Safety & efficacy of sodium glucose co-transport 2 (SGLT2) inhibitors in elderly patients with heart failure

Introduction Sodium-glucose cotransporter-2 (SGLT2) inhibitors have emerged as an important therapy in heart failure (HF). However, their safety and efficacy in elderly patients remain underexplored, as this group is often underrepresented in clinical trials. Aim This study aimed to evaluate safety outcomes and describe changes in clinical parameters following initiation of SGLT2 inhibitors in elderly Malaysian patients with heart failure. Methods A multicentre, single-arm, retrospective cohort study was conducted from January to December 2023 at two Malaysian hospitals. Patients aged ≥65 years initiated on empagliflozin or dapagliflozin were included. Safety outcomes assessed were acute kidney injury (AKI), orthostatic hypotension, genitourinary infections, hypoglycemia, volume depletion, and diabetic ketoacidosis (DKA). Efficacy outcomes included changes in left ventricular ejection fraction (LVEF), glycated haemoglobin (HbA1c), estimated glomerular filtration rate (eGFR), and New York Heart Association (NYHA) class. Descriptive statistics and chi-square tests were applied. Results Among 126 patients (median age 70 years), AKI was the most frequent adverse event (12.1%), followed by orthostatic hypotension (3.0%) and urinary tract infection (1.5%). More than half (51.4%) showed LVEF improvement, while 38.2% of diabetic patients achieved better HbA1c control. Renal function improved or was preserved in 40.7%, and 21.4% demonstrated NYHA class improvement. Significant associations were observed between CKD and AKI ( p = 0.003), and between systolic BP ≤140 mmHg and both eGFR improvement ( p = 0.034) and NYHA class improvement ( p = 0.029). Conclusion In this retrospective cohort, SGLT2 inhibitor use was associated with observed improvements in selected cardiometabolic and functional parameters, with acute kidney injury being the most frequently recorded adverse event. However, given the single-arm retrospective design and the absence of a comparator group, these observed changes cannot be definitively attributed to SGLT2 inhibitor therapy alone and should therefore be interpreted as associations rather than evidence of a causal treatment effect. Careful clinical monitoring remains essential, particularly in patients with underlying renal impairment.