2026 Southeastern Residency Conference

Authors:
Austin Seawright, Natalie Giddens, Marci Swanson, Alexis Pruitt

Purpose:
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular benefits in patients with heart failure, regardless of diabetes status. Despite strong guideline recommendations, prescribing rates remain suboptimal at the Carl Vinson VA Medical Center. This quality improvement project aims to optimize the use of SGLT2 inhibitors in Veterans with heart failure by identifying eligible patients, initiating therapy when appropriate, and improving adherence to guideline-directed medical therapy.

Methods:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization. Exclusion criteria included: active prescription for an SGLT2 inhibitor, documented severe allergy to an SGLT2 inhibitor, type 1 diabetes mellitus, history of diabetic ketoacidosis, genitourinary infections, eGFR <20 mL/min/1.73m², age ≥90 years, or deceased status. Chart review was conducted to verify eligibility, evaluate contraindications, and identify potential clinical considerations influencing initiation. Eligible Veterans or their providers were contacted via a multimodal approach to provide education regarding benefits and assess interest in therapy. Those agreeable were referred to a pharmacist‑led clinic for further evaluation and potential initiation of empagliflozin, the VA formulary‑preferred agent. Baseline laboratory values, renal function, blood pressure, and medication history were reviewed prior to initiation. Follow‑up included monitoring for tolerability, adverse reactions, adherence, and continued appropriateness of therapy.

Results:
Of 396 Veterans identified, 339 met inclusion criteria. A total of 83 Veterans (24.5%) initiated an SGLT2 inhibitor following outreach and clinical evaluation. The most common reasons for non‑initiation included urinary incontinence (30.5%), predominantly outside care (12.5%), and inability to reach patients (10.2%). Seven adverse drug reactions were reported, most commonly dizziness or renal function decline, with only two events leading to discontinuation. Seven Veterans discontinued therapy. Five discontinuations were attributed to ADRs, while two Veterans self‑discontinued due to concerns regarding polypharmacy. Initiation rates increased across heart failure classifications.

Conclusions:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization.