Ask AI
Back Back
Nursing strategies in heart failure for SGLT2i
Nursing Strategies to Optimize SGLT2 Inhibitors in Heart Failure: Experts Answer Your Questions

Released: July 08, 2025

Expiration: July 07, 2026

Midge Bowers
Midge Bowers, DNP, FNP-BC, FAANP, FAAN, FACC
Stephen J. Greene
Stephen J. Greene, MD
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • SGLT2 inhibitors have demonstrated reassuring safety in older adults and those with multiple comorbidities, supporting their use in nearly all patients with heart failure (HF) while also offering early benefits such as improved symptoms and reduced hospitalizations.
  • Nurse-led follow-up calls and coordinated documentation play a critical role in HF care by identifying patient concerns at vulnerable points in care. Timely outreach ensures that issues are captured early and addressed during follow-up visits.
  • Healthcare professionals need not routinely decrease or discontinue loop diuretics when initiating SGLT2 inhibitors. However, for patients with HF receiving low doses of diuretics, discontinuation or de-escalation of diuretics can be considered when initiating an SGLT2 inhibitor.

In this commentary Midge Bowers, DNP, FNP-BC, FAANP, FAAN, FACC, and Stephen J. Greene, MD, address questions posed by healthcare professionals (HCPs) during a live event titled, “Transforming Cardiorenal Care: Nurse-Led Strategies for Heart Failure Management With SGLT2 Inhibitors.” These questions highlight the evolving treatment landscape for patients with heart failure (HF) and nurse-led strategies for aligning your practice with guideline-directed medical therapy (GDMT).

What are some nurse-led interventions that you have found successful in getting patients with HF started on SGLT2 inhibitors?

Midge Bowers, DNP, FNP-BC
I work with a great team of experienced nurses that has been in cardiology for a long time. These nurses complete our follow-up phone calls and will add patients’ concerns to their visit notes. They call patients 24-48 hours after their discharge and track things like, “They have not been able to pick up their prescriptions because the copay is too high.” Another key concern they ask patients is about their symptoms. These nurses are asking the right questions at the right time—that vulnerable point post discharge. In our HF access clinic during hospital follow-up visits, I then address patients’ concerns that were identified in their follow-up phone call. I cannot speak enough of the role that a nurse navigator has. Any kind of nurse-led phone call done in a timely manner that is then tied to a discharge or follow-up after a clinic visit is crucial. I work with great nurses who actively call patients to understand how they are feeling, if they have had a chance to pick their prescriptions, and how they are doing with SGLT2 inhibitor treatment. We use our voices in all the spaces that we touch the patient in their care.

Stephen J. Greene, MD: 
I completely agree with those strategies. Another thing—whether it is led by the nurse or attending HCP—is to recognize that patient visits in the clinic are often short, and that clinic schedules might not have the room for frequent in-person visits. I hear those concerns all the time, and they are valid. To overcome that, we need to be willing to start or titrate multiple HF medications at the same time. I am not saying this is for every single patient, but that should be our default practice. When patients are missing multiple agents in their treatment regimen, our default should be to start those missing agents at that same clinic visit. We need to make the most of the face-time we have with the patient. There is nothing in the HF handbook that says you are only allowed to make 1 medication change at a time. Rather, the slow, serial, one-move-at-a-time approach is the status quo, and what has this status quo been proven to lead to? It leads to the enormous gaps in GDMT prescribing we repeatedly see in our real-world studies. With all the challenges with scheduling and bandwidth of our clinics, the reality is that we are never going to get our patients on combination medical therapy at good doses if we take a slow and steady approach. What the status quo means is that every day we have patients with HF who were being hospitalized or dying without ever getting the chance to receive medications that are proven to prevent those events. These preventable deaths and hospitalizations need to be recognized. Therefore, we must be willing to make more than 1 move at the same time. There are huge risks when people leave the clinic without receiving all the life-saving medications for which they are eligible.

What do you do with a loop diuretic when you start patients on SGLT2 inhibitors?

Stephen J. Greene, MD:
In the SGLT2 inhibitor clinical trials, a fairly consistent finding is that patients randomized to SGLT2 inhibitors are less likely to need increases or initiations of loop diuretic over time. The way I think about that is that SGLT2 inhibitors prevent HF progression. SGLT2 inhibitors reduce the risk of HF-related hospitalization and the need for adding loop diuretics to patients’ therapy down the road. What do I do with the discontinuation of loop diuretics? Also based on trial data, SGLT2 inhibitors do not lead to a substantial or consistent signal of needing fewer loop diuretics. So I do not routinely discontinue or decrease diuretics in every patient where I start an SGLT2 inhibitor. But anecdotally I will discontinue or decrease the loop diuretic in patients who are taking low daily doses or doses only a couple of times a week. I do think that in these patients with low baseline diuretic requirement that the SGLT2 inhibitor can probably replace a loop diuretic, but that is not a uniform rule. For more context, I am more likely to decrease loop diuretics upfront when adding an angiotensin receptor neprilysin inhibitor (ARNI) vs an SGLT2 inhibitor because I think an ARNI is better tolerated if you leave the tank a little fuller.

Midge Bowers, DNP, FNP-BC:
The other thing to think about: If you stop 1 pill and start another, it is net neutral. That is a negotiation strategy.

Stephen J. Greene, MD:
With that polypharmacy comment, the thing to remember is that not all medications on a patient’s list are created equal when considering patient-prioritized outcomes. Sometimes patients will tell me that they do not want to start another medicine because they already are receiving 10 others. But we have to ask some key questions. How many of those therapies are proven to make patients live longer or feel better? In particular, among those who are 85 years of age and have comorbidities, how many of their prescribed therapies are proven to be safe? We have reassuring safety data on using SGLT2 inhibitors in older adults with HF and other comorbidities. When you ask these questions regarding evidence, effects on survival, effects on quality of life, and safety, you then realize that not all medications on the medication list are of potentially the same value to the patient. These discussions need to happen with patients so that they can make truly informed decisions about which medicines are worth it for them to take.

What are your thoughts on SGLT2 inhibitor therapy once patients are listed for transplant?

Stephen J. Greene, MD:
At our program, we routinely discontinue SGLT2 inhibitors once patients are listed for transplant because theoretically they could go into the operating room at any time. FDA guidance states that patients should be off SGLT2 inhibitor therapy at least 3 days before major surgery. That approach aligns with our practice, and it appears clinically appropriate.

What is the lowest ejection fraction that SGLT2 inhibitors can be used?

Midge Bowers, DNP, FNP-BC:
SGLT2 inhibitors can be used across all ejection fractions. Everybody is eligible, and that is a benefit to all patients with HF.

Stephen J. Greene, MD:
That is exactly right. Ejection fraction guides our HF management strategy for other agents in terms of the value of the therapy. For example, the juice may not be worth the squeeze in switching to an ARNI in patients with a high ejection fraction. But that reasoning does not apply to SGLT2 inhibitors. Even if there is a delay in getting an echocardiogram and if patients have clinical HF, their ejection fraction does not matter when deciding to start an SGLT2 inhibitor. That is not going to change your management strategy with this therapy. This is one more element that makes SGLT2 inhibitors simple and easy to use.

Is peripheral vascular disease a contraindication for SGLT2 inhibitors?

Stephen J. Greene, MD: 
There was a safety signal reported in certain early studies of canagliflozin. That has not been replicated since in the other SGLT2 inhibitor trials. It is not a contraindication. In fact, a consistent benefit is seen in these patients with peripheral vascular disease who get enrolled in the trials, whether they have diabetes or HF. Therefore, peripheral vascular disease is not a reason to withhold SGLT2 inhibitors.

Do you recommend holding SGLT2 inhibitor therapy in patients who need a procedure with contrast (ie, cardiac catheterization)?

Stephen J. Greene, MD:
Many clinical trials evaluated SGLT2 inhibitors across a spectrum of diseases, including diabetes, HF, and chronic kidney disease. But 1 other study that should be recognized is the EMPACT-MI trial that studied empagliflozin in patients hospitalized for acute myocardial infarction at risk for HF vs placebo. There were all these thoughts with this study, such as maybe we should not start SGLT2 inhibitors in patients who just received contrast from a coronary angiogram a couple of days ago. But there were no new safety concerns reported in EMPACT-MI and empagliflozin was well-tolerated, just like in the trials in other disease states.

Whenever we discuss therapy discontinuation or a pause in treatment, I want HCPs to be aware that the biggest risk is not that patients are going to be off the agent for a day or 2. Biologically, they will likely be okay if they skip a day of medication. Rather, the big risk is that you forget to restart the SGLT2 inhibitor. Every time HCPs mess with discontinuing medications, we run the risk of forgetting to restart it or making a downstream excuse of why we do not want to restart it. I do not think it is evidence based to hold the SGLT2 inhibitor for every procedure requiring nothing by mouth. Patients do need their SGLT2 inhibitor on hold for the surgery at least 3 days prior. But we do not need to extrapolate that to every instance someone is missing breakfast they need to skip their SGLT2 inhibitor that day.

What about patients with a history of urinary tract infections (UTIs) and HCP or patient anxiety related to this when starting SGLT2 inhibitors?

Stephen J. Greene, MD:
This whole thing regarding UTIs came about because it makes biological sense. You would think that if you are urinating out extra glucose, surely you must have increased risk for UTIs. This does hold true for genital mycotic infection, as there is a small increased absolute risk. But it is not evidence based that SGLT2 inhibitors increase patients’ risk of UTIs. Furthermore, multiple trials found that the placebo arm had a numerically higher chance of a UTI compared with SGLT2 inhibitors. This is just noise that we have to drown out.

We must take treatment with an SGLT2 inhibitor seriously. If we were treating cancer, not giving patients an SGLT2 inhibitor would be like withholding chemotherapy. Now there are some patients with cancer for whom we have to withhold chemotherapy and some patients with HF for whom we have to withhold GDMT. Again, that is the gravity with which you must consider a HF patients’ care. The reality is that patients who already had 3 UTIs are likely going to get a fourth, whether or not we start an SGLT2 inhibitor. We just have to deal with that. UTIs have been around long before SGLT2 inhibitors were added to our toolbox.

How do you manage SGLT2 inhibitors in patients with euglycemic diabetic ketoacidosis?

Midge Bowers, DNP, FNP-BC:
That is important. Without getting a urine sample, HCPs must be able to recognize the signs and symptoms of ketoacidosis (eg, confusion, fatigue). This may sound like advanced HF, but the nausea and abdominal pain help differentiate the 2 diagnoses. If you are suspicious, as nurses do what your gut tells you. We know that we can smell diabetic ketoacidosis, thinking about ketogenic diets and the sweet smell of ketones. Be thoughtful about that. If your gut tells you, “I am concerned,” then phone an HCP and ask, “What do you think we should do?”

What strategies do you have for dealing with patients’ health insurance and lack of coverage for their HF therapy?

Midge Bowers, DNP, FNP-BC:
Something that I have heard as a concern with this is prior authorizations. They are extremely burdensome. If you are fortunate like I am to work with fabulous pharmacists, HF specialists, and pharmacy technicians who meet you and the patient at the point of care, they are critical in addressing this burden. My practice has a pharmacy technician who will come into the room with the patient to discuss prior authorization. We have already had the discussion and looked at what is available in our system. I am also fortunate to work at an academic health center with these resources. For those practicing in smaller communities, I would seek out your community pharmacists. How can they partner with you? You can also find people in the health insurance company who are good liaisons. How can they help you navigate this process and hopefully make the process electronic? I encourage all HCPs to think about the resources that are available. Even if you are a small community hospital, somebody should be able to help (eg, social work case managers and nurse navigators).

Stephen J. Greene, MD:
I agree. That is one of the reasons practically speaking why I love in-hospital initiation for all therapies. At my practice if there are hurdles, the in-hospital setting has more people and resources to help with prior authorizations or other barriers to patient access. What we also do in the hospital is that for every branded HF medication we want to initiate, we price-check it with the patients’ pharmacy before they are discharged. We just want to ensure that there are no surprises with the out-of-pocket cost when the patient gets to the pharmacy.

Your Thoughts
Do you often encounter barriers such as cost or safety concerns that delay or prevent patients from receiving SGLT2 inhibitors? You can get involved in the discussion by answering the poll question and posting a comment below.

Continue

Poll

1.

Do you commonly encounter barriers such as cost or safety concerns that delay or prevent patients from receiving SGLT2 inhibitors?

Submit