Longitudinal loop diuretic use in patients with HFrEF initiated with sodium-glucose cotransporter 2 inhibitors

A reduction in loop diuretics need after sodium-glucose cotransporter-2 inhibitors (SGLT2i) initiation has been suggested by retrospective analyses of clinical trials. We aimed to investigate long-term changes in loop diuretic therapy after SGLT2i initiation in an unselected, real-world heart failure (HF) cohort.

Patients with HF with reduced ejection fraction (HFrEF) enrolled in the SwedeHF between January 2020 and October 2021 were considered. Patients initiated with SGLT2i were the cases. Controls did not initiate SGLT2i despite having an indication. Trajectories in daily furosemide-equivalent doses from baseline to 1-year follow-up were compared in cases vs. controls. Overall, 5623 (81.6%) controls and 1265 (18.4%) cases were analysed. At baseline, 5224 (75.8%) patients were prescribed with loop diuretics with a mean (SD) furosemide-equivalent dose of 36.7 (27.4) mg. SGLT2i users, compared with controls, more likely experienced a loop diuretic withdrawal/dose reduction (difference between proportions 6% [3%; 9%] P-value <0.001), and less likely had a loop diuretic initiation or dose increase (difference between proportions -5% [-7%; -3%], P-value <0.001), leading to a more accentuated net decrease in furosemide-equivalent daily doses (adjusted mean difference between groups -4.2 [-7; -1.5] mg, P-value 0.002). In a multivariable regression model, the adjusted odds ratio (OR) for decrease in loop diuretic doses/withdrawn after SGLT2i initiation was 1.58 (1.35-1.85), and the adjusted OR for increase in loop diuretic doses/new initiation was 0.50 (0.38-0.64).

In this real-world population with HFrEF, SGLT2i initiation was associated with a decrease in loop diuretic need at 1-year follow-up.