update from the European Society of Cardiology.
Evidence Base: The change reflects consistent findings from large clinical trials that demonstrated significant reductions in heart failure hospitalizations and, in some cases, in cardiovascular mortality.
The Problem: Underutilization
Despite this strong evidence base, real-world use remains uneven, particularly in primary care, where many clinicians still associate the medications with diabetes management and hesitate to prescribe them to nondiabetic patients. A 2023 study found that SGLT2 inhibitors remain underutilized in patients with heart failure with or without type 2 diabetes.
Barriers to PCP Adoption
1. Insurance and Prior Authorization
Dr. Joyce Oen-Hsiao stated: “The prescription requires a prior authorization from the insurance company, which does not want to pay for the higher-priced medication. In addition, the SGLT2 for heart failure with preserved left ventricular function is newer, so there may be a delay in PCPs knowing the new guidelines”.
2. Medication Burden
Dr. Renato Apolito noted: “These patients may be on five to seven drugs, and they’re going to be like, what the hell is this guy doing? All he does is give me a new drug every time I see him”.
3. Perception as “Diabetes Drug.”
Dr. Johanna Contreras explained: “The medication started as a diabetes medicine, so a lot of people only saw it like that. People were reluctant at the beginning because I think they didn’t understand what the effect was in reality”.
4. Patient Education Gaps
Contreras added: “I give you the medication, you go to the pharmacy, and the pharmacy is like, ‘Oh my god, you have diabetes,’ and you’re like, ‘No, I don’t.’ Patients don’t understand the concept, so we must explain”.
5. Cost Issues
Cost frequently prevents patients from filling prescriptions, as these medications are expensive and have high co-payments.
How SGLT2 Inhibitors Work in Heart Failure
Multiple Mechanisms (Not Just Diabetes)
Dr. Oen-Hsiao outlined mechanisms:
- Mild diuresis
- Decreased arterial pressure
- Improved renal hemodynamics
- Anti-inflammatory effects
- Improved myocardial energetics
Dr. Contreras explained: “We know that there is a natriuretic effect — when you’re eliminating sugar in the urine, you also eliminate fluids. But there is also an effect on the myocytes, in the heart muscle. Some data show that when sugar is eliminated from the body, the heart muscle favors using fatty acids, which are more potent as a fuel in the myocyte than sugar.
With the combination of natriuresis, the change in the metabolism of the myocytes, and an improvement in kidney function, “that’s when the whole thing called the cardiokinetic metabolic theory comes out”.
Safety Concerns PCPs Have (and Responses)
Common Concerns:
“When they are hesitant to start a patient on SGLT2 inhibitors, PCPs most often raise the question of worsening kidney function and dropping blood sugars. There have also been cases of ketoacidosis in nondiabetic patients started on SGLT-2 inhibitors”.
Reality on Kidney Function:
Data have shown that by reducing urinary sugar and sodium, SGLT2 inhibitors lower glomerular pressure, thereby improving kidney function.
Important Caution: UTIs
Both Contreras and Apolito highlighted the importance of counseling around urinary tract infections (UTIs). Patient education is important in women, especially older women, while Apolito said he would not use the drug in patients with a history of recurrent UTIs.
Which Patients Benefit Most
Broad Indications:
Contreras: “Any patient with heart failure, independent of what kind — definitely the benefit is there. Absolutely start [an SGLT2 inhibitor]. We all have enough data showing that when you keep the SGLT2 inhibitor, or you start in an acute setting when the person is congested, it’s actually helpful in decongesting a patient”.
Special Populations with Enhanced Benefit:
- Patients with chronic kidney disease – renal effects are especially meaningful
- Postmenopausal women – disproportionately affected by HFpEF
- Patients with left ventricular hypertrophy
- Hypertrophic cardiomyopathy patients
- Patients with atherosclerosis
Expert Perspective on Clinical Use
Dr. Apolito: “They’re equivalent to all the other drugs now that are out there for heart failure. Like, hey, if you want to start Farxiga before Entresto, you’re allowed to”.
Key Takeaways
- SGLT2 inhibitors are now foundational therapy for ALL heart failure patients – diabetes status irrelevant
- Multiple barriers prevent PCP adoption: insurance, perception, education gaps, and cost.
- Mechanisms extend far beyond glucose control, including natriuresis, improved myocardial metabolism, and renal protection.
- Safety concerns about kidneys are unfounded – actually protective
- Main real concern is UTIs – counsel patients, especially women
- Broad indications: All HF types, even acute/inpatient settings
- Patient and provider education is critical to overcome the “diabetes drug” stigma
Bottom Line: PCPs need support overcoming logistical, perceptual, and educational barriers to prescribe these evidence-based, guideline-recommended medications for nondiabetic heart failure patients.
