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Lee EK, Yang WS. Use of Fludrocortisone for Hyperkalemia in Chronic Kidney Disease Not Yet on Dialysis. Electrolyte Blood Press 2024; 22:8-15. [PMID: 38957547 PMCID: PMC11214912 DOI: 10.5049/ebp.2024.22.1.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 06/23/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024] Open
Abstract
Background Hyperkalemia is a frequent and potentially lethal complication of chronic kidney disease (CKD). We retrospectively examined the potassium-lowering effect of oral fludrocortisone and its adverse effects in hyperkalemic CKD patients not yet on dialysis. Methods Thirty-three patients (23 men and 10 women, ages 69±14 years) were included. To control hyperkalemia at the outpatient clinic, twenty-one patients (Group 1) received fludrocortisone (0.05-0.1 mg/day) without changes in angiotensin II receptor blockers (ARBs) and calcium polystyrene sulfonate (CPS), while twelve patients (Group 2) were treated with fludrocortisone in addition to stopping ARBs and/or adding low-dose CPS. Results Fludrocortisone was administered for a median of 169 days (interquartile range, 47-445). At the first follow-up after fludrocortisone administration, serum potassium dropped from 6.14±0.32 mEq/L to 4.52±1.06 mEq/L (p<0.001) in Group 1 and from 6.37±0.35 mEq/L to 4.08±0.74 mEq/L (p<0.01) in Group 2. Ten patients in Group 1 and five patients in Group 2 measured serum potassium levels at four outpatient visits before and after fludrocortisone administration, respectively. The frequency of serum potassium ≥6.0 mEq/L decreased from 19/40 (48%) to 2/40 (5%) (p<0.001) in Group 1 and from 11/20 (55%) to 0/20 (0%) (p<0.001) in Group 2. Eleven patients experienced sodium retention-related problems after fludrocortisone administration: 7 with worsening leg edema, 2 with pleural effusions, and 2 with pulmonary edema. Conclusion In pre-dialysis CKD patients, fludrocortisone at low doses effectively reduced serum potassium levels; however, sodium retention was a common adverse effect.
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Affiliation(s)
- Eun Kyoung Lee
- Division of Nephrology, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Won Seok Yang
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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2
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Ferrannini G, Biber ME, Abdi S, Ståhlberg M, Lund LH, Savarese G. The management of heart failure in Sweden-the physician's perspective: a survey. Front Cardiovasc Med 2024; 11:1385281. [PMID: 38807949 PMCID: PMC11130511 DOI: 10.3389/fcvm.2024.1385281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the barriers to guideline-directed medical therapy (GDMT) use in heart failure (HF), diagnostic workup and general knowledge about HF among physicians in Sweden. Methods A survey about the management of HF was sent to 828 Swedish physicians including general practitioners (GPs) and specialists during 2021-2022. Answers were reported as percentages and comparisons were made by specialty (GPs vs. specialists). Results One hundred sixty-eight physicians participated in the survey (40% females, median age 43 years; 41% GPs and 59% specialists). Electrocardiography and New York Heart Association class evaluations are mostly performed once a year by GPs (46%) and at every outpatient visit by specialists (40%). Echocardiography is mostly requested if there is clinical deterioration (60%). One-third of participants screen for iron deficiency only if there is anemia. Major obstacles to implementation of different drug classes in HF with reduced ejection fraction are related to side effects, with no significant differences between specialties. Device implantation is deemed appropriate regardless of aetiology (69%) and patient age (86%). Specialists answered correctly to knowledge questions more often than GPs. Eighty-six percent of participants think that GDMT should be implemented as much as possible. Most participants (57%) believe that regular patient assessment in nurse-led HF clinics improve adherence to GDMT. Conclusion Obstacles to GDMT implementation according to physicians in Sweden mainly relate to potential side effects, lack of specialist knowledge and organizational aspects. Further efforts should be placed in educational activities and structuring of nurse-led clinics.
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Affiliation(s)
- Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Internal Medicine Unit, Södertälje Hospital, Södertälje, Sweden
| | - Mattia Emanuele Biber
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Studies, University of Trieste School of Medicine, Trieste, Italy
| | - Sam Abdi
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Ståhlberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H. Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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3
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Kuan WC, Sim R, Wong WJ, Dujaili J, Kasim S, Lee KKC, Teoh SL. Economic Evaluations of Guideline-Directed Medical Therapies for Heart Failure With Reduced Ejection Fraction: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1558-1576. [PMID: 37236395 DOI: 10.1016/j.jval.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/13/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Decision-analytic models (DAMs) with varying structures and assumptions have been applied in economic evaluations (EEs) to assist decision making for heart failure with reduced ejection fraction (HFrEF) therapeutics. This systematic review aimed to summarize and critically appraise the EEs of guideline-directed medical therapies (GDMTs) for HFrEF. METHODS A systematic search of English articles and gray literature, published from January 2010, was performed on databases including MEDLINE, Embase, Scopus, NHSEED, health technology assessment, Cochrane Library, etc. The included studies were EEs with DAMs that compared the costs and outcomes of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin-receptor neprilysin inhibitors, beta-blockers, mineralocorticoid-receptor agonists, and sodium-glucose cotransporter-2 inhibitors. The study quality was evaluated using the Bias in Economic Evaluation (ECOBIAS) 2015 checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklists. RESULTS A total of 59 EEs were included. Markov model, with a lifetime horizon and a monthly cycle length, was most commonly used in evaluating GDMTs for HFrEF. Most EEs conducted in the high-income countries demonstrated that novel GDMTs for HFrEF were cost-effective compared with the standard of care, with the standardized median incremental cost-effectiveness ratio (ICER) of $21 361/quality-adjusted life-year. The key factors influencing ICERs and study conclusions included model structures, input parameters, clinical heterogeneity, and country-specific willingness-to-pay threshold. CONCLUSIONS Novel GDMTs were cost-effective compared with the standard of care. Given the heterogeneity of the DAMs and ICERs, alongside variations in willingness-to-pay thresholds across countries, there is a need to conduct country-specific EEs, particularly in low- and middle-income countries, using model structures that are coherent with the local decision context.
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Affiliation(s)
- Wai-Chee Kuan
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Ruth Sim
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Wei Jin Wong
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Juman Dujaili
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia; Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Sazzli Kasim
- Department of Internal Medicine (Cardiology), Universiti Teknologi MARA (UiTM), Sungai Buloh, Selangor, Malaysia
| | | | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.
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4
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX, USA and Imperial College, London, UK
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5
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Heidenreich PA, Fonarow GC, Opsha Y, Sandhu AT, Sweitzer NK, Warraich HJ. Economic Issues in Heart Failure in the United States. J Card Fail 2022; 28:453-466. [PMID: 35085762 PMCID: PMC9031347 DOI: 10.1016/j.cardfail.2021.12.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 12/27/2022]
Abstract
The cost of heart failure care is high owing to the cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in 1 year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failure for patients and the health care system in the United States. It also provides a summary of the cost effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include angiotensin-converting enzyme inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out-of-pocket costs for patients.
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Affiliation(s)
- Paul A. Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA,VA Palo Alto Health Care System, Palo Alto, CA
| | - Gregg C. Fonarow
- Division of Cardiology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Yekaterina Opsha
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ,Saint Barnabas Medical Center, Livingston, NJ
| | - Alexander T. Sandhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nancy K. Sweitzer
- Division of Cardiology, University of Arizona College of Medicine, Tucson, AZ
| | - Haider J. Warraich
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA
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6
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González-Juanatey JR, González-Franco Á, de Sequera P, Valls M, Ramirez de Arellano A, Pomares E, Nieves D. A cost-effectiveness analysis of patiromer for the treatment of hyperkalemia in chronic kidney disease patients with and without heart failure in Spain. J Med Econ 2022; 25:640-649. [PMID: 35510569 DOI: 10.1080/13696998.2022.2074193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Renin-angiotensin-aldosterone system inhibitors (RAASi) therapy is commonly used to reduce the risk of death and to slow down disease progression in patients with chronic kidney disease (CKD), heart failure (HF) and hypertension. However, the cardio-renal benefits of RAASi therapy are also associated with an increased risk of hyperkalemia (HK), which may lead to dose reduction or discontinuation of therapy. Patiromer has demonstrated to reduce the risk of HK, which enables to maintain optimal doses of RAASi therapy. This study aimed to assess the cost-effectiveness of patiromer for the management of HK in CKD patients with and without HF in Spain. METHODS A Markov model was developed to evaluate the costs and benefits of patiromer for the management of HK in patients with CKD stages 3-4 with and without HF treated with RAASi over a lifetime horizon. The main outcomes included total direct costs (€2021), quality-adjusted life-years (QALYs), life-years gained (LYG) and incremental cost-effectiveness ratio (ICER). Deterministic one-way and probabilistic sensitivity analyses were performed to assess the robustness of the results. RESULTS Patiromer was more effective compared to no patiromer (5.76 vs 5.57 QALYs; 7.73 vs 7.50 LYG), and resulted in an incremental cost of €3,574, yielding an ICER of €19,092/QALY gained and of €15,236/LYG. Sensitivity analyses suggested that the results were robust to changes in most input parameters. CONCLUSIONS Patiromer is a cost-effective intervention in maintaining normokalemia and enabling optimal RAASi therapy in patients with CKD stages 3-4 with and without HF in Spain.
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Affiliation(s)
| | - Álvaro González-Franco
- Servicio Medicina Interna, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Patricia de Sequera
- Servicio Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, Spain
| | - Marta Valls
- Market Access, Vifor Pharma Group., Barcelona, Spain
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7
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Tessler I, Leshno M, Shmueli A, Shpitzen S, Ronen D, Gilon D. Cost-effectiveness analysis of screening for first-degree relatives of patients with bicuspid aortic valve. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:447-457. [PMID: 34227670 DOI: 10.1093/ehjqcco/qcab047] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 12/25/2022]
Abstract
AIMS Bicuspid aortic valve (BAV) is the commonest congenital heart valve malformation, and is associated with life-threatening complications. Given the high heritability index of BAV, many experts recommend echocardiography screening for first-degree relatives (FDRs) of an index case. Here we aim to evaluate the cost-effectiveness of such cascade screening for BAV. METHODS Using a decision-analytic model, we performed a cost-effectiveness analysis of echocardiographic screening for FDRs of BAV index case. Data on BAV probabilities and complications among FDRs were derived from our institution's BAV familial cohort and from the literature on population-based BAV cohorts with long-term follow-up. Health gain was measured as quality-adjusted life years (QALYs). Cost inputs were based on list prices and literature data. One-way and probabilistic sensitivity analyses were performed to account for uncertainty in the model's variables. RESULTS Screening of FDRs was found to be the dominant strategy, being more effective and less costly than no screening, with savings of €644 and gains of 0.3 QALYs. Results were sensitive throughout the rang of the model's variables, including the full range of reported BAV rates among FDRs across the literature. A gradual decrease of the incremental effect was found with the increase in screening age. CONCLUSIONS This economic evaluation model found that echocardiographic screening of FDRs of BAV index case is not only clinically important but also cost-effective and cost-saving. Sensitivity analysis supported the model's robustness, suggesting its generalization.
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Affiliation(s)
- Idit Tessler
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University, Jerusalem, Israel.,Heart institute, Hadassah Medical Center, Jerusalem, Israel
| | - Moshe Leshno
- Faculty of Management and School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shmueli
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Shoshana Shpitzen
- Heart institute, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Durst Ronen
- Heart institute, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Dan Gilon
- Heart institute, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University, Jerusalem, Israel
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8
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Shrestha DB, Budhathoki P, Sedhai YR, Baniya R, Cable CA, Kashiouris MG, Dixon DL, Kidd JM, Adhikari Y, Marasini A, Bhandari S. Patiromer and Sodium Zirconium Cyclosilicate in Treatment of Hyperkalemia: A Systematic Review and Meta-Analysis. Curr Ther Res Clin Exp 2021; 95:100635. [PMID: 34367383 PMCID: PMC8326359 DOI: 10.1016/j.curtheres.2021.100635] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022] Open
Abstract
Background Patiromer and sodium zirconium cyclosilicate (SZC) are newer options for hyperkalemia treatment. This systematic review and meta-analysis were conducted to assess the safety and side effect profile of patiromer and SZC compared with placebo or other standards of care in the management of hyperkalemia. Methods We searched electronic databases for relevant articles. The screening was performed independently and data were extracted among the selected studies. We performed a statistical analysis on Revman 5.4 software. The odds ratio (OR) was used for outcome estimation with a 95% CI. Results Patiromer had lower rates of hyperkalemia (OR = 0.44; 95% CI, 0.22–0.89) compared with standard of care. The analysis showed no significant differences between the 2 groups in terms of overall adverse effects, any serious/specific adverse effects, or treatment discontinuation as a result of adverse effects. Comparing the SZC-10 group with standard of care showed no significant differences in the occurrence of hyperkalemia during treatment, overall adverse effects, any serious/specific adverse effects, or treatment discontinuation as a result of adverse effects but showed a higher rate of edema in the treatment group (OR = 6.77; 95% CI, 1.03–44.25). Similarly, no significant differences were seen between the 2 SZC doses for the occurrence of any adverse effects, hyperkalemia, constipation, diarrhea, or urinary tract infection, whereas edema was higher among patients receiving SZC-10 (OR = 3.13; 95% CI, 1.19–8.27). Conclusions In patients with acute hyperkalemia, SZC is the drug of choice due to its more rapid reduction of serum potassium level, whereas in patients with chronic hyperkalemia, patiromer appears to be the drug of choice because SZC is associated with an increase in edema, likely due to an increase in sodium absorption, which could have important adverse consequences in patients with chronic kidney disease and or heart failure. Thus, both drugs were found to be safe while treating hyperkalemia. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)
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Affiliation(s)
| | | | - Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Ramkaji Baniya
- Department of Internal Medicine, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Casey A Cable
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Markos G Kashiouris
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Jason M Kidd
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia
| | - Yuvraj Adhikari
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | | | - Shakar Bhandari
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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9
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Almalki B, Cunningham K, Kapugi M, Kane C, Agrawal A. Management of hyperkalemia: A focus on kidney transplant recipients. Transplant Rev (Orlando) 2021; 35:100611. [PMID: 33711778 DOI: 10.1016/j.trre.2021.100611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/15/2022]
Abstract
Hyperkalemia is a frequent complication among kidney transplant recipients that can lead to fatal arrhythmias. The causes of hyperkalemia post kidney transplant are multifactorial and often are drug-induced, and include decreased glomerular filtration rate, tubular dysfunction, and impaired sodium delivery in the distal nephron. This review will discuss pathophysiology and recent updates in the management of both acute and chronic hyperkalemia with a focus on kidney transplant recipients.
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Affiliation(s)
- Bassem Almalki
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States.
| | - Kathleen Cunningham
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Michelle Kapugi
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Clare Kane
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Akansha Agrawal
- Department of Nephrology, Northwestern Memorial Hospital, Chicago, IL, United States
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10
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Palmer BF, Carrero JJ, Clegg DJ, Colbert GB, Emmett M, Fishbane S, Hain DJ, Lerma E, Onuigbo M, Rastogi A, Roger SD, Spinowitz BS, Weir MR. Clinical Management of Hyperkalemia. Mayo Clin Proc 2021; 96:744-762. [PMID: 33160639 DOI: 10.1016/j.mayocp.2020.06.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022]
Abstract
Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K+) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K+ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K+-binding agents. Monitoring serum K+ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K+ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K+-binding agents requires further study to establish whether stringent dietary K+ restrictions are needed in patients receiving K+-binder therapy. Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Deborah J Clegg
- Drexel University College of Nursing and Health Professions, Philadelphia, PA
| | | | | | - Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Debra J Hain
- Christine E. Lynn College of Nursing, Florida Atlantic University, and Cleveland Clinic Florida, Weston, FL
| | - Edgar Lerma
- Department of Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn
| | - Macaulay Onuigbo
- Robert Larner College of Medicine, University of Vermont Medical Center, Burlington
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles
| | - Simon D Roger
- Renal Research, Gosford Hospital, Gosford, Australia
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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11
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Weir MR, Slee A, Sun T, Balis D, Oh R, de Zeeuw D, Perkovic V. Effects of canagliflozin on serum potassium in the CANagliflozin cardioVascular Assessment Study (CANVAS) Program. Clin Kidney J 2020; 14:1396-1402. [PMID: 34221371 PMCID: PMC8247742 DOI: 10.1093/ckj/sfaa133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background The sodium-glucose cotransporter 2 inhibitor canagliflozin has been shown to reduce the risk of cardiovascular and renal events in patients with Type 2 diabetes mellitus and high risk. Pooled analyses of data from early studies and interim data from the CANagliflozin cardioVascular Assessment Study (CANVAS) suggested that canagliflozin might lead to increases in serum potassium, particularly the 300 mg dose in patients with renal impairment, which is important because high serum potassium is associated with increased cardiovascular and renal risk. We examined the effect of canagliflozin on serum potassium levels and hyperkalemia rates in the completed CANVAS Program. Methods The CANVAS Program (n = 10,142) was comprised of two comparable double-blind, randomized, placebo-controlled trials (CANVAS and CANVAS-Renal). Participants received canagliflozin 100 or 300 mg or placebo. Serum potassium measurements were performed in a central laboratory0 and assessed at ∼6-month intervals. Results In the CANVAS Program, mean potassium levels were generally consistent with canagliflozin and placebo, overall and by baseline estimated glomerular filtration rate (eGFR; ≥60, 45 to<60 and <45 mL/min/1.73 m2). The risk of increased or decreased potassium was similar with canagliflozin and placebo overall and by baseline eGFR (all P-heterogeneity ≥0.56) or use of renin–angiotensin–aldosterone system inhibitors (all P-heterogeneity ≥0.71); levels did not appear different by canagliflozin dose. Hyperkalemia {hazard ratio (HR) [95% confidence interval (CI)] 1.60 (0.92–2.81)} and serious hyperkalemia [HR (95% CI) 0.75 (0.27–2.11)] adverse events were not different across groups. Conclusions In the CANVAS Program, there were no meaningful effects of canagliflozin on serum potassium in the overall population or key subgroups. Hyperkalemia adverse events were uncommon and occurred at comparable rates with canagliflozin and placebo.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Tao Sun
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Dainius Balis
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Richard Oh
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia.,The Royal North Shore Hospital, Sydney, Australia
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12
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Abstract
PURPOSE OF REVIEW The purpose of this review is to present data from clinical trials that resulted in the key data supporting the use of patiromer as a potassium binder in clinical practice today. RECENT FINDINGS In addition to trials that support the current Food and Drug Administration label and published over the past 3 years, the recently published Spironolactone With Patiromer in the Treatment of Resistant Hypertension in Chronic Kidney Disease (AMBER) trial provides clear benefits of patiromer use in a group of resistant hypertension patients. The AMBER was a phase 2, multicenter, randomized, double-blind, parallel-group, placebo-controlled study that evaluated 295 participants stratified by local serum potassium measurement (4.3 to < 4.7 mmol/L vs 4.7 to 5.1 mmol/L) and history of diabetes and chronic kidney disease. The focus was on enabling participants with resistant hypertension to achieve blood pressure goals by using spironolactone. Additionally, the ongoing Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure (DIAMOND) trial is designed to demonstrate how patiromer is an "enabler" of therapies that are needed to either control resistant hypertension or reduce mortality in heart failure but generate hyperkalemia. These and other studies are discussed in detail. Patiromer is one of two new potassium binders that are far better tolerated than the previous agent and can be given chronically to participants who need life-saving therapies but have elevations of potassium into a dangerous range as a consequence.
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Affiliation(s)
- Waleed Ali
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism and the Am. Heart Assoc. Comprehensive Hypertension Center, University of Chicago Medicine, 5841 S. Maryland Ave. MC 1027, Chicago, IL, 60637, USA
| | - George Bakris
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism and the Am. Heart Assoc. Comprehensive Hypertension Center, University of Chicago Medicine, 5841 S. Maryland Ave. MC 1027, Chicago, IL, 60637, USA.
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13
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Widén J, Ivarsson M, Schalin L, Vrouchou P, Schwenkglenks M, Heimbürger O, Ademi Z, Sutherland CS. Cost-Effectiveness Analysis of Patiromer in Combination with Renin-Angiotensin-Aldosterone System Inhibitors for Chronic Kidney Disease in Sweden. PHARMACOECONOMICS 2020; 38:747-764. [PMID: 32239480 DOI: 10.1007/s40273-020-00902-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Patients with chronic kidney disease (CKD) are commonly treated with renin-angiotensin-aldosterone system inhibitors (RAASi) in order to delay progression of renal disease. However, research has shown that RAASi in CKD patients increases hyperkalaemia (HK) prevalence, which leads to RAASi discontinuation or dose reduction with the loss of benefits on the kidney. Patiromer is a novel therapy for HK treatment and may enable patients to remain on their RAASi regimen. This study aimed to assess the cost-effectiveness of patiromer from a Swedish healthcare perspective. METHODS A Markov model was developed to evaluate the economic outcomes of patiromer versus no patiromer in HK patients with stage 3-4 CKD taking RAASi. The model consisted of six health states reflecting disease progression and hospitalisations. The analysis mainly considered clinical data from the OPAL-HK trial and national costs. The main outcomes of interest were incremental costs (euro [EUR] 2016) and quality-adjusted life years (QALYs), discounted at 3%, and the incremental cost-effectiveness ratio (ICER). Extensive uncertainty analyses were performed. RESULTS In comparison to no patiromer, a patiromer patient gained 0.14 QALYs and an incremental cost of EUR 6109 (Swedish krona [SEK] 57,850), yielding an ICER of EUR 43,307 (SEK 410,072)/QALY gained. The results were robust to a range of sensitivity analyses. At a willingness-to-pay threshold of EUR 52,804 (SEK 500,000)/QALY, patiromer had a 50% chance of being cost-effective. CONCLUSIONS The results indicate that patiromer may demonstrate value for money in Swedish patients with stage 3-4 CKD, by enabling RAASi treatment. However, there is a considerable degree of uncertainty.
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Affiliation(s)
| | | | | | | | | | - Olof Heimbürger
- Patient Area Endocrinology and Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Zanfina Ademi
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, Australia
| | - C Simone Sutherland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
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14
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Wang AYM. Optimally managing hyperkalemia in patients with cardiorenal syndrome. Nephrol Dial Transplant 2020; 34:iii36-iii44. [PMID: 31800079 DOI: 10.1093/ndt/gfz225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 12/27/2022] Open
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). The European Society of Cardiology and the American College of Cardiology/American Heart Association gave a Class IA recommendation for the use of RAASi in the treatment of Classes II-IV symptomatic HF with reduced ejection fraction (HFREF), based on their strong clinical benefits of lowering all-cause mortality and HF hospitalizations in these subjects. However, RAASi therapy or adding mineralocorticoid receptor antagonists in subjects receiving background angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with an increased risk of hyperkalemia (HK), especially in those with reduced kidney function. As a result, a significant proportion of these subjects either have RAASi dose reduced or more often discontinued when they develop HK. Discontinuation of RAASi in patients hospitalized with HFREF was associated with higher postdischarge mortality and rehospitalization rates, while optimal dosing of RAASi significantly reduced median hospital stays, outpatient visits and related costs. Thus, effective treatment is required to lower potassium level and maintain normokalemia in subjects with HF and reduced kidney disease who develop or are at risk of HK, thus enabling them to continue their RAASi therapy and maximize benefits from RAASi. In this review, we provide an up-to-date review of the prevalence and significance of HK in patients with cardiorenal syndrome, as well as their optimal management of HK with recent novel therapies.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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15
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Manolis AA, Manolis TA, Melita H, Manolis AS. Spotlight on Spironolactone Oral Suspension for the Treatment of Heart Failure: Focus on Patient Selection and Perspectives. Vasc Health Risk Manag 2019; 15:571-579. [PMID: 31920323 PMCID: PMC6941679 DOI: 10.2147/vhrm.s210150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/08/2019] [Indexed: 11/28/2022] Open
Abstract
Spironolactone, an antagonist of aldosterone, initially used as a potassium-sparing diuretic, was subsequently shown to be a very effective adjunctive agent in the treatment of patients with heart failure with reduced ejection fraction, by halting the disease progression, with significant beneficial effects on both morbidity and mortality. Other uses comprise resistant hypertension, edema in patients with cirrhosis, and other on- and off-label uses. Recent data indicate that spironolactone also may offer some symptomatic relief in patients with heart failure and preserved ejection fraction. However, a variable percentage of patients, particularly among the aged group, may have difficulty in swallowing or may be unable to swallow tablets and thus are deprived of the benefits of such therapy. In 2017, the FDA approved a liquid suspension formulation of spironolactone, CaroSpir®, which will enable more heart failure and other patients in need of aldosterone inhibition to avail themselves of the protective and beneficial effects of spironolactone. The new drug formulation comes as a banana-flavored oral suspension that contains 25 mg/5 mL of spironolactone, supplied in 4-ounce (118 mL) and 16-ounce (473 mL) bottles. The details of this drug formulation development and the benefits of spironolactone use in patients with heart failure with a focus on patient selection are herein reviewed.
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16
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Desai NR, Reed P, Alvarez PJ, Fogli J, Woods SD, Owens MK. The Economic Implications of Hyperkalemia in a Medicaid Managed Care Population. AMERICAN HEALTH & DRUG BENEFITS 2019; 12:352-361. [PMID: 32055283 PMCID: PMC6996620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Hyperkalemia, defined as a serum potassium level >5 mEq/L that results from multiple mechanisms, is a serious medical condition that can lead to life-threatening arrhythmias and sudden cardiac death. The coexistence of cardiac and renal diseases (ie, cardiorenal syndrome) significantly increases the complexity of care, but its economic impact is not well-characterized in this understudied Medicaid managed care population with hyperkalemia. OBJECTIVE To calculate the economic impact of hyperkalemia on patients with cardiorenal syndrome in a Medicaid managed care population in the United States using real-world data. METHODS In this retrospective cohort study, we used a proprietary Medicaid managed care database from 1 southern state. The total study population included 3563 patients, including 973 patients with hyperkalemia and 2590 controls (without hyperkalemia), who were matched based on age, comorbidities, and Medicaid eligibility status and duration, during a 30-month period between 2013 and 2016. The inclusion criteria for the hyperkalemia cohort were age ≥18 years, Medicaid-only insurance status, coded cardiorenal diagnosis, and a claim for hyperkalemia during the study period. The cost was determined using paid claims data. RESULTS The mean healthcare costs (medical and pharmacy per member per year [PMPY] for patients with hyperkalemia was higher than that for the control cohort without hyperkalemia ($56,002 vs $23,653, respectively). These cost differences were driven by medical costs accrued in the hyperkalemia and in the control cohorts ($49,648 and $18,399 PMPY, respectively). Two of the largest drivers of the medical cost variance were inpatient costs ($33,116 vs $10,629 PMPY for the hyperkalemia and control cohorts, respectively) and dialysis costs ($2716 vs $810 PMPY, respectively). The medical loss ratios were 552% for the hyperkalemia cohort and 260% for the control cohort. Both cohorts had revenue deficits to the health plan, but the hyperkalemia cohort had double the medical loss ratio compared with the control cohort. CONCLUSIONS The findings from this Medicaid managed care population suggest that hyperkalemia increases healthcare utilization and costs, which were primarily driven by the costs associated with inpatient care and dialysis. Our findings demonstrate that the Medicaid beneficiaries who have cardiorenal comorbidities accrue high costs to the Medicaid health plan, and these costs are even higher if a hyperkalemia diagnosis is present. The very high medical loss ratio for the hyperkalemia cohort in our analysis indicates that enhanced monitoring and management of patients with hyperkalemia should be considered.
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Affiliation(s)
- Nihar R Desai
- Assistant Professor of Medicine, Yale School of Medicine, New Haven, CT
| | - Pamala Reed
- Senior Director, Outcomes Research and Analysis, Intelligent Health Analytics, Tallahassee, FL
| | - Paula J Alvarez
- Senior Director, Managed Care Health Outcomes, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Jeanene Fogli
- Executive Director, Medical Affairs, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Steven D Woods
- Senior Director, Managed Care Health Outcomes, Relypsa, a Vifor Pharma Group Company, Redwood City, CA
| | - Mary Kay Owens
- President and Chief Executive Officer, Intelligent Health Analytics
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