Identifying Barriers To SGLT2 Inhibitor Use In Eligible Patients With Heart Failure: A Real-world Experience From A Single Centre

Abstract

Background Recent landmark trials investigating the use of sodium glucose cotransporter 2 (SGLT2) inhibitors in patients with heart failure (HF) with reduced ejection fraction (HFrEF) have demonstrated significant reductions in cardiovascular mortality and heart failure hospitalization. As a result of these trials, recent updates to major societal guidelines have included a strong recommendation for the initiation of SGLT2 inhibitors in patients with HFrEF and HF symptoms. The routine initiation of SGLT2 inhibitors in eligible patients, however, has been limited by several factors including cost, increased pill burden, concomitant chronic kidney disease and adverse effects, among others. Real-world data investigating the use of SGLT2 inhibitors and perceived barriers to their initiation in eligible heart failure patients are currently lacking. Methods/Results This is a prospective, single center, observational study evaluating the use of SGLT2 inhibitors in a specialized heart function clinic. Patients seen in clinic from January 1, 2021 to April 30, 2021 were screened for eligibility of SGLT2 inhibitor initiation. Patient characteristics, background medical therapy and lab values of interest were recorded using paper charts and local electronic records. Providers were asked to record whether SGLT2 inhibitor therapy was successfully initiated and if not, the reason it was not prescribed. In total 286 of 496 (57.7%) patients screened were eligible for SGLT2 inhibitor therapy. Among eligible patients, average age was 63.0 years (SD +/- 13.5); 217 patients were male (75.9%) and 69 female (24.1%); 17 (5.9%) were NYHA class 1, 220 (76.9%) were NYHA class 2, 47 (16.4%) were NYHA class 3 and 2 (0.7%) were NYHA class 4. In total 113/286 eligible patients were prescribed SGLT2 inhibitors (39.5%). Of these 286 eligible patients, 265 had HFrEF, of which 101 were prescribed an SGLT2 inhibitor (38.1%). The most common reasons for not prescribing SGLT2 inhibitor therapy included: up-titration or initiation of other medications/defer to future visit in 110 patients (63.6%), patient preference or refusal in 15 patients (8.7%) and inability to afford the cost of medication in 11 patients (6.4%). Conclusion A substantial proportion (57.7%) of HF patients are eligible for an SGLT2 inhibitor. However, SGLT2 inhibitors are currently underutilized in eligible patients seen in a specialized heart function clinic predominantly due to up-titration or initiation of other HF therapies. Strategies should be undertaken to increase utilization of this new class of therapy for HF to reduce cardiovascular events. Recent landmark trials investigating the use of sodium glucose cotransporter 2 (SGLT2) inhibitors in patients with heart failure (HF) with reduced ejection fraction (HFrEF) have demonstrated significant reductions in cardiovascular mortality and heart failure hospitalization. As a result of these trials, recent updates to major societal guidelines have included a strong recommendation for the initiation of SGLT2 inhibitors in patients with HFrEF and HF symptoms. The routine initiation of SGLT2 inhibitors in eligible patients, however, has been limited by several factors including cost, increased pill burden, concomitant chronic kidney disease and adverse effects, among others. Real-world data investigating the use of SGLT2 inhibitors and perceived barriers to their initiation in eligible heart failure patients are currently lacking. This is a prospective, single center, observational study evaluating the use of SGLT2 inhibitors in a specialized heart function clinic. Patients seen in clinic from January 1, 2021 to April 30, 2021 were screened for eligibility of SGLT2 inhibitor initiation. Patient characteristics, background medical therapy and lab values of interest were recorded using paper charts and local electronic records. Providers were asked to record whether SGLT2 inhibitor therapy was successfully initiated and if not, the reason it was not prescribed. In total 286 of 496 (57.7%) patients screened were eligible for SGLT2 inhibitor therapy. Among eligible patients, average age was 63.0 years (SD +/- 13.5); 217 patients were male (75.9%) and 69 female (24.1%); 17 (5.9%) were NYHA class 1, 220 (76.9%) were NYHA class 2, 47 (16.4%) were NYHA class 3 and 2 (0.7%) were NYHA class 4. In total 113/286 eligible patients were prescribed SGLT2 inhibitors (39.5%). Of these 286 eligible patients, 265 had HFrEF, of which 101 were prescribed an SGLT2 inhibitor (38.1%). The most common reasons for not prescribing SGLT2 inhibitor therapy included: up-titration or initiation of other medications/defer to future visit in 110 patients (63.6%), patient preference or refusal in 15 patients (8.7%) and inability to afford the cost of medication in 11 patients (6.4%). A substantial proportion (57.7%) of HF patients are eligible for an SGLT2 inhibitor. However, SGLT2 inhibitors are currently underutilized in eligible patients seen in a specialized heart function clinic predominantly due to up-titration or initiation of other HF therapies. Strategies should be undertaken to increase utilization of this new class of therapy for HF to reduce cardiovascular events.