Fixed-Dose Versus Off-Label Combination of Isosorbide Dinitrate Plus Hydralazine Hydrochloride: Retrospective Propensity-Matched Analysis in Black Medicare Patients with Heart Failure

Costs of care and financial hardship among patients with heart failure

With the implementation of new therapies, more patients are living with heart failure (HF) as a chronic condition. Alongside these advances, out-of-pocket (OOP) medical costs have increased, and patients experience significant financial burden. Despite increasing interest in understanding and mitigating financial burdens, there is a relative paucity of data specific to HF. Here, we explore financial hardship in HF from the patient perspective, including estimated OOP costs for guideline-directed medical therapy for HF with reduced ejection fraction, hospitalizations, and total direct medical costs, as well as the consequences of high OOP costs. Studies estimate that high OOP costs are common in HF, and a large proportion are related to prescription drugs. Subsequently, the effects on patients can lead to worsening adherence, delayed care, and poor outcomes, leading to a financial toxicity spiral. Further, we summarize patients' cost preferences and outline future research that is needed to develop evidence-based solutions to reduce costs in HF.

Effectiveness of Single-Tablet Combination Therapy in Improving Adherence and Persistence and the Relation to Clinical and Economic Outcomes

Background: Single-tablet combination therapies (STCTs) combine multiple drugs into one formulation, making drug administration more convenient for patients. STCTs were developed to address concerns with treatment adherence and persistence, but the impact of STCT use is not fully understood across indications. Objectives: We conducted a systematic literature review (SLR) to examine STCT-associated outcomes across 4 evidence domains: clinical trials, real-world evidence (RWE), health-related quality of life (HRQoL) studies, and economic evaluations. Methods: Four SLRs were conducted across the aforementioned domains. Included studies compared STCTs as well as fixed-dose combinations ([FDCs] of non-tablet formulations) with the equivalent active compounds and doses in loose-dose combinations (LDCs). Original research articles were included; case reports, case series, and non-English-language sources were excluded. Databases searched included EconLit, Embase, and Ovid MEDLINE® ALL. Two independent reviewers assessed relevant studies and extracted data. Conflicts were resolved with a third reviewer or consensus-based discussion. Results: In all, 109 studies were identified; 27 studies were identified in more than one SLR. Treatment adherence was significantly higher in patients receiving FDCs vs LDCs in 12 of 13 RWE studies and 3 of 13 clinical trials. All 18 RWE studies reported higher persistence with FDCs. In RWE studies examining clinical outcomes (n = 17), 14 reported positive findings with FDCs, including a reduced need for add-on medication, blood pressure control, and improved hemoglobin A1C. HRQoL studies generally reported numerical improvements with STCTs or similarities between STCTs and LDCs. Economic outcomes favored STCT use. All 6 cost-effectiveness or cost-utility analyses found FDCs were less expensive and more efficacious than LDCs. Four budget impact models found that STCTs were associated with cost savings. Medical costs and healthcare resource use were generally lower with FDCs than with LDCs. Discussion: Evidence from RWE and economic studies strongly favored STCT use, while clinical trials and HRQoL studies primarily reported similarity between STCTs and LDCs. This may be due to clinical trial procedures aimed at maximizing adherence and HRQoL measures that are not designed to evaluate drug administration. Conclusions: Our findings highlight the value of STCTs for improving patient adherence, persistence, and clinical outcomes while also offering economic advantages.

Cardiologists' Perspectives on BiDil and the Use of Race in Drug Prescribing

OBJECTIVES

We explored cardiologists' attitudes and prescribing patterns specific to the use of generic isosorbide dinitrate and hydralazine hydrochloride, and the fixed-dose patented drug, BiDil.

BACKGROUND

Since the Food and Drug Administration approved BiDil in 2005 with an indication for self-identified black patients, disagreement about the appropriateness of race-based drugs has intensified and led to calls for providers and researchers to abandon race-based delimitations. This paper reports empirical evidence of cardiologists' views on BiDil's race-based indication and their ongoing inertia with respect to the debate about BiDil.

METHODS

We conducted a 2010 cross-sectional online survey of members of the Association of Black Cardiologists.

RESULTS

Fifty-nine cardiologists responded to the survey. Most participants (62.7%) prescribed BiDil to their patients. More than 40% of respondents did not prescribe BiDil to any non-African Americans. When considering whether to prescribe BiDil, a patient's race determined by physician assessment was the third most important factor considered by participants. The majority of participants (72.7%) selected symptoms as the most important factor. Most participants (59.2%) perceived race as defining biologically distinct individuals. Respondents prescribed BiDil more often to African American patients than non-African American patients. However, they prescribed the generic components that makeup BiDil to African Americans and non-African American patients similarly.

CONCLUSIONS

The survey provides useful findings that, when viewed within the context of ongoing debates about race-based medicine, show little progress toward appropriately utilizing BiDil to maximize health outcomes, yet, might inform the development of practical and effective guidelines concerning the use of race in medicine.

Underuse of hydralazine and isosorbide dinitrate for heart failure in patients of African ancestry: a cross-European survey

Aims

Population data indicate that one in 25 persons of African ancestry has heart failure, a condition with relatively high mortality of around 50% in 5 years. Combined hydralazine and isosorbide dinitrate added to conventional therapy in African ancestry patients with heart failure and reduced ejection fraction improves quality of life and reduces the rate of first hospitalization for heart failure by 33% and annual mortality by 43%. The objectives of this study were to quantify the use of this guideline‐recommended therapy in Europe and the potential effect of implementation gaps on mortality.

Methods and results

Prescription drug registration and utilization databases and population statistics were analysed in a cross‐European survey without language restriction. Main outcomes were the number of unique patients prescribed the fixed combination hydralazine–isosorbide dinitrate (primary) or both drugs (secondary) in Europe in 2015, and the excess mortality related to prescribing practices was estimated. The survey indicates that around 12 million persons of African ancestry live in Europe. It is estimated that 480 000 persons of this population group have heart failure, with 120 000 eligible for hydralazine and isosorbide dinitrate therapy. However, single‐pill hydralazine–isosorbide dinitrate is not authorized and therefore not dispensed in Europe in 2015. Out of the 25 European nations surveyed, the UK and the Netherlands are the only countries with major African ancestry populations where both hydralazine and isosorbide dinitrate are available for oral use, aside Norway, Sweden, and Finland. Hydralazine and isosorbide dinitrate are prescribed to <500 European patients in 2015. Thus, despite the recommendations of the European Society of Cardiology, the large majority of African‐European patients with heart failure do not receive this drug combination, potentially resulting in 4800 to 5800 excess deaths yearly.

Conclusions

The life‐saving, guideline‐recommended, adjunctive therapy for heart failure in African ancestry patients with hydralazine and isosorbide dinitrate is rarely used in Europe. This major evidence‐practice gap should urgently be overcome to reduce excess mortality in African‐European patients with heart failure.

Practical and Scalable Synthesis of Isosorbide Derivatives Containing an Active Amine Group

The synthesis of two derivatives of isosorbide containing an amine group, 6-amino-6-deoxy- O-3-methyl-isosorbide and 6-amino- O-3-benzoyl-6-deoxy-isosorbide, has been achieved. These compounds provide scope for the introduction of additional groups via their amino functions and thereby can provide access to novel isosorbide derivatives that can be screened for biological activity.