Management of Diabetes in Heart Failure Patients

Primary Medications to Avoid

The American Heart Association recommends that Thiazolidinediones (TZDs) are contraindicated in all patients with established heart failure (HF), regardless of functional class, due to increased risk of fluid retention and HF events 1, 2, 3, 4
The European Society of Cardiology states that both rosiglitazone and pioglitazone cause fluid retention through increased renal sodium reabsorption, leading to volume expansion and HF events 1, 2, 5
The American College of Cardiology recommends that TZDs increase HF risk even in patients without baseline HF, making them inappropriate for diabetic patients at high risk for developing HF 1, 3, 4
The European Heart Journal advises that saxagliptin is not recommended in patients with HF or at high risk of HF due to increased HF hospitalization risk 3, 4, 6

The American Heart Association suggests that GLP-1 Receptor Agonists should be avoided in patients with recent HF decompensation, but may be used in stable HF patients as they show neutral effects on HF hospitalization in cardiovascular outcomes trials 1, 2
The American College of Cardiology recommends that insulin be used with caution due to associations with weight gain, hypoglycemia risk, and observational data suggesting increased mortality in HF patients 1, 7

The European Society of Cardiology recommends that SGLT-2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) are preferred to decrease HF hospitalization risk 1, 3, 4, 6
The American Heart Association suggests that metformin is preferred if eGFR >30 mL/min/1.73 m² 1, 6

The American College of Cardiology recommends that for patients with established HF, immediately discontinue TZDs if currently prescribed, and initiate or continue SGLT-2 inhibitors as first-line diabetes therapy 1, 8
The European Heart Journal advises that for patients at high risk of HF, do not initiate TZDs, prefer SGLT-2 inhibitors and metformin, and avoid saxagliptin 1, 3, 4