Gregg C. Fonarow, MD, FACC, FAHA, FHFSA
SGLT2 inhibitors provide substantial clinical benefits to patients with heart failure, patients with chronic kidney disease and patients with type 2 diabetes. For patients with HF, across the entire spectrum of left ventricular ejection fraction, early in-hospital initiation of SGLT2 inhibitor therapy improved clinical outcomes and was generally safe and well-tolerated.
However, in clinical trials and clinical series, there has been a small risk for diabetic ketoacidosis (DKA) and euglycemic diabetic ketoacidosis. The incidence of DKA with SGLT2 inhibitors may be in the range 0.1 to 0.8 per 1,000 patient-years.
Hospitalization or major surgery may be a trigger for DKA in vulnerable patients. Currently, the FDA label recommends holding SGLT2 inhibitors for 3 to 5 days prior to planned surgeries. However, some also have recommended not starting or discontinuing SGLT2 inhibitors in hospitalized patients not undergoing planned surgery.
This new analysis of three randomized controlled trials involved over 6,000 patients randomly assigned to an SGLT2 inhibitor or matching placebo while hospitalized with COVID-19. While these studies did not demonstrate a benefit for treating COVID-19, these findings can be used to evaluate safety. There were no unexpected safety signals with SGLT2 inhibitors used in patients hospitalized with COVID-19.
These findings further suggest that there is not a need to routinely discontinue SGLT2 inhibitors in the setting of hospitalization for an acute illness. Further, these findings also suggest SGLT2 inhibitors can be safely initiated de novo in-hospital, if otherwise indicated, with overall tolerability comparable with placebo.
Nevertheless, clinicians should be aware that euglycemic DKA is a rare but important complication that can occur with these medications. Clinicians should be aware of the symptoms of DKA and know how to manage this condition.
Gregg C. Fonarow, MD, FACC, FAHA, FHFSA
Eliot Corday Chair in Cardiovascular Medicine and Science
Director, Ahmanson-UCLA Cardiomyopathy Center
Co-director, UCLA Preventive Cardiology Program
Co-chief, Division of Cardiology, UCLA
Disclosures: Fonarow reports receiving consultant fees from Amgen, AstraZeneca, Bayer, Cytokinetics, Eli Lilly, Johnson & Johnson, Merck, Novartis and Pfizer.
