Optimizing Utilization of SGLT2 Inhibitors in an Outpatient LVAD Population

Abstract

<h3>Purpose</h3> SGLT2 inhibitors (SGLT2i) decrease morbidity and mortality in patients with HFrEF and have potential but unstudied benefits in LVAD patients. The purpose of this study was to assess the impact of a provider education program and SGLT2i initiation protocol on SGLT2i prescribing and to determine barriers to SGLT2i utilization. <h3>Methods</h3> This was a single center, retrospective, cross-sectional cohort study of an outpatient LVAD patient population. The primary outcome was the proportion of patients on SGLT2i therapy seen in clinic prior to (May/June 2019) and after (May/June 2020) pharmacist-led protocol development and provider education. Candidates for SGLT2i were those with NYHA Class II-IV symptoms, MAP ≥ 80 mmHg, and eGFR ≥ 20 mL/min. Chi-square and t-tests were used to compare categorical and continuous data, respectively. <h3>Results</h3> A total of 272 LVAD outpatient encounters were evaluated; patient characteristics were similar between the pre- and post-protocol cohorts (<b>Table 1</b>). No patients in the pre-protocol cohort received SGLT2i therapy despite 67 being appropriate candidates. In the post-protocol cohort, 25 patients (16.0%) were already receiving an SGLT2i (p<0.001 vs pre-protocol) and 109 patients were candidates. Of those, 9 patients (5.8%) were initiated on an SGLT2i (p=0.01 vs pre-protocol). NYHA Class I (23.4%) and MAP <80 mmHg (21.3%) were the most common reasons patients were not SGLT2i candidates. Rationale for failing to initiate SGLT2i post-protocol was poorly documented, but primarily included other medication changes (n=12) or patient instability (n=7) (<b>Table 2</b>). In addition to improved rates of SGLT2i prescribing, rates of prescribing of other guideline-directed therapies also improved (<b>Table 1</b>). <h3>Conclusion</h3> Pharmacist-led provider education and initiation protocols can increase SGLT2i utilization in outpatients supported by LVADs, leading to a larger patient population in which the potential benefits of these therapies on clinical outcomes can be evaluated.