New Quadruple Therapy Shows Promise, But More Data are Needed

December 4, 2019 – In a recent editorial in Circulation, the DCRI’s Michael Felker, MD, raises questions that the heart failure field should consider in light of new results from the DAPA-HF trial.

Recent results from DAPA-HF may be moving the treatment of heart failure into a new era of “quadruple therapy,” but further studies are needed to understand the benefits of using an SGLT2 inhibitor such as dapagliflozin in addition the guideline-recommended triple therapy, wrote the DCRI’s Michael Felker, MD, in a recent editorial in Circulation.

The editorial, which accompanied new results published from DAPA-HF on quality of life and the impact of patient age, points to the importance of these findings in understanding the role of dapagliflozin in patients with heart failure with reduced ejection fraction regardless of diabetes status. SGLT2 inhibitors had previously been found to prevent heart failure in patients with Type 2 diabetes.

Michael Felker, MD

More studies will need to be conducted, Felker notes, to determine whether these benefits are specific to dapagliflozin or whether they extend to the entire class of SGLT2 inhibitors. Additional study of the specific mechanisms that result in the benefits of the drug is also needed. Implementation of this new quadruple therapy will also be challenging in a landscape in which it is already difficult to get patients on guideline-directed medical therapy, especially in at-risk subsets of patients like older patients.

Felker points to two papers published in the same issue of Circulation that help provide some insight to answer these questions. A paper by Kosiborod et al. found that dapagliflozin resulted in an improvement in health-related quality of life that was sustained over six months. Another paper by Martinez et al. reports on the effects of dapagliflozin stratified by age group. Although adults over 75 were more likely to have adverse events, the study saw similar rates between the intervention group and the control group, suggesting that dapagliflozin is well tolerated even in older patients.

Although the results from DAPA-HF are promising, more data are needed to confirm the benefit of dapagliflozin and other SGLT2 inhibitors in the treatment of heart failure, Felker writes. This is especially important in other subsets of the population, such as patients with heart failure with preserved ejection fraction. In addition, physicians will have to focus on implementing these new findings into clinical practice to provide the best care for patients with heart failure.