Pharmacists Play Essential Roles in New Pharmacologic Therapies for Heart Failure

Pharmacy Times spoke with Dave Dixon, PharmD, an associate professor and department chair at the Virginia Commonwealth University School of Pharmacy, to learn more about his presentation titled “New Pharmacologic Therapies for Heart Failure.

Q: How have pharmacologic treatments for heart failure evolved over the last decade?

Dave Dixon, PharmD: Yes, heart failure treatments have changed dramatically. Over the past decade, we've had multiple first class therapeutic options come to market with the angiotensin receptor neprilysin inhibitors, we now have a cyclic GMP stimulating agents and, of course, the SGLT2 inhibitors, as well. So, it's really been fantastic to see that we have many more options to treat patients.

Q: Are there any key treatments that pharmacists should be aware of?

Dave Dixon, PharmD: Sure, so I think the biggest thing, as I’ve mentioned, is the SGLT2 inhibitors. First is that the data we have in terms of heart failure benefit with these therapies is irrespective of whether or not a patient has diabetes. So, you will see individuals that are prescribed an SGLT2 inhibitor that don't have diabetes, and it's perfectly fine because the benefit from a heart failure standpoint appears to be the same whether you have diabetes or not.

We also have ivabradine, which is obviously on the market is well. It is kind of a niche drug in that [it is for] patients who aren't able to tolerate appropriate doses of beta blockers or maybe have severe pulmonary disease and can’t tolerate a beta blocker. It’s a useful agent but it only reduces heart failure hospitalizations, which is still an important outcome. But it's important to realize that it's not going to impact mortality.

And vericiguat is the cyclic GMP stimulating agent that essentially helps relax the muscle and helps with vasodilation. [With that, you’re] going to see a reduction in the risk of heart failure hospitalizations, but again, no impact on fatality. So, it's kind of piecing together, you know, the medications and prioritizing the medications that are going to reduce mortality, and then in some select situations, adding on extra therapies for select patients.

Q: What common adverse effects should pharmacists be aware of?

Dave Dixon, PharmD: Sure, so with the SGLT2 inhibitors, you can see an initial decline in the GFR function, and that’s perfectly okay. It's very similar to what we see when we initiate an ACE inhibitor or an ARB. And then in the weeks that follow, you will see that GFR kind of increase again, and actually now we have good data to show that these drugs have favorable impacts or improvements in kidney function, prevention of worsening of kidney function over time. Blood pressure should be monitored, but the blood pressure reduction generally is modest.

And the other side effect that comes up a lot is the risk of infection. And so really what we see in both the studies that have been done in practice is an increase in risk of fungal infections, not necessarily urinary tract infections. The rates between placebo and the SGLT2 inhibitors in terms of UTI risk is pretty similar. But you may see an increased risk of fungal infection, so encouraging good hygiene [is important]. In patients with a strong history of fungal infections, it maybe is not a great class of drugs. And there been some rare case reports of [diabetic ketoacidosis], but this is extremely rare, something that was initially seen more with patients that had type 1 diabetes, and just to remind everyone that the SGLT2 inhibitors are not approved in type 1 diabetes. So, utilizing those drugs in the right patients is kind of a key part of that.

In terms of the sacubitril-valsartan, or Entresto, it does have a more robust effect on blood pressure. So, if the patient's hypertensive, that could be a great thing. But if that patient's more normotensive or on the low end, you have to be very careful in monitoring blood pressure. And of course, kidney function, electrolytes, the things that we would normally monitor kind of fall into place. So, for those 2 classes, those are some key things.