Managing heart failure with reduced ejection fraction (HFrEF): Integrating SGLT2 inhibitors

Pharmacologic treatment of heart failure with reduced ejection fraction (HFrEF) has been a focus of research for decades. HFrEF guidelines recommend use of medications from four different classes (beta blockers, renin-angiotensin-aldosterone system [RAAS] inhibitors, mineralocorticoid receptor antagonists [MRAs], and sodium-glucose cotransporter-2 [SGLT2] inhibitors) to modulate the neurohormonal complexities of cardiomyopathies that result in a reduction in left ventricular function. Clinicians have become comfortable managing the triad of beta blockers, RAAS inhibitors, and MRAs. Adding the fourth class, SGLT2 inhibitors, poses more challenges, especially with regard to volume management. This article will explore clinical considerations of the integration of SGLT2 inhibitors into complex regimens in the outpatient setting.