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 entitled “New Pharmacological Therapies for Heart Failure.
Q: How have pharmacological treatments for heart failure evolved over the past decade?
Dave Dixon, PharmD: Yes, treatments for heart failure have changed dramatically. Over the past decade, we’ve brought several premium therapeutic options to the market with the angiotensin receptor neprilysin inhibitors, we now have cyclic GMP stimulants, and of course the SGLT2 inhibitors. So it was really great to see that we have a lot more options for treating patients.
Q: Are there any important treatments that pharmacists should be aware of?
Dave Dixon, PharmD: Sure, so I think the biggest thing, like I said, is the SGLT2 inhibitors. First, that’s the data we have in terms of the benefit of heart failure with these therapies regardless of whether a patient has diabetes or not. So you’ll see individuals who are prescribed an SGLT2 inhibitor who don’t have diabetes, and that’s fine because the benefit from a heart failure standpoint seems to be the same whether you have diabetes or not.
We also have ivabradine, which is of course well on the market. It’s a kind of niche medicine in that [it is for] patients who cannot tolerate appropriate doses of beta-blockers or who may have severe lung disease and cannot tolerate a beta-blocker. It is a useful drug, but it only reduces hospitalizations for heart failure, which is still an important result. But it is important to realize that it will not affect mortality.
And vericiguat is the cyclic GMP stimulant that essentially helps relax the muscle and aids in vasodilation. [With that, you’re] are going to see a reduction in the risk of hospitalization for heart failure, but again, no impact on death. So it’s kind of puzzling, you know, prioritizing the drugs and prioritizing the drugs that are going to reduce mortality, and then, in some select situations, add additional therapies for selected patients.
Q: What common side effects should pharmacists be aware of?
Dave Dixon, PharmD: Sure, so with the SGLT2 inhibitors you can see an initial decline in GFR function, and that’s perfectly fine. It’s very similar to what we see when we start an ACE inhibitor or an ARB. And then in the weeks that follow, you’ll see that GFR rise again, and actually we now have good data to show that these drugs have beneficial effects or improvements in kidney function, preventing worsening of kidney function over time. . Blood pressure should be monitored, but the blood pressure reduction is generally modest.
And the other side effect that comes up a lot is the risk of infection. And so what we’re really seeing in both studies that have been done in the field is an increased risk of yeast infections, not necessarily urinary tract infections. The percentages between placebo and the SGLT2 inhibitors in terms of UTI risk are quite similar. But you may see an increased risk of yeast infections, so encourage good hygiene [is important]. In patients with a strong history of yeast infections, it may not be a great class of drugs. And some rare cases have been reported of [diabetic ketoacidosis], but this is extremely rare, something that was initially seen more in patients with type 1 diabetes, and to remind everyone that the SGLT2 inhibitors are not approved in type 1 diabetes. So using those drugs in the right patients is an important part of that.
In terms of sacubitril-valsartan, or Entresto, it has a stronger effect on blood pressure. So if the patient is hypertensive, that could be a good thing. But if that patient is more normotensive or on the low side, you need to be very careful when monitoring blood pressure. And of course kidney function, electrolytes, the things we would normally monitor fall into place. So for those 2 classes, those are some important things.