Verquvo Is A Promising New Heart Failure Treatment

Heart failure (HF) is a chronic condition in which the heart cannot pump adequate blood to the body.

This results in the heart not being able to pump enough blood (systolic) and fill (diastolic) appropriately. A condition such as this can create many problems for patients who suffer from HF, such as continuous shortness of breath, fatigue, rapid heartbeat, and swollen legs.

Treatment options for HF include dietary measures, as well as medications according to national guidelines. It is important for patients with HF to be diagnosed correctly and early. Upon diagnosis, it is crucial that these patients are prescribed the correct medications with the optimal dosing to prevent the HF from advancing to higher stages. The stages of this disease per the American College of Cardiology are stage A (risk for heart failure), stage B (heart failure no symptoms), stage C (symptomatic heart failure) and stage D (End-stage heart failure).¹

When it comes to the disease severity, the categories include²:

• Preserved ejection fraction 50%
• Mildly reduced 40% to 49%
• Moderately reduced 30% to 39%
• Severely reduced ˂ 30%
• HF improved ejection fraction (HFrEF)

When it comes to treatment options, there are few first-line drug classifications that are prescribed. These include angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), and beta blockers. For class II-IV HF with GFR > 30 ml, the addition of Aldosterone blockers may also be an option to control the HF. For Black patients who are symptomatic, using long-acting nitrates/hydralazine may also be beneficial. If patients experience volume overload, they can also be treated with loop diuretics. ARBs can be used if ACE inhibitors are not well-tolerated.²

It is important to note that these patients should be started on the correct medications mentioned above and be titrated to goal, so that they can maximally benefit from these medications and their effects. As far as ARNI classification goes, Entresto (sacubitril/valsartan) has demonstrated improved function over the use of ACE inhibitors, especially in populations with left ventricle ejection fraction < 40% and on maximally tolerated beta blocker doses. The doses for Entresto may include 24mg/26mg, 49mg/51mg, 97mg/103mg, with the goal dose of 97mg/103mg twice daily.

When it comes to beta blockers, the most effective choices are bisoprolol, carvedilol, and metoprolol succinate extended release. The providers may titrate these medications every 2 weeks as tolerated by patients. For aldosterone blockers, options include eplerenone and spironolactone (aldactone). Kidney function should be monitored accordingly to ensure that patients receive the correct dose.

When it comes to patients with HF with or without diabetes, sodium-glucose co-transporter-2inhibitors (SGLT2) can also be used to decrease HF-associated hospitalizations. Canagliflozin, dapagliflozin, and empagliflozin are all FDA-approved to reduce congestive HF risk in diabetes patients. The FDA also approved Dapagliflozin to be used in HFrEF with or without diabetes. Empagliflozin has recently showed the same benefits for HFrEF patients, with or without diabetes, whereas sotogliflozin trials have shown similar benefits, though it has not been approved by the FDA.³

Verquvo (vericiguat), from Merck pharma, which the FDA approved on January 20, 2021, is the newest addition for treating HF. The drug is indicated to reduce the risk of cardiovascular death, HF hospitalizations, or the need for outpatient intravenous diuretics. It is recommended in adults with symptomatic chronic HF and ejection fraction less than 45%. Verquvo is a stimulator of soluble guanylate cyclase, an important enzyme in the nitric oxide signaling pathway. This drug can augment the level of intracellular cGMP, leading to smooth muscle relaxation and vasodilation. Verquvo comes in 3 dosages: 2.5, 5, and 10 mg and is recommended to be taken by mouth with food. The dose should be titrated every 2 weeks to reach the target dose of 10 mg once daily, as tolerated by the patient. Adverse effects may include anemia and low blood pressure.⁴

With better staging of the disease and newer treatment options for HF, such as Verquvo and SGLT2 inhibitors, the path for a better quality of life for patients who suffer from the disease is brighter. Providers must diagnose these patients and start them on medications as soon as possible. Encourage patients with HR to comply with their diet and medications regiments to reach their treatment goals and have a better quality of life.

Saro Arakelians, PharmD, is vice president of pharmacy operations at a pharmacy in the Los Angeles, California, area.

References

1. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary.J Heart Lung Transplant. 2002;21(2):189-203. doi:10.1016/s1053-2498(01)00776-8.
2. Writing Committee, Maddox TM, Januzzi Jr JL, et al. 2021 Update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee.J Am Coll Cardiol. 2021;77(6):772-810. doi:10.1016/j.jacc.2020.11.022
3. Murphy SP, Ibrahim NE, Januzzi Jr JL. Heart failure with reduced ejection fraction.JAMA. 2020;324(5):488-504. doi:10.1001/jama.2020.10262
4. Verquvo. Prescribing information. Merck; 2021. Accessed April 29, 2021. https://www.merck.com/product/usa/pi_circulars/v/verquvo/verquvo_pi.pdf