In Reply: Should I start an SGLT-2 inhibitor in my patient with heart failure and chronic kidney disease?

We thank Dr. Modarressi for his important and timely response. We agree with his recommendations for optimizing the utilization of this therapeutic class. Regarding dosing, we agree that the “set it and forget it” approach of starting an SGLT-2 inhibitor has been particularly beneficial for this class of medications. As opposed to other medications that require frequent titration and follow-up laboratory work, SGLT-2 inhibitors may be started earlier in patients with heart failure while other medications are added and titrated up.

We also agree that the role of routine laboratory testing for hyperkalemia has limited value, especially in light of new guidelines and data. Several studies have shown that hyperkalemia is not a common side effect of SGLT-2 inhibitors, and we agree that laboratory testing can be done on a case-by-case basis rather than routinely. Patients who can maintain adequate hydration generally will have limited side effects from SGLT-2 inhibitors. Additionally, while changes in serum creatinine levels and eGFR may be alarming at first, they do not correlate with kidney injury, and therapy should be continued regardless. For most patients, we agree that routine laboratory checks may be burdensome and unnecessary, and may lead to premature interruption of SGLT-2 inhibitor therapy.

Thus, overall we agree with Dr. Modarressi’s statements and observations, and believe that SGLT-2 inhibitors may be started earlier in a patient’s course because of the “set it and forget it” approach. Most important, in light of new data and guidelines, patients with chronic kidney disease should have access to SGLT-2 inhibitor therapy to help mitigate cardiovascular risk. Additionally, follow-up laboratory tests may not be necessary in all patients given the remarkable safety profile of SGLT-2 inhibitors.

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