Quiz

Case scenario

Malcolm (68 years old, male) visits your pharmacy with a new prescription for sacubitril/valsartan. He mentions he has recently been diagnosed with heart failure with reduced ejection fraction (HFrEF). You review his records and confirm he is still taking metformin/sitagliptin for type 2 diabetes.

Malcolm explains that he has taken this for many years, and that his general practitioner has advised him that his blood glucose control needs to be better. He expresses frustration that the shortness of breath from his heart failure limits his ability to exercise and improve his diabetes. Malcolm hopes that starting this new medicine will improve this.

Recognising the benefits of an SGLT2i for both Malcolm’s heart failure and diabetes, you discuss the option of adding an SGLT2i to his regimen, and the potential benefits and risks. Malcolm explains that his main priority is to get his heart failure symptoms under control so that he can play with his grandchildren and exercise comfortably.

At Malcolms request, you contact his GP, and it is agreed to commence empagliflozin 10 mg daily (after ensuring his eGFR is appropriate). This intervention may help to reduce Malcolm’s risk of death from heart failure, improve his quality of life, delay disease progression, improve diabetic control and assist in helping Malcolm achieve his health goals.

Multiple choice questions

1. On a patient’s home medicine review referral, you see that they have ‘systolic heart failure’ and they have a recent left ventricular ejection fraction (LVEF) of 39%. Which ONE of the following is the correct classification of this patient’s heart failure?

1. Heart failure with reduced ejection fraction (HFrEF)
2. Heart failure with preserved ejection fraction (HFpEF)
3. Heart failure with mildly reduced ejection fraction (HFmrEF)
4. Heart failure with diastolic dysfunction.

2. Which ONE of the following accurately lists the four classes of medicines which comprise guideline directed medical therapy for HFrEF?

1. A beta-blocker, an aldosterone agonist, a diuretic and a SGLT2i.
2. A mineralocorticoid receptor antagonist, a beta-blocker, a renin angiotensin system inhibitor and an ACE inhibitor.
3. A SGLT2i, a beta-blocker, a mineralocorticoid receptor antagonist and a renin angiotensin system inhibitor.
4. A beta-blocker, a diuretic, a mineralocorticoid receptor antagonist and an ACE inhibitor.

3. A local GP asks you about the appropriateness of commencing empagliflozin for her patient with type 2 diabetes with an eGFR of 25mL/min. The patient has recently been diagnosed with heart failure with preserved ejection fraction. Which ONE of the following is the MOST appropriate advice to provide?

1. Explain that dapagliflozin would be a more appropriate option for this patient due to their eGFR.
2. Explain that glucose-lowering ability is likely absent at this eGFR, however it can be commenced as part of HFpEF management if eGFR >20mL/min.
3. Explain the evidence does not support an improvement in mortality for HFpEF patients with SGLT2i’s and there is no benefit in prescribing.
4. Explain it may be commenced for its heart failure indication with this eGFR (if otherwise appropriate) however its cardiovascular benefits are only seen in non-diabetic patients.

4. Tom, a long-term heart failure patient mentions during a medication review that his GP tried to prescribe dapagliflozin for him, but he read on the internet that it was used for diabetes and could cause genital infections and did not commence it. Which ONE of the following is the MOST appropriate advice to provide Tom?

1. He should return for a HbA1c and blood glucose monitoring to confirm his diabetic status before starting.
2. Dapagliflozin should only be used if Tom has HFrEF.
3. Adverse effects of dapagliflozin include genital infections which cannot be prevented.
4. SGLTi’s have cardiovascular and renal benefits, and these are irrespective of diabetic status.