Heart Failure and Related Conditions

Patient Selection Criteria

• Patients with symptomatic heart failure of any class should be considered for treatment, as recommended by the American Heart Association 1
• Patients with active liver disease should not be considered for certain treatments due to potential hepatotoxicity, as recommended by the American Diabetes Association 2
• Patients at high risk for heart failure development, including those with a history of coronary artery disease, should be considered for treatment, according to the American Heart Association and American College of Cardiology 1, 3
• Patients receiving insulin therapy are at increased risk of fluid retention, as noted by the American College of Cardiology 3

Treatment Considerations

• Pioglitazone should not be used in patients with active liver disease, elevated liver enzymes, NYHA Class III or IV cardiac status, pre-existing heart failure, active bladder cancer, or significant liver disease, due to potential hepatotoxicity and heart failure exacerbation, as recommended by the American Diabetes Association, American College of Cardiology, European Heart Journal guidelines, and European Society of Cardiology 4, 5, 6, 2
• DPP-4 inhibitors, such as saxagliptin and alogliptin, should be used with caution due to potential increased heart failure risk, as suggested by the American College of Cardiology 3
• Alternative diabetes medications, such as metformin (if eGFR >30 mL/min/1.73m²), SGLT-2 inhibitors, or GLP-1 receptor agonists, can help manage diabetes without worsening heart failure, as recommended by the American Diabetes Association, European Society of Cardiology, and American Heart Association 5, 6, 7
• The following populations have specific recommendations:

Monitoring and Follow-up

• Monitor for fluid status improvement, signs/symptoms of heart failure (shortness of breath, rapid weight gain, edema), and kidney function, especially if eGFR <45 mL/min/1.73m², as recommended by the American Heart Association, European Heart Journal guidelines, and National Kidney Foundation 4, 8
• Check HbA1c after 3 months of medication adjustment, as recommended by the American Diabetes Association 7
• Consider adding a GLP-1 receptor agonist instead of pioglitazone, especially if the patient has established cardiovascular disease, as recommended by the American Heart Association and American College of Cardiology 7, 8
• Regular monitoring for signs and symptoms of heart failure, kidney function, genital mycotic infections, weight changes, and glycemic control is necessary when using combination therapy, as recommended by the American Heart Association and American College of Cardiology 4