Dr John McMurray: The Next Step for SGLT 2 Inhibitors in Patients With HF Is Implementation

It's a great time to be a doctor treating patients with heart failure, what with the development of 2 fantastic new treatments within the space of 5 years, said John McMurray, MD, FRCP, FESC, professor of medical cardiology in the Institute of Cardiovascular and Medical Sciences at the University of Glasgow.

The American Journal of Managed Care®(AJMC®): EMPEROR-Reduced results published in The New England Journal of Medicine reported a 6% difference in the hazard ratio in the outcomes for patients with diabetes and those without diabetes; the paper characterized the effect as basically the same. Do you agree?

Dr. McMurray:Absolutely. We saw this in DAPA-HF, completely consistent effects in patients with and without diabetes. Maybe this has been the problem, maybe cardiologists are still thinking, although this is rather old fashioned thinking, that these are treatments only for diabetes. They're not. They are a treatment for diabetes, but they are also a treatment for heart failure. We've repurposed SGLT 2 inhibitors to be treatment for heart failure. It's like Sildenafil. It was it introduced as a treatment for erectile dysfunction. But we cardiologists use it today as a treatment for pulmonary hypertension. It's same molecule, but 2 completely different indications. So yes, useful glucose lowering therapy for diabetes. This is our drug. This is a heart failure drug, and we can do a huge amount of good for our patients.

AJMC®: Results from DAPA-HF found dapagliflozin could prevent diabetes in individuals with prediabetes. Does empagliflozin show potential diabetes prevention effects in this population? Can you discuss the debate around preventing type 2 diabetes with a drug?

Dr. McMurray: That is correct. We did show reduction in new onset diabetes amongst those patients who didn't have diabetes at baseline in DAPA-HF. These same analyses have not been presented for EMPEROR-Reduced. So we don't know if that's the case with empagliflozin, but I would anticipate broadly similar effects because these drugs are similar in structure and act in the same way. But we haven't seen those data and we only know that for dapagliflozin at the moment.

I don't think there is much debate about it. It's a great additional benefit to have. If you're a patient with heart failure, the last thing you want to do is to develop diabetes as well. So that is what I would call a bonus of this therapy. It does all the good things I mentioned earlier: improves symptoms, reduces hospitalization, reduces mortality. We know it also reduces worsening renal function. And now this is an additional benefit: it reduces new onset diabetes. So little controversy, no discussion, great bonus effects in patients who don't have diabetes at the moment, who are at very high risk of developing diabetes that's maybe not often realized. Heart failure is an extremely diabetogenic disease. It's great that we can reduce or delay the development of new onset diabetes.

AJMC®: Do you have any final thoughts you'd like to share?

Dr. McMurray: It's fantastic to be in this new era of heart failure therapy and in the space of 5 years to have 2 fantastic new treatments completely complimentary and additive to the other therapies that we have. It's a great time to be a doctor treating patients with heart failure. And hopefully it's a great time for patients with heart failure because we now have so much more to offer them if they get the therapy. So the key from here on is implementation. The way the trials have given our colleagues the evidence, we need everybody now to put that evidence into practice.