Red Flags
- Acute decompensated HF in DM with hyperglycaemic crisis (DKA or HHS) — admit; insulin infusion plus IV diuresis under monitoring[1]
- DM patient with new dyspnoea on minimal exertion + leg oedema — screen for HF with NT-proBNP and echocardiography[1]
- Established HF + diabetes not on SGLT2 inhibitor — significant evidence-care gap; initiate at next visit unless contraindicated[1]
- T2DM with HFrEF on insulin and high-dose sulphonylurea — reassess; both increase HF hospitalisation; switch to SGLT2 inhibitor + GLP-1 RA combination[1]
First-line treatment
Interventions
- Multidisciplinary HF–diabetes care[1]Joint cardiology and endocrinology / diabetology review; structured nurse-led HF clinic where available
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Dapagliflozin or empagliflozin[1] | SGLT2 inhibitor | 10 mg PO once daily | — | First-line in HF + DM regardless of LVEF; cardio-renal protection independent of glycaemic effect |
| Sacubitril/valsartan (ARNI)[1] | ARNI | 49/51 mg PO BD, titrate to 97/103 mg BD | — | First-line in HFrEF + DM; replaces ACE-i where tolerated |
| Bisoprolol or carvedilol[1] | Beta-blocker | Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD | — | Pillar 2 of HFrEF foundation therapy; carvedilol favoured in DM (insulin sensitivity) |
| Spironolactone or eplerenone[1] | MRA | Spironolactone 12.5–50 mg daily | — | Pillar 3 in HFrEF; monitor K+ closely in DM with CKD |
| Semaglutide or dulaglutide[1] | GLP-1 receptor agonist | Semaglutide 0.5–1 mg SC weekly; dulaglutide 1.5 mg SC weekly | — | Add for weight reduction and additional CV/renal benefit; especially valuable in HFpEF + obesity |
| Metformin[1] | Biguanide | 500–1000 mg PO BD | — | Safe in stable HF including HFrEF (counter to legacy concerns); first-line glucose-lowering |
Dapagliflozin or empagliflozin[1]
SGLT2 inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- —
First-line in HF + DM regardless of LVEF; cardio-renal protection independent of glycaemic effect
Sacubitril/valsartan (ARNI)[1]
ARNI
- Adult
- 49/51 mg PO BD, titrate to 97/103 mg BD
- Paediatric
- —
First-line in HFrEF + DM; replaces ACE-i where tolerated
Bisoprolol or carvedilol[1]
Beta-blocker
- Adult
- Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD
- Paediatric
- —
Pillar 2 of HFrEF foundation therapy; carvedilol favoured in DM (insulin sensitivity)
Spironolactone or eplerenone[1]
MRA
- Adult
- Spironolactone 12.5–50 mg daily
- Paediatric
- —
Pillar 3 in HFrEF; monitor K+ closely in DM with CKD
Semaglutide or dulaglutide[1]
GLP-1 receptor agonist
- Adult
- Semaglutide 0.5–1 mg SC weekly; dulaglutide 1.5 mg SC weekly
- Paediatric
- —
Add for weight reduction and additional CV/renal benefit; especially valuable in HFpEF + obesity
Metformin[1]
Biguanide
- Adult
- 500–1000 mg PO BD
- Paediatric
- —
Safe in stable HF including HFrEF (counter to legacy concerns); first-line glucose-lowering
Safety-net
- Continue SGLT2 inhibitor and HF medications during minor illness; pause SGLT2 only during severe vomiting or dehydration to avoid euglycaemic DKA[1]
- Recognise signs of euglycaemic DKA on SGLT2 inhibitor — nausea, abdominal pain, breathlessness despite normal glucose; seek same-day care[1]
- Weigh daily; weight gain >2 kg in 3 days warrants same-day medical review[1]
Referral criteria
Clinical summary
Joint cardiology–diabetology management of patients with concurrent heart failure and type 2 diabetes, prioritising SGLT2 inhibitors as foundation therapy.