Title: SGLT2i Utility in a Community Based Hospital Cohort for Glycemic Control in Patients with Type II Diabetes Mellitus and Heart Failure
Authors: Mara Banez, MD; Mohammad Qazziha, MBBS; Rasik Neupane, MD; Louis Rondinelli; Gregory Polcha Jr., DO
Email: mbanez@mercy.com
Introduction: ADA updated guidelines to recommend the use of sodium glucose co-transporter 2 inhibitors (SGLT2i) for patients with type 2 diabetes mellitus (T2DM) to improve glycemic control, improve weight loss, and complications from uncontrolled T2DM. Further evidence has shown they have an improved efficacy in treating patients with complications from uncontrolled T2DM. Due to patients being resistant to starting insulin therapy, the efficacy of oral anti-diabetic agents needs evaluation. Various studies show that these oral agents can have synergistic effects and can reduce obesity and thus reduce insulin resistance. In this QI Study, we evaluate a cohort of Heart Failure patients with reduced, preserved, and recovered EF and T2DM at a community-based hospital while working to improve patient’s glycemic control.
Methods: To establish a patient population, authors utilized SlicerDicer through Epic Systems to obtain a cohort of patients with heart failure (HFrEF, HFmrEF, HFpEF) and T2DM. In this cohort, authors specifically identified patients using SGLT2i and evaluated current glycemic control, exacerbations causing hospitalization, current glycemic treatment, and adverse effects related to SGLT2i such as euglycemic diabetic ketoacidosis, pancreatitis, and/or UTI. A formal educational process occurred for physicians through lectures, emails, and pamphlets for appropriate use of SGLT2i. Six months after the education occurred, additional data was gathered to evaluate the QI portion of this study.
Results: Data was abstracted from the EMR of internal medicine residency clinic patients with co-diagnoses of heart failure and diabetes mellitus (N=137). Average age was 63.512 years, 43.8% for female and approximately 46.2% were white. Average A1c in the series was 7.32.0%; 52.6% of the diabetic mellitus patients exhibited an A1c > 7.0% and three quarters of diabetic mellitus patients had an A1c > 8.0%. Only 22.6 % (31/137) of diabetes mellitus patients had SGLT2 therapy. Insulin use, both insulin and non-insulin medication use, and non-insulin use was noted in 38% (52/137), 11.7% (16/137) and 61.3% (84/137) of patients, respectively. Mean A1c for DM patients on SGLT2i was 7.4% 2%; and mean A1c for those not on SGLT2i was similar to 7.42 (T equals 0.064, P equals 0.949). No DKA was noted in the series. The rate of UTI was also similar by whether or not SGLT2 therapy was offered, (12/106) 11.3% versus 2/31) 6.5% (Chi square X squared equals 0.6-0, P equals 0.431).
Discussion/Conclusion: Despite the recognized benefits of SGLT2i in improving glycemic control and reducing cardiovascular risks, only a minority of patients in this cohort were prescribed this therapy. This suggests underutilization of SGLT2i in this population. Furthermore, the comparison between diabetic patients on SGLT2i and those not on this therapy revealed no significant difference in A1c levels, meaning that the use of SGLT2i did not significantly impact glycemic control in this cohort. Additionally, the absence of DKA and similar rates of UTI regardless of SGLT2i therapy suggest the safety profile of this medication. However, the findings also raise questions about the reasons behind the limited adoption of SGLT2i despite their established benefits. Factors such as physician awareness, patient eligibility, and healthcare barriers may contribute to this discrepancy. While SGLT2i offers promising benefits in glycemic management, addressing cost barriers and ensuring patient safety remain critical. Our findings encourage further research and real-world evidence to guide optimal utilization of SGLT2i in diverse patient populations.
