Heart Failure - Episode 12
Switching HF Medications in the Inpatient Setting
In this segment, Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; Scott Solomon, MD; and Orly Vardeny, PharmD, MS, debate the potential for switching patients with heart failure to newer medications, such as sacubitril/valsartan, in the inpatient setting.
Peter L. Salgo, MD: Somebody is admitted with, perhaps, decompensated heart failure, and they’re on the regimen that you said should be switched. Do you switch them in the hospital?
Orly Vardeny, PharmD, MS: You can.
Peter L. Salgo, MD: That’s not what I asked. Do you? Should you?
Orly Vardeny, PharmD, MS: You should, only at the point where they are no longer acutely decompensated.
Peter L. Salgo, MD: OK.
Orly Vardeny, PharmD, MS: So, somewhere during the hospitalization, if the patient goes from becoming acute to chronic, and there’s no perfect line in the sand, it could be an eyeball test from the door; or when that patient is no longer acutely decompensated, this is a good opportunity to potentially switch—especially if you may have 36 hours left in the hospitalization, it’s a good time to wash out the ACE (angiotensin-converting enzyme) inhibitor, potentially.
Sheryl Chow, PharmD, BCPS: I would also add that at the time of hospitalization, we can also draw labs and make sure the patient is stable when you’re initiating Entresto or the ARNI (angiotensin receptor neprilysin inhibitor). There was actually a study that showed medications that are continued on just prior to discharge are those that patients will continue to the outpatient setting. So, we want to make sure that we tune up those medications just prior to discharge, before sending them out.
Scott Solomon, MD: I think that’s a great strategy. However, I have to be honest and say this wasn’t what we studied in PARADIGM, and there’s no clinical trials data yet. There is a trial going on, currently, called PIONEER, in which patients are being randomly assigned to either the ARNI or enalapril after they were hospitalized and then became stable. So, there will be data on this, but, in the meantime, I think that as clinicians, we can use our judgment if a patient has been stabilized. If we feel they’re about to go home, or are within a few days of going home, I personally think that’s a great time to start a new medication.
Akshay Desai, MD: Let me push back a little bit though, because I think 1 of the challenges is that we’ve talked about a lot of medications that patients have to go home on. The hospital stay is an attractive time to make some of those changes, but we also have to be sure that when patients leave the hospital, there’s adequate surveillance of the potential for adverse effects. And the fact is, not every patient can get every medicine we can deliver to them in the hospital. I think, particularly for some of these newer medications, one of the questions is, what’s the cost of the point of care to the patient which may be different for different payers? One of the challenges with starting medicines in the hospital (and this is not peculiar to heart failure), is that not all those medicines are uniformly available to every patient in the outpatient setting.
Scott Solomon, MD: So, Peter, Akshay just used 2 words that we’ve not used before in this program: adverse effects. We talked about the efficacy associated with sacubitril/valsartan, and we hinted that this is a medicine that is a potent blood pressure lowering drug. And so, hypotension is something we have to worry about. But it’s also important to note that there are other adverse effects that people get when they’re either put on RAAS (renin angiotensin aldosterone system) inhibitors, and this includes renal dysfunction and hyperkalemia. There was actually less renal dysfunction and less hyperkalemia in the sacubitril/valsartan arm in PARADIGM than in the enalapril arm, which I think is very important. It’s especially important if you also want to use a mineralocorticoid receptor antagonist because, as we know, those drugs increase the risk of hyperkalemia, for certain. Akshay has actually published a paper showing that if you’re on both a mineralocorticoid receptor antagonist and sacubitril/valsartan, you have a lower risk of hyperkalemia than if you’re on a mineralocorticoid receptor antagonist and enalapril. And you have a better outcome to boot.
Peter L. Salgo, MD: Are physicians in the community sufficiently aware of these new drugs (of the ARNIs, for example), that you feel comfortable sending patients out on them to the care of a primary care doctor?
Orly Vardeny, PharmD, MS: I feel like we have to do our homework before we send patients out.
Peter L. Salgo, MD: What does that mean?
Orly Vardeny, PharmD, MS: Akshay mentioned making sure that the medication can be paid for once that patient leaves. I think that’s number 1 when starting a new medication. When they leave, is their insurance going to cover it, or are they going to be able to afford to pay for it? And then number 2 is that when we’re sending the patient out the door, who’s catching them on the other side? Is there a plan for immediate follow up within the first 2 or 3 days, or an immediate in-person meeting within a week? That communication needs to be in place between us, in the hospital, and whoever is managing in the community.
Peter L. Salgo, MD: So, this is the classic transition of care. This is, “You’re in our care, the specialists care.” Now, they’re going out and somebody has to shepherd this. Who does that?
Orly Vardeny, PharmD, MS: Correct. We have to, together. There are people that do this as part of their jobs (in terms of discharge planners). But as clinicians, it’s our responsibility to make sure that they land on their feet on the other side.
Sheryl Chow, PharmD, BCPS: In fact, a lot of hospitals are, in fact, paying for nurse practitioners and pharmacists to meet in the clinic 1 week after discharge, for these patients, to make sure they’re followed up on with cardiology and their PMD. They basically are paid to reduce 30-day readmission rates.