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Preserving hope for patients with Heart Failure with Preserved Ejection Fraction (HFpEF)?

Although guideline-directed medical therapy substantially improves morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), treatments that clearly improve outcomes in those with HF and an EF >40% remain elusive. Unfortunately, the incidence and prevalence of HF are expected to substantially increase in the coming decades.  More evidence and effective treatments for those with HF with preserved ejection fraction are clearly needed.  Enter the EMPEROR-Preserved trial.

Guest Authors:  Gabrielle Givens, PharmD, BCPS and Robert Parker, PharmD

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SGLT2i plus MRAs for Heart Failure: A Sweet or Sour Combination?

We now have “diabetes medications” to treat heart failure with reduced ejection practice (HFrEF). Many clinicians have not yet used a sodium-glucose transporter 2 inhibitor (SGLT2i) for the treatment of HF and are (rightfully) concerned about potential drug-drug interactions, particularly when using an SGTL2i with a mineralocorticoid (MRA). A recent secondary analysis using data from the EMPEROR-Reduced study may provide some reassurance.

Guest Authors:  B. Blake Miller, PharmD, BCPS and Jennifer Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM

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Raised From The Grave: A Second Life for Sotagliflozin?

The prevalence of heart failure in patients with diabetes is four times higher than in the general population.  Likewise, chronic kidney disease (CKD) and diabetes are common morbidities. As new drug classes emerge in the management of diabetes and heart failure and CKD, it is important to thoroughly evaluate available literature and identify opportunities to reduce complications and costs. Sotagliflozin is a first-in-class dual SGLT-1 and 2 inhibitor approved in Europe.  Does it improve outcomes in patients with heart failure or CKD?

Guest Authors:  Maren Richards Brinton, PharmD and Jonathan C. Hughes, PharmD, BCPS, BCACP

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DECLARE-ing Another Victory for Dapagliflozin

Until now, only two classes of medications have been definitively shown to delay the decline in renal function in patients with CKD: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).  The sodium glucose co-transporter 2 inhibitors are increasingly prescribed to a wider and wider population of patients. And the latest data suggest they may have an important role in the treatment of chronic kidney disease (CKD) in patients with ... or without ... diabetes. 

Guest Authors:  Stefanie C. Nigro, PharmD, BCACP and Jennifer N. Clements, PharmD, BCPS, BCACP, CDCES, BC-ADM

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Canagliflozin Comeback? New Data on the Risk of Amputation

Patients with diabetes are 10 times more likely to experience lower limb amputations than the general population and amputations have very significant morbidity, mortality, and financial implications. While common risk factors for amputation in patients with diabetes include poor glycemic control, diabetic peripheral neuropathy, or peripheral arterial disease, canagliflozin use was implicated in the CANVAS and CANVAS-R trials. However, the CANVAS Program trials were not specifically designed to evaluate the risk of lower-extremity amputations.  Clearly, we need more information about the magnitude of risk when canagliflozin is used widely in a general population and who is at most risk.

Guest Authors:  Julie Dally, PharmD, BCPS, BCACP and Amanda Schartel, PharmD, BCACP

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Is Dapagliflozin aDAPtAble to Treating HFrEF in Patients Without Diabetes?

Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality. Current guidelines recommend a renin-angiotensin inhibitor, beta-blocker, and aldosterone antagonist to reduce morbidity and mortality in these patients. Despite the use of multiple drug classes, 5-year mortality rates hover near 50% in patients with heart failure (HF). Despite the numerous medications available, mortality and the risk of HF hospitalizations remains high. Sodium-glucose cotransporter-2 inhibitors (SGLT2-I) have been shown to reduce HF hospitalizations in patients with diabetes. Could this medication class be useful for HF treatment even in patients without diabetes?

Guest Authors:  John Andraos, PharmD; Alexa Zeiger, PharmD; and Michael S. Kelly, PharmD, BCACP

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Using Sotagliflozin In Tandem with Insulin: Weighing the Benefits in Type 1 Diabetes

Patients with type 1 diabetes often have sub-optimal glycemic control.  The gold standard of treatment is basal-bolus insulin or continuous subcutaneous insulin infusion via an insulin pump.  However, only a third of patients with type 1 diabetes achieve the American Diabetes Association A1C goal <7%.  There has been particular interest in using SGLT-2 inhibitors in patients with type 1 diabetes due to their ability to decrease body weight and blood pressure as well as improve glycemic control and perhaps cardiovascular outcomes. InTandem3 was a phase III, multicenter, randomized, double-blind, placebo-controlled trial evaluating the safety and efficacy of sotagliflozin, a novel dual SGLT 1 and 2 inhibitor, in patients with Type 1 diabetes.

Guest Author:  Diana Isaacs, Pharm.D., BCPS, BD-ADM, CDE

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Painting a New CANVAS for SGLT-2 Inhibitors?

While good glycemic control has been shown to prevent microvascular complications (e.g. retinopathy, nephropathy, neuropathy), only a few anti-diabetic agents have been shown to reduce macrovascular complications (e.g. cardiovascular events. Empagliflozin, a sodium glucose transporter-2 (SGLT2) inhibitor, not only reduced the risk of CV events but also all-cause mortality in the EMPA-REG OUTCOME study.  Based on this data, the SGLT2 inhibitors were given favorable second-line treatment status in the most recent AACE/ACE clinical practice guidelines. But do all SGLT2 inhibitors confer the same benefits… and risks? The Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes (CANVAS) trial assessed the cardiovascular and renal benefits from long-term canagliflozin use.  The results are both reassuring and unexpected.

Guest Author:  Sean Lasota, Pharm.D.

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Sweetening the Deal: Effects of SGLT-2 Inhibitors on Kidney Disease Progression

Approximately one in three patients with diabetes in the United States have chronic kidney disease (CKD).  The Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG OUTCOME) trial, published in 2015, demonstrated a reduction in cardiovascular and all-cause mortality in patients treated with empagliflozin. More recent data from the EMPA-REG OUTCOME trial suggests that empagliflozin may also confer significant renal protection. 

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