Pill burden and out-of-pocket medication costs of a contemporary heart failure with reduced ejection fraction cohort
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Abstract Introduction Modern pharmacological treatment of heart failure with reduced ejection fraction (HFrEF) dramatically improves its prognosis. However, the increasingly complexity and associated costs might threat their effective uptake in clinical practice. We aimed to study the pill burden and out-of-pocket costs of cardiovascular drug therapy of a contemporary cohort of HFrEF patients. Methods We performed a retrospective, cross-sectional, single-center study on a convenience sample of 100 consecutive HFrEF patients assessed at our HF outpatient clinic (January-June 2020). The pill burden was assessed by the number of prescribed different cardiovascular drugs and pills per day. The out-of-pocket (OOP) costs were defined using the total patients co-payment of cardiovascular medications per month of treatment, taken in account the exemptions provided by the Portuguese National Health System (NHS). The included drug classes were antiplatelets, anticoagulants, statins, HF drugs (Beta-blockers [BB], angiotensin-converting enzyme inhibitors [ACEi]/ angiotensin receptor blockers [ARBs]/ angiotensin receptor-neprilysin inhibition [ARNI], mineralocorticoid antagonists [MRA], sodium glucose cotransport inhibitors [iSGLT2], digoxin, loop diuretic) and antiarrhythmics. Results The mean age was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. 92% of patients were on BB, 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The number of cardiovascular (CV) drugs per day was 5.4±1.6 per patient and the number of CV pills per day was 6.6±2. Most patients (65%) had low income and had the maximal exemption on medication costs provided by NHS. Overall, the mean OOP costs was €16.1 per month of treatment and the mean OOP costs for patients exempted and not exempted was €12.9 and €22.3, respectively. The mean OOP costs of evidence-based HF-modifying drugs (BB, ACEI/ARBs, ARNI, MRA, iSGLT2) was €10.1 and the mean OOP costs of evidence-based HF-modifying drugs for patients exempted and not exempted were €7.9 and €14.2, respectively. However, for patients on ARNI the mean OOP costs was almost 3 times higher (€33.6). Conclusions In this optimally treated contemporary cohort of HFrEF, the pill burden due to cardiovascular therapy only is high (7 pills/day). With the exception of patients on ARNI, the overall OOP costs of HF-modifying prognostic drugs are low. Funding Acknowledgement Type of funding sources: None.Keywords:
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Loop diuretic
Loop diuretics are recommended to treat congestive symptoms in patients with heart failure. However, observational studies have indicated that loop diuretic treatment in heart failure is associated with increased mortality. Therefore, loop diuretic discontinuation or dose reduction, when clinically possible, is recommended. Our aim was to study nationwide temporal trends in loop diuretic treatment from 2005 to 2014 in real-life patients with chronic heart failure.Data from the nationwide Swedish National Patient, Prescribed Drug and Cause of Death Registers were linked. The annual proportions of patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. In addition, the annual median loop diuretic doses (DDD) in patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated.The proportion of real-life patients with chronic heart failure treated with loop diuretics decreased from 73.2% in 2005 to 65.7% in 2014 (p for trend < 0.001). The median loop diuretic DDD in real-life patients with chronic heart failure decreased from 2.13 (IQR 1.09-2.77) in 2005 to 1.63 (IQR 1.09-2.25) in 2014 (p = 0.001 for trend).Loop diuretic treatment decreased from 2005 to 2014 in real-life patients with chronic heart failure. The prognostic impact of changes in loop diuretic treatment in patients with heart failure remains unclear.
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Background: This study investigates spot urinary chloride concentration in euvolemic chronic heart failure (CHF) patients.Methods: This prospective cohort study included 50 ambulatory CHF patients on maintenance loop diuretics without recent hospital admission, clinical signs of volume overload, or adjustment in neurohumoral blocker or diuretic therapy. Spot urinary samples were collected immediately after loop diuretic intake. Subsequently, loop diuretic dose was reduced with 50% or stopped if ≤40 mg furosemide equivalents. Successful down-titration was defined as persistent dose reduction after 7 d without body weight increase >1.5 kg.Results: Urinary chloride concentration was 3045 ± 1271 mg/L overall. Patients with higher versus lower urinary chloride concentrations took the same dose of loop diuretics [40 mg (20–40 mg) furosemide equivalents; p value = .509] and had similar plasma NT-proBNP levels [1179 ng/L (311–2195 ng/L) versus 900 ng/L (255–1622 ng/L), respectively; p value = .461]. Down-titration was successful in 72% versus 76%, respectively (p value = 1.000). At 30 d, loop diuretic dose remained reduced in 59% versus 76% of patients, respectively (p value = .238). The proportion of patients free from diuretic therapy was 45% versus 62% in the high versus low chloride concentration group (p value = .265).Conclusions: Loop diuretic down-titration was successful in 3 out of 4 euvolemic CHF patients, irrespectively of urinary chloride concentration on spot samples collected after diuretic intake.
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Objective: To Compare the effects of Ramipril, Digoxin and Diuretic with Digoxin and Diuretic on cardiac function, heart rate, cardio-thoracic ratio and left ventricular ejection fraction (LVEF) in chronic congestive heart failure (CHF) patients. Methods: Sixty patients were allocated randomly into two groups , one group received Ramipril, Digoxin and Diuretic, and the other group received Digoxin and Diuretic as control group, for 12 weeks. Results: The heart rate were lower significantly in both groups after treatment of one week (P0.01), the cardio-thoracic ratio reduced, LVEF increased significantly(P0.05) in ramipril group after 12 weeks treatment, while no significant changes in control group (P0.05). Conclusions: Ramipril, Digoxin and Diuretic is more effective than Digoxin and Diuretic treatment on heart rate reduction, cardio-thoracic ratio decrease, LVEF increase in CHF patiens.
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Congestive heart failure is a disease state distinguished by the regular presence of both renal and hepatic abnormalities in drug handling. One such abnormality involves flaws in the process of drug absorption. In most instances, congestive heart failure‐related abnormalities in drug absorption are of inconsequential significance. However, this is not the case with loop diuretics. Loop diuretic action ordinarily tracks the rate and extent of absorption if a sufficient amount of diuretic has been given to exceed the threshold for diuretic effect. In congestive heart failure, both the rate and absolute amount of loop diuretic absorbed can be reduced as a function of the heart failure state itself. In this setting, drug dissolution characteristics can assume added significance. Furosemide is the loop diuretic with the widest intra‐ and interpatient variability of absorption. Alternatively, the loop diuretic torsemide is rapidly and fairly completely absorbed independent of the heart failure state. This pattern of absorption establishes it as the preferred loop diuretic in the otherwise diuretic‐resistant heart failure patient. However, the exact role of torsemide in the outpatient management of congestive heart failure remains to be determined.
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Background: Loop diuretics play a crucial role in symptom management in patients with fluid overload. There is a paucity of data regarding optimal diuretic dose at hospital discharge for acute decompensated heart failure (ADHF) patients requiring loop diuretics. Objective: To compare all-cause 30-day readmission in ADHF patients on chronic loop diuretics who had an increase in loop diuretic dose at discharge (relative to their preadmission dose) with patients without a change or a decrease in loop diuretic dose at discharge. Methods: This was a multicenter, retrospective cohort study. Institutional review board approval was obtained. Patients admitted with a primary discharge diagnosis of heart failure, evidence of fluid overload, and reduced ejection fraction were included. Patients were divided into 2 groups based on total daily loop diuretic dose at discharge: those discharged on an increased dose and those discharged on a dose less than or equal to their preadmission dose. Results: A total of 131 patient admissions met inclusion criteria; 50 had an increase in loop diuretic dose at discharge, and 81 were discharged with no change or a decrease in diuretic dose. Patients in the increased dose group had an all-cause 30-day readmission rate of 20% compared with 38% of patients with no change or a decrease in diuretic dose (adjusted odds ratio = 0.320; 95% CI = 0.117-0.873). Conclusion: In patients admitted for ADHF with reduced ejection fraction and evidence of fluid overload, an increase in loop diuretic dose at discharge was associated with a reduced rate of 30-day hospital readmission.
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Introduction: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have demonstrated cardiovascular benefits in patients with heart failure, many of which take loop diuretics. There are no evidence-based recommendations identifying which patients may require loop diuretic dose decreases or how to adjust loop diuretic doses when SGLT2is are initiated. Objectives: The main objective of this study was to investigate the frequency and degree of adjustments in loop diuretic doses after SGLT2i initiation in patients with heart failure. Methods: In this retrospective evaluation, patients seen in the UCHealth system with a diagnosis of heart failure who were prescribed a loop diuretic before initiation of SGLT2i were identified. We described loop diuretic dose changes at the time of SGLT2i initiation, at 6 months after initiation, and at 1 year after initiation. We also described de-escalation of maintenance medications that can contribute to hypotension at these time points. Data were evaluated using descriptive statistics. Results: A total of 100 patients were included. Loop diuretic dose was reduced empirically upon SGLT2i initiation in 2.0% of patients. Reduction of loop diuretic dose within the first 6 months of starting an SGLT2i occurred in 8.0% of patients. From baseline to 12 months after starting SGLT2i therapy, 14.0% of patients had loop diuretic dose reduction. Conclusions: Most of our patients with HF did not have change in loop diuretic dose after initiation of an SGLT2i. In patients who did have loop diuretic dose reduction, most occurred within 6 months after starting SGLT2i therapy rather than empirically at time of initiation.
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In the present study, the authors have examined the diuretic action of a novel loop diuretic torasemide and compared it to those of other diuretics, employing normal rats and dogs. Oral administration of torasemide elicited a dose-dependent increase in urine volume and electrolyte excretion, and elevated the urinary Na/K ratio in rats. These effects were more potent than those of the other diuretics furosemide, trichlormethiazide, indapamide and spironolactone. Moreover, torasemide exhibited a similar or higher urinary Na/K ratio than the combination of these diuretics and spironolactone. In a study employing anaesthetized dogs, i.v. injection of torasemide resulted in a higher urinary Na/K ratio in comparison to furosemide, in addition to potent and long-lasting diuretic activity.
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