Abstract：
Background: Large cardiovascular outcomes trials in individuals with heart failure, with and without diabetes, have demonstrated a significant risk reduction in the composite outcome of cardiovascular death or hospitalizations for heart failure with SGLT2 inhibitor therapy. These positive outcomes have led to the recommendation that SGLT2 inhibitors serve as backbone therapy in patients with heart failure reduced ejection fraction (HFrEF). To date, there has not been enough participants in clinical trials on concomitant SGLT2 inhibitor and angiotensin receptor-neprilysin inhibitor therapy to evaluate the benefits and risks of combination therapy with these two agents outside of smaller subgroup analyses. Case Summary: This case describes a Black female with diabetes meeting her glycemic targets and concomitant stable NYHA FC II HFrEF on guideline-directed medical therapy (GDMT) with sacubitril/valsartan, spironolactone and metoprolol succinate who developed severe hypotension and dehydration requiring hospitalization after initiation of SGLT2 inhibitor therapy. Practice Implications: This case report raises the question of whether those with type 2 diabetes, and/or those on background angiotensin receptor-neprilysin inhibitor therapy, who are euvolemic or sensitive to diuretic therapy should be started on lower dose dapagliflozin and titrated to 10 mg daily based on response. It also raises awareness to the potential increased diuretic effect produced with concomitant use of sacubitril/valsartan and dapagliflozin. Caution and education to mitigate the risk for volume depletion should be provided to those patients who are euvolemic and initiated on a SGLT2 inhibitor, regardless of their background diuretic and GDMT. Conclusion: Future research should focus on the benefits and safety considerations and provide education on how to best initiate and adjust SGLT2 inhibitors in the setting of sacubitril/valsartan use in diverse heart failure patient populations.
摘要：
背景：心力衰竭患者的大型心血管结局试验，有和没有糖尿病，已经证明SGLT2抑制剂治疗可显著降低心血管死亡或心力衰竭住院的复合结局风险.这些积极的结果导致建议SGLT2抑制剂作为心力衰竭患者射血分数降低（HFrEF）的骨干治疗。迄今为止,在SGLT2抑制剂和血管紧张素受体-脑啡肽抑制剂联合治疗的临床试验中,在较小的亚组分析之外,没有足够的参与者来评估这两种药物联合治疗的获益和风险.病例摘要：该病例描述了一名黑人女性，患有糖尿病，达到了她的血糖目标，并伴随着稳定的NYHAFCIIHFrEF，并采用沙库必曲/缬沙坦进行了指南指导的药物治疗（GDMT）。在开始SGLT2抑制剂治疗后出现严重低血压和脱水需要住院治疗的人螺内酯和琥珀酸美托洛尔。实践含义：此病例报告提出了一个问题，即是否患有2型糖尿病，和/或那些背景血管紧张素受体-脑啡肽抑制剂治疗，血容量正常或对利尿剂治疗敏感的患者应开始服用较低剂量的达格列净，并根据反应滴定至每日10mg。它还提高了人们对伴随使用沙库巴曲/缬沙坦和达格列净产生的潜在增加的利尿作用的认识。应谨慎和教育，以减轻容量耗尽的风险，应提供给那些正常容量并开始使用SGLT2抑制剂的患者。无论其背景利尿剂和GDMT。结论：未来的研究应集中在益处和安全性方面，并提供有关如何在不同心力衰竭患者人群中使用沙库巴曲/缬沙坦的情况下最佳启动和调整SGLT2抑制剂的教育。
