SGLT2 Inhibitors in Heart Failure Patients with Concomitant Liver Cirrhosis

Patient Selection Based on Cirrhosis Severity

SGLT2 inhibitors can be used in heart failure patients with compensated cirrhosis (Child-Pugh A and B), but should be avoided in decompensated cirrhosis due to risks of hemodynamic instability and acute kidney injury. 1
The American Diabetes Association recommends SGLT2 inhibitors specifically in Child-Pugh class A and B cirrhosis, distinguishing them from GLP-1 receptor agonists which are only recommended in Child-Pugh A. 1
SGLT2 inhibitors are appropriate for patients with Child-Pugh class A and B cirrhosis who have heart failure, with the strongest evidence supporting use in Child-Pugh A cirrhosis. 1

SGLT2 inhibitors are Class 1 recommendations for HFrEF patients to reduce cardiovascular death and heart failure hospitalization, irrespective of diabetes status. 2, 3
The 2024 ACC/AHA guidelines designate SGLT2 inhibitor prescription as a quality measure for all HFrEF patients unless contraindicated. 2
Medical exceptions include eGFR <20 mL/min/1.73 m², type 1 diabetes, and documented intolerance. 2
SGLT2 inhibitors are Class 2a recommendations for HFmrEF and HFpEF to decrease heart failure hospitalizations and cardiovascular mortality. 3
These recommendations apply irrespective of diabetes status. 4, 5

Child-Pugh A or B with compensated cirrhosis → Proceed to Step 2 1
Decompensated cirrhosis → Do not initiate SGLT2 inhibitor 1
LVEF ≤40% → Strong Class 1 indication 2, 3
LVEF >40% with NYHA Class II-IV symptoms → Class 2a indication 3
eGFR <20 mL/min/1.73 m² → Contraindicated 2
Type 1 diabetes → Contraindicated 2
Active decompensation (new ascites, encephalopathy, variceal bleeding) → Defer initiation 1
Frequent monitoring of organ function including liver, kidney, and hemodynamic parameters is recommended, as both cirrhosis and heart failure are dynamic conditions. 1