the metabolic pillar
Originally diabetic drugs, now a “fourth pillar” of Heart Failure therapy and CKD progression. They induce osmotic diuresis, natriuresis, and metabolic reprogramming of the heart.
- Mechanism: Inhibits SGLT2 in the Proximal Convoluted Tubule. Effects: Glycosuria (calorie loss), Natriuresis (decongestion), Reduced intraglomerular pressure.
- Dosing: Empagliflozin 10 mg QD / Dapagliflozin 10 mg QD. Note: Little benefit to higher doses for HF/CKD indications.
- PK: Efficacy relies on GFR (less glycemic control at low GFR), but CV/Renal benefits persist down to eGFR ~20.
indications
- Heart Failure: HFrEF (DAPA-HF, EMPEROR-Reduced) and HFpEF (EMPEROR-Preserved).
- CKD: Delays progression (DAPA-CKD, EMPA-KIDNEY).
- Type 2 Diabetes: Glycemic control + CV risk reduction.
adverse effects
- Genital Mycotic Infections: Thrush/balanitis (glucose in urine).
- Euglycemic DKA: DKA with normal/mildly elevated blood sugar. Rare but critical. Hold when unwell/fasting/peri-operative.
- Fournier’s Gangrene: Very rare necrotizing fasciitis of perineum.
- Volume Depletion: Additive effect with diuretics.