Empagliflozin (Elderly HFpEF/HFrEF)

How it works

It inhibits sodium-glucose co-transporter 2 in the proximal renal tubule, producing glycosuria and natriuresis with osmotic diuresis and favourable cardiac and renal haemodynamic effects.

Prescribing in practice

• In frail older heart-failure patients monitor volume status and renal function, as the diuretic effect can cause hypotension and dehydration, and review concurrent loop diuretics to avoid excessive fluid loss.
• Counsel on diabetic ketoacidosis risk, which can occur with near-normal glucose, and consider temporary withholding during acute illness, dehydration or before major surgery (sick-day rules).
• Genital and urinary infections are more common; advise on hygiene and prompt reporting, and be alert to the rare risk of Fournier's gangrene.

Monitoring

Monitor renal function, blood pressure and volume status after initiation and during intercurrent illness, with an expected small initial dip in renal function that usually stabilises.

Counselling the patient

• This medicine helps your heart even if you do not have diabetes; take it once daily as directed.
• Stop temporarily and seek advice if you become acutely unwell, dehydrated or stop eating and drinking.
• Maintain good genital hygiene and report genital pain, swelling or signs of infection promptly.

Evidence & guidelines

The EMPEROR-Reduced and EMPEROR-Preserved trials demonstrated reductions in heart-failure hospitalisation across the ejection-fraction spectrum, supporting empagliflozin use in older heart-failure patients.