1
|
Wang L, Liang B, Teng Y, Zhang C, Zhang Y, Zhang Z, Zhang A, Dong S, Fan H. Assessment of drug-drug interaction of dapagliflozin with LCZ696 based on an LC-MS/MS method. Biomed Chromatogr 2024; 38:e5924. [PMID: 38922973 DOI: 10.1002/bmc.5924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 06/28/2024]
Abstract
The co-administration of dapagliflozin (DPF) and sacubitril/valsartan (LCZ696) has emerged as a promising therapeutic approach for managing heart failure. Given that DPF and LCZ696 are substrates for P-glycoprotein, there is a plausible potential for drug-drug interactions when administered concomitantly. To investigate the pharmacokinetic changes when these drugs are co-administered, we have established and validated a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method capable of simultaneously detecting DPF, LBQ657 (the active metabolite of sacubitril) and valsartan in rat plasma. This method has demonstrated selectivity, sensitivity, and accuracy. Drug-drug interactions were examined by the LC-MS/MS method. The mechanisms were investigated using everted intestinal sac models and Caco-2 cells. The results showed that DPF significantly increased the area under the curve (AUC(0-t)) (3,563.3 ± 651.7 vs. 7,146.5 ± 1,714.9 h μg/L) of LBQ657 (the active metabolite of sacubitril) and the AUC(0-t) (24,022.4 ± 6,774.3 vs. 55,728.3 ± 32,446.3 h μg/L) of valsartan after oral co-administration. Dapagliflozin significantly increased the amount of LBQ657 and valsartan in intestinal sacs by 1- and 1.25-fold at 2.25 h. Caco-2 cell uptake studies confirmed that P-glycoprotein is the transporter involved in this interaction. This finding enhances the understanding of drug-drug interactions in the treatment of heart failure and provides a guidence for clinical therapy.
Collapse
Affiliation(s)
- Lingmei Wang
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| | - Bohan Liang
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| | - Yunhua Teng
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| | - Chenchen Zhang
- Tianjin University of Traditional Chinese Medicine, Tianjin, People's Republic of China
| | - Yufeng Zhang
- Tianjin University of Traditional Chinese Medicine, Tianjin, People's Republic of China
| | - Zhidan Zhang
- Tianjin Institute of Industrial Biotechnology, Chinese Academy of Sciences, Tianjin, People's Republic of China
| | - Aijie Zhang
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| | - Shiqi Dong
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| | - Huirong Fan
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, People's Republic of China
| |
Collapse
|
2
|
Feinman J, Barghash M. One Size Does Not Fit All: Tailoring Sacubitril/Valsartan in Mid-Range and Preserved Ejection Fraction Heart Failure. J Card Fail 2024:S1071-9164(24)00358-0. [PMID: 39187063 DOI: 10.1016/j.cardfail.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/10/2024] [Indexed: 08/28/2024]
Affiliation(s)
- Jason Feinman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Maya Barghash
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
3
|
Davogustto G, Wells QS, Harrell FE, Greene SJ, Roden DM, Stevenson LW. Impact of Insurance Status and Region on Angiotensin Receptor-Neprilysin Inhibitor Prescription During Heart Failure Hospitalizations. JACC. HEART FAILURE 2024; 12:864-875. [PMID: 38639698 DOI: 10.1016/j.jchf.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND An angiotensin receptor-neprilysin inhibitor (ARNI) is the preferred renin-angiotensin system (RAS) inhibitor for heart failure with reduced ejection fraction (HFrEF). Among eligible patients, insurance status and prescriber concern regarding out-of-pocket costs may constrain early initiation of ARNI and other new therapies. OBJECTIVES In this study, the authors sought to evaluate the association of insurance and other social determinants of health with ARNI initiation at discharge from HFrEF hospitalization. METHODS The authors analyzed ARNI initiation from January 2017 to June 2020 among patients with HFrEF eligible to receive RAS inhibitor at discharge from hospitals in the Get With The Guidelines-Heart Failure registry. The primary outcome was the proportion of ARNI prescription at discharge among those prescribed RAS inhibitor who were not on ARNI on admission. A logistic regression model was used to determine the association of insurance status, U.S. region, and their interaction, as well as self-reported race, with ARNI initiation at discharge. RESULTS From 42,766 admissions, 24,904 were excluded for absolute or relative contraindications to RAS inhibitors. RAS inhibitors were prescribed for 16,817 (94.2%) of remaining discharges, for which ARNI was prescribed in 1,640 (9.8%). Self-reported Black patients were less likely to be initiated on ARNI compared to self-reported White patients (OR: 0.64; 95% CI: 0.50-0.81). Compared to Medicare beneficiaries, patients with third-party insurance, Medicaid, or no insurance were less likely to be initiated on ARNI (OR: 0.47 [95% CI: 0.31-0.72], OR: 0.41 [95% CI: 0.25-0.67], and OR: 0.20 [95% CI: 0.08-0.47], respectively). ARNI therapy varied by hospital region, with lowest utilization in the Mountain region. An interaction was demonstrated between the impact of insurance disparities and hospital region. CONCLUSIONS Among patients hospitalized between 2017 and 2020 for HFrEF who were prescribed RAS inhibitor therapy at discharge, insurance status, geographic region, and self-reported race were associated with ARNI initiation.
Collapse
Affiliation(s)
- Giovanni Davogustto
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA.
| | - Quinn S Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dan M Roden
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
4
|
Krychtiuk KA, Andersson TL, Bodesheim U, Butler J, Curtis LH, Elkind M, Hernandez AF, Hornik C, Lyman GH, Khatri P, Mbagwu M, Murakami M, Nichols G, Roessig L, Young AQ, Schilsky RL, Pagidipati N. Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank. Am Heart J 2024; 270:23-43. [PMID: 38242417 DOI: 10.1016/j.ahj.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.
Collapse
Affiliation(s)
| | | | | | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, TX
| | | | - Mitchell Elkind
- American Heart Association, Dallas, TX; Columbia University, New York, NY
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Trinkley KE, Dafoe A, Malone DC, Allen LA, Huebschmann A, Khazanie P, Lunowa C, Matlock DC, Suresh K, Rosenberg MA, Swat SA, Sosa A, Morris MA. Clinician challenges to evidence-based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation. J Eval Clin Pract 2023; 29:1363-1371. [PMID: 37335624 PMCID: PMC11075805 DOI: 10.1111/jep.13885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Reasons for suboptimal prescribing for heart failure with reduced ejection fraction (HFrEF) have been identified, but it is unclear if they remain relevant with recent advances in healthcare delivery and technologies. This study aimed to identify and understand current clinician-perceived challenges to prescribing guideline-directed HFrEF medications. METHODS We conducted content analysis methodology, including interviews and member-checking focus groups with primary care and cardiology clinicians. Interview guides were informed by the Cabana Framework. RESULTS We conducted interviews with 33 clinicians (13 cardiology specialists, 22 physicians) and member checking with 10 of these. We identified four levels of challenges from the clinician perspective. Clinician level challenges included misconceptions about guideline recommendations, clinician assumptions (e.g., drug cost or affordability), and clinical inertia. Patient-clinician level challenges included misalignment of priorities and insufficient communication. Clinician-clinician level challenges were primarily between generalists and specialists, including lack of role clarity, competing priorities of providing focused versus holistic care, and contrasting confidence regarding safety of newer drugs. Policy and system/organisation level challenges included insufficient access to timely/reliable patient data, and unintended care gaps for medications without financially incentivized metrics. CONCLUSION This study presents current challenges faced by cardiology and primary care which can be used to strategically design interventions to improve guideline-directed care for HFrEF. The findings support the persistence of many challenges and also sheds light on new challenges. New challenges identified include conflicting perspectives between generalists and specialists, hesitancy to prescribe newer medications due to safety concerns, and unintended consequences related to value-based reimbursement metrics for select medications.
Collapse
Affiliation(s)
- Katy E. Trinkley
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Health, Denver, Colorado, USA
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daniel C. Malone
- Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA
| | - Larry A. Allen
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Center for Women’s Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Prateeti Khazanie
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cali Lunowa
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daniel C. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Geriatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Colorado, USA
| | - Krithika Suresh
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Colorado School of Public Health, Aurora, Colorado, USA
| | - Michael A. Rosenberg
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stanley A. Swat
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Aracely Sosa
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Megan A. Morris
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
6
|
Damera N, Shah C, George B, Chapa J, Lee E, Bernhardt R, Reese L, Rao RA. Using Sacubitril/Valsartan to Decrease Health care Costs in Population Health Patients. Am J Cardiol 2023; 201:142-147. [PMID: 37385166 DOI: 10.1016/j.amjcard.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
Value-based care is the foundation of population health. The Health care Economic Efficiency Ratio (HEERO) scoring system is a promising new tool to measure the cost benefits of care in our Accountable Care Organization. HEERO score compares actual costs spent (utilizing insurance claims) and expected costs spent (estimated using the Centers for Medicare/Medicaid Services Risk score). Scores <1 suggest economic benefit. Sacubitril/valsartan has been shown to decrease readmissions for patients with heart failure (HF) and decrease health care costs. We explored the utility of sacubitril/valsartan in reducing HEERO scores and decreasing overall health care expenditure in patients with HF. Patients with HF in the population health cohort were enrolled. HEERO score was calculated for patients taking sacubitril/valsartan and other HF medications at 3-month intervals up to a year. We compared the average and total health care expenditure and inpatient days for patients on sacubitril/valsartan, spironolactone, β blocker (BB) along with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. For patients on sacubitril/valsartan, HEERO scores and inpatient days decreased (decreased health care expenditure) as the number of days of utilization increased (p <0.0001). In total, 270+ days of sacubitril/valsartan decreased health care costs by 22%. This cost reduction was mainly attributed to decreased inpatient days. Additionally, the combination of sacubitril/valsartan, spironolactone, and BB showed decreased HEERO score and inpatient days compared with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in male patients. Sacubitril/valsartan use beyond 270 days resulted in decreased health care expenditure in a population health cohort compared with other HF medications. This economic benefit is achieved through the reduction in hospitalizations. Sacubitril/valsartan is an integral part of value-based care providing high-value, cost-effective care, and bolstering the economic wellbeing of patient care. Payor sources should consider this in subsidizing the cost of the medicine.
Collapse
Affiliation(s)
- Nihanth Damera
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Chirag Shah
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bistees George
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey Chapa
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ed Lee
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Richard Bernhardt
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lindsey Reese
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| | - Roopa A Rao
- Internal Medicine Department, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
7
|
Nargesi AA, Clark C, Aminorroaya A, Chen L, Liu M, Reddy A, Amodeo S, Oikonomou EK, Suchard MA, McGuire DK, Lin Z, Inzucchi S, Khera R. Persistence on Novel Cardioprotective Antihyperglycemic Therapies in the United States. Am J Cardiol 2023; 196:89-98. [PMID: 37012183 PMCID: PMC11007258 DOI: 10.1016/j.amjcard.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/09/2023] [Accepted: 03/01/2023] [Indexed: 04/05/2023]
Abstract
Selected glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have cardioprotective effects in patients with type 2 diabetes mellitus (T2D) and elevated cardiovascular risk. Prescription and consistent use of these medications are essential to realizing their benefits. In a nationwide deidentified United States administrative claims database of adults with T2D, the prescription practices of GLP-1RAs and SGLT-2i were evaluated across guideline-directed co-morbidity indications from 2018 to 2020. The monthly fill rates were assessed for 12 months after the initiation of therapy by calculating the proportion of days with consistent medication use. Of 587,657 subjects with T2D, 80,196 (13.6%) were prescribed GLP-1RAs and 68,149 (11.5%) SGLT-2i from 2018 to 2020, representing 12.9% and 11.6% of patients with indications for each medication, respectively. In new initiators, 1-year fill rate was 52.5% for GLP-1RAs and 52.9% for SGLT-2i, which was higher for patients with commercial insurance than those with Medicare Advantage plans for both GLP-1RAs (59.3% vs 51.0%, p <0.001) and SGLT-2i (63.4% vs 50.3%, p <0.001). After adjusting for co-morbidities, there were higher rates of prescription fills for patients with commercial insurance (odds ratio 1.17, 95% confidence interval 1.06 to 1.29 for GLP-1RAs, and 1.59 [1.42 to 1.77] for SGLT-2i); and higher income (odds ratio 1.09 [1.06 to 1.12] for GLP-1RAs, and 1.06 [1.03 to 1.1] for SGLT-2i). From 2018 to 2020, the use of GLP-1RAs and SGLT-2i remained limited to fewer than 1 in 8 patients with T2D and indications, with 1-year fill rates around 50%. The low and inconsistent use of these medications compromises their longitudinal health outcome benefits in a period of expanding indications for their use.
Collapse
Affiliation(s)
- Arash A Nargesi
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Lian Chen
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mengni Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | | | | | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health and; Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Cardiology Department, Parkland Health and Hospital Systems, Dallas, Texas
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Silvio Inzucchi
- Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Rohan Khera
- Cardiovascular Medicine, and; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
| |
Collapse
|
8
|
Ozaki AF, Ko DT, Chong A, Fang J, Atzema CL, Austin PC, Stukel TA, Tu K, Udell JA, Naimark D, Booth GL, Jackevicius CA. Prescribing patterns and factors associated with sodium-glucose cotransporter-2 inhibitor prescribing in patients with diabetes mellitus and atherosclerotic cardiovascular disease. CMAJ Open 2023; 11:E494-E503. [PMID: 37311594 DOI: 10.9778/cmajo.20220039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors are cardioprotective agents in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). Since little is known about their uptake in atherosclerotic CVD, we examined SGLT2 inhibitor prescribing trends and identified potential disparities in prescribing patterns. METHODS We conducted an observational study using linked population-based health data in Ontario, Canada, from April 2016 to March 2020 of patients aged 65 years or older with concomitant type 2 diabetes and atherosclerotic CVD. To examine prevalent prescribing of SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin), we constructed 4 cross-sectional yearly cohorts from Apr. 1 to Mar. 31 (2016/17, 2017/18, 2018/19 and 2019/20). We estimated prevalent SGLT2 inhibitor prescribing by year and by subgroups, and identified factors associated with SGTL2 inhibitor prescribing using multivariable logistic regression. RESULTS There were 208 303 patients in our overall cohort (median age 74.0 yr [interquartile range 68.0-80.0 yr], 132 196 [63.5%] male). Although SGLT2 inhibitor prescribing increased over time, from 7.0% to 20.1%, statin prescribing was initially 10-fold higher and later threefold higher than SGLT2 inhibitor prescribing. In 2019/20, SGLT2 inhibitor prescribing was roughly 50% lower among those aged 75 years or older than among those younger than 75 years (12.9% v. 28.3%, p < 0.001) and in women than in men (15.3% v. 22.9%, p < 0.001). Age 75 years or older, female sex, history of heart failure and kidney disease, and low income were independent factors of lower SGLT2 inhibitor prescribing. Among physician specialists, visits to endocrinologists and family physicians were stronger factors of SGLT2 inhibitor prescribing than cardiologist visits. INTERPRETATION We found that 1 in 5 patients with diabetes and atherosclerotic CVD were prescribed SGLT2 inhibitors in 2019/20, whereas statins were prescribed for 4 of every 5 patients. Although SGLT2 inhibitor prescribing increased over the study period, disparities in adoption by age, sex, socioeconomic status, comorbidities and physician specialty remained.
Collapse
Affiliation(s)
- Aya F Ozaki
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Dennis T Ko
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Alice Chong
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Jiming Fang
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Clare L Atzema
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Peter C Austin
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Therese A Stukel
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Karen Tu
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Jacob A Udell
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - David Naimark
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Gillian L Booth
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Cynthia A Jackevicius
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif.
| |
Collapse
|
9
|
Abdin A, Schulz M, Riemer U, Hadëri B, Wachter R, Laufs U, Bauersachs J, Kindermann I, Vukadinović D, Böhm M. Sacubitril/valsartan in heart failure: efficacy and safety in and outside clinical trials. ESC Heart Fail 2022; 9:3737-3750. [PMID: 35921043 PMCID: PMC9773772 DOI: 10.1002/ehf2.14097] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/13/2022] [Accepted: 07/19/2022] [Indexed: 01/19/2023] Open
Abstract
Heart failure (HF) treatment has changed substantially over the last 30 years, leading to significant reductions in mortality and hospital admissions in patients with HF with reduced ejection fraction (HFrEF). Currently, the optimization of guideline-directed chronic HF therapy remains the mainstay to further improve quality of life, mortality, and HF hospitalizations for patients with HFrEF. The angiotensin receptor-neprilysin inhibitor sacubitril/valsartan (S/V) has an important role in the treatment of patients with HFrEF. The PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) randomized controlled trial has established solid evidence for the treatment of HFrEF in various subgroups. Apart from HFrEF, several studies have been conducted using S/V in various indications: patients hospitalized with acute decompensated HF, HF with preserved ejection fraction, acute myocardial infarction with reduced ejection fraction, uncontrolled and resistant hypertension, and chronic kidney disease. Data from the German Institute for Drug Use Evaluation reveal that implementation of S/V has increased steadily over time and, by the end of 2021, an estimated 266 000 patients were treated with S/V in Germany. The estimated cumulative real-world patient exposure is >5.5 million patient-treatment years worldwide. The number of patients treated with S/V largely exceeds the number of patients treated in clinical trials, and the current indication for S/V is larger than the strict inclusion/exclusion criteria of the randomized trials. Especially elderly patients, women, and patients with more and more severe comorbidities are underrepresented in the clinical trials. We therefore aimed to summarize the importance of S/V in HF in terms of efficacy and safety in clinical trials and daily clinical practice.
Collapse
Affiliation(s)
- Amr Abdin
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Martin Schulz
- Institute of PharmacyFreie Universität BerlinBerlinGermany,German Institute for Drug Use Evaluation (DAPI)BerlinGermany
| | - Uwe Riemer
- Medical DepartmentNovartis Pharma GmbHNurembergGermany
| | - Bledar Hadëri
- Medical DepartmentNovartis Pharma AGBaselSwitzerland
| | - Rolf Wachter
- Klinik und Poliklinik für KardiologieUniversitätsklinikum LeipzigLeipzigGermany
| | - Ulrich Laufs
- Klinik und Poliklinik für KardiologieUniversitätsklinikum LeipzigLeipzigGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Ingrid Kindermann
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Davor Vukadinović
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| | - Michael Böhm
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic IIISaarland University HospitalKirrberger Street 10066421HomburgSaarlandGermany
| |
Collapse
|
10
|
Latif A, Ahsan MJ, Lateef N, Kapoor V, Tran A, Abusnina W, Lundgren S, Goldsweig A, Ahsan MZ, Mirza M. Implementation of Multiple Evidence-Based Heart Failure Therapies. Curr Probl Cardiol 2022; 47:101293. [PMID: 35753401 DOI: 10.1016/j.cpcardiol.2022.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/17/2022] [Indexed: 11/03/2022]
Abstract
Despite the advancements in the management of heart failure, acute heart failure is one of the most common causes of mortality and morbidity. In light of the financial burden imposed by heart failure hospitalizations on the health care system, this area remains the focus of research, clinical advances, and policy changes aimed at improving the quality of care and outcomes. Despite practice guidelines, high-quality trial data, and consensus statements, barriers to therapy remain. The barriers related to physician, patient, economic, health care system, and logistical factors prevent widespread adoption of available therapeutics. In this review article, we outline guidelines directed therapies for heart failure, challenges associated with their implementation, and potential solutions to these challenges to help reduce mortality and improve clinical outcomes in this patient population.
Collapse
Affiliation(s)
- Azka Latif
- Creighton University School of Medicine, Omaha, NE, USA.
| | | | | | | | - Amy Tran
- Creighton University School of Medicine, Omaha, NE, USA
| | | | | | | | | | - Mohsin Mirza
- Creighton University School of Medicine, Omaha, NE, USA
| |
Collapse
|
11
|
Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
Collapse
Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
| |
Collapse
|