Empagliflozin and renal sodium handling: an intriguing smart osmotic diuretic
Abstract
The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) recommend sodium–glucose co-transporter 2 inhibitors (SGLT2i) to be used in type 2 diabetes mellitus patients with either established cardiovascular (CV) disease or at high CV risk in order to prevent or delay the onset of and hospitalizations for heart failure (HF).1 Based upon randomized prospective trials, dapagliflozin and empagliflozin are now also recommended in symptomatic patients with HF and reduced ejection fraction, on guideline-directed medical therapy, regardless of the presence of type 2 diabetes mellitus.2–4 At present, the mechanisms underlying the beneficial CV and renal effects of SGLT2i are not completely understood and several, not mutually exclusive, mechanisms have been proposed.1 In this issue of the Journal, Boorsma et al.5 describe the effects of empagliflozin on renal sodium and glucose handling in a pre-defined sub-analysis of the EMPA-RESPONSE-AHF trial. This was a randomized, double-blind, placebo-controlled, multicentre pilot study which demonstrated that empagliflozin was safe and well tolerated in acute HF on top of classic loop diuretics, while it did not improve dyspnoea, N-terminal pro B-type natriuretic peptide, diuretic response and length of hospital stay.6 Importantly, the trial demonstrated that early addition of empagliflozin to standard diuretic therapy did increase cumulative diuresis during the decongestive phase of the treatment of acute HF, which was…
How strong is the evidence?
Evidence Hub reads this as a randomized trial. Its evidence level is 2 of 5 (High · randomized trial). Randomized trials of a reasonable size are the strongest single-study design.
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