SGLT2 Inhibitors in Heart Failure: A Guide for Older Adults

SGLT2 inhibitors are a group of medicines that started as diabetes treatment and now form a core part of heart failure care. Heart failure is one of the most common reasons for hospital stays after 65. Many older people also have diabetes, chronic kidney disease or high blood pressure. A medicine that protects both the heart and the kidneys therefore has special value. Below we explain what these medicines do, who they suit and what families should watch for.

What are SGLT2 inhibitors?

SGLT2 is a protein in the kidneys. It takes glucose and sodium back from the urine into the blood. When a medicine blocks it, the body passes more glucose, salt and a little water. The heart works under less strain, blood pressure falls slightly and weight drops a little. Researchers think other helpful effects also exist, but they do not fully understand them yet.

In Europe, doctors mainly use two medicines for heart failure:

• Dapagliflozin: usually 10 mg once a day.
• Empagliflozin: usually 10 mg once a day.

In heart failure the dose stays the same from the first day. It does not need slow increases, unlike some other heart medicines. These medicines help patients with or without diabetes.

What studies show for the heart and kidneys

Large clinical trials showed that SGLT2 inhibitors reduce hospital stays for worsening heart failure. In heart failure with reduced ejection fraction, the combined risk of cardiovascular death or worsening fell by about a quarter. In heart failure with preserved ejection fraction, the benefit mainly means fewer hospital stays. The differences appeared within the first weeks.

The European Society of Cardiology guidelines now recommend them across the whole range of heart failure, unless a reason exists not to use them. The same medicines also slow chronic kidney disease. The benefits held in patients over 75 too. Fewer hospital stays matter, but the risk does not fall to zero. Other medicines, a low-salt diet and exercise remain essential.

Before treatment starts: what the doctor checks

The cardiologist or physician reviews the full history and the medicine list. Before the first dose, they usually check:

• kidney function (creatinine, eGFR) and electrolytes.
• blood pressure, and whether the person feels dizzy when standing up from a chair or bed.
• the diuretic dose, which sometimes needs lowering.
• diabetes medicines, especially insulin or sulfonylureas, because of the risk of low blood sugar.

When kidney function is very low (eGFR below about 20–25), doctors usually do not start treatment. In the first weeks, eGFR may dip slightly. Doctors expect this small dip, and it is usually no reason to stop. The doctor repeats the tests and decides. These medicines have no role in type 1 diabetes without specialist guidance.

Side effects of SGLT2 inhibitors in older adults

Most people tolerate them well. Still, families should know about some side effects:

• Genital fungal infections: the most common side effect. Good daily hygiene helps limit them.
• Urinary infections: slightly more common. Burning, frequent urination or fever need a check.
• Dehydration and low blood pressure: more likely with diuretics, hot weather or low fluid intake. Dizziness raises the risk of falls.
• Euglycaemic ketoacidosis: rare but serious, mainly in people with diabetes. It can occur even with near-normal blood sugar.

Ketoacidosis causes nausea, vomiting, stomach pain, unusual tiredness or fast breathing. If these symptoms appear, seek medical help at once and mention the medicine. Very rarely, doctors have seen a serious infection in the genital area. Pain, swelling or redness there, together with fever, need urgent assessment.

Sick days and surgery

When an older person has vomiting, diarrhoea or fever, or is not eating and drinking normally, the risk of dehydration and ketoacidosis rises. On such days, the doctor often advises a short pause until normal eating returns. Before planned surgery, the doctor usually stops the medicine three days earlier. Do not stop or restart the medicine without asking the doctor.

Good hydration matters, but without excess in people on a fluid limit. Read more in our article on dehydration in older adults on our blog. The NHS page on dapagliflozin also gives practical advice for patients.

Daily monitoring at home or in a care home

Daily care makes a real difference in heart failure. A few simple habits are very useful:

• Weigh the person every morning, and tell the doctor if weight rises by more than 1.5–2 kg in two to three days.
• Measure blood pressure when the person feels dizzy or unusually tired.
• Note any ankle swelling, breathlessness at night or less urine.

At ΔΕΛΦΙΝΙ, medical follow-up includes regular checks of weight, blood pressure and hydration, together with the treating cardiologist. For rebuilding strength after a hospital stay, see our guide to gentle exercise for older adults on our blog.

Frequently asked questions

Are SGLT2 inhibitors safe for older adults?

Studies showed benefit in patients over 75 too. Safety depends on kidney function, hydration and other medicines, so the doctor monitors the person regularly.

Do people without diabetes take them?

Yes. In heart failure and chronic kidney disease, the benefit does not depend on diabetes. In people without diabetes, low blood sugar is very rare.

What are the most common side effects?

Genital fungal infections, urinary infections and dehydration with dizziness. Euglycaemic ketoacidosis is rare but serious and needs urgent medical care.

How quickly does the medicine work?

In studies, hospital stays fell within the first weeks. The person may not feel any change, because the benefit mainly lies in preventing decline.

For personal advice about your relative, please contact us and we will get back to you.