Psychiatric Manifestations With Sacubitril/Valsartan: A Case Report

Angiotensin Receptor-neprilysin Inhibitor Versus Renin-angiotensin System Inhibitor for Dementia Risk in Patients With Heart Failure

ABSTRACT

The authors report the impact of angiotensin receptor-neprilysin inhibitor (ARNI) versus renin-angiotensin system inhibitor (RASI) on the management and outcomes in dementia among heart failure (HF) patients as obtained from the real-life nationwide registry. In this study, HF patients between January 1, 2017 and December 31, 2019 were divided into 2 groups, including subjects receiving RASI and ARNI. The incidence rate of dementia was calculated with the unit of 1000 person-years. Cox proportional hazard model was applied for the examination of the hazard ratio, and also presented with 95% confidence interval. Between 2017 and 2019, RASI and ARNI cohorts contain 18,154 subjects. After adjusting with age, sex, comorbidities, and medications, ARNI cohort had a lower risk of dementia (adjusted hazard ratio = 0.83; 95% confidence interval = 0.72, 0.95) than RASI cohort. The authors concluded that use of ARNI was associated with a lower risk of new-onset dementia in patients with HF.

Updated insights on dementia‐related risk of sacubitril/valsartan: A real‐world pharmacovigilance analysis

AIM

Sacubitril/valsartan is a new cardiovascular agent characterized by its dual inhibition on the reninangiotensin system (RAS) and the neprilysin. As neprilysin also involved itself in the degradation of amyloid-β, there is an ongoing concern about the effect of sacubitril/valsartan on cognition, especially in case of long-term administration.

METHODS

The FDA Adverse Event Reporting System (FAERS) was mined between 2015Q3 and 2022Q4 to analyze the association between sacubitril/valsartan and adverse events (AEs) involving dementia. Standardized Medical Dictionary for Regulatory Activities (MedDRA) Queries (SMQs) with "broad" and "narrow" preferred terms (PTs) relevant to dementia was applied to systematically search demented AE reports. The Empirical Bayes Geometric Mean (EBGM) from Multi-Item Gamma Poisson Shrinker (MGPS) and proportional reporting ratio with Chi-square (PRR, χ2 ) were used to calculate the disproportionality.

RESULTS

We filtered the query for indication and identified 80,316 reports with heart failure indication in FAERS during the analytical period. Among all the reports, sacubitril/valsartan was listed as primary suspected or secondary suspected drug in 29,269 cases. No significantly elevated reporting rates of narrow dementia were evident with sacubitril/valsartan. The EBGM05 for narrow dementia-related AEs associated with sacubitril/valsartan was 0.88 and the PRR (χ2 ) was 1.22 (2.40). Similarly, broad demented complications were not over-reported in the heart failure patients administrated with sacubitril/valsartan (EBGM05 1.11; PRR 1.31, χ2 109.36).

CONCLUSION

The number of dementia-related cases reported to FAERS generate no safety signal attributable to sacubitril/valsartan in patients with heart failure for now. Further follow-ups are still warranted to address this question.

Evaluating sacubitril/valsartan as a treatment option for heart failure with reduced ejection fraction and preserved ejection fraction

INTRODUCTION

Sacubitril/valsartan is the first-in-class angiotensin-receptor neprilysin inhibitor approved in 2015 for the treatment of heart failure with reduced ejection fraction (HFrEF). On 16 February 2021, the Food and Drug Administration acknowledged that "Benefits are most clearly evident in patients with left ventricular ejection fraction below normal," thus potentially extending the use in subjects with heart failure and preserved ejection fraction (HFpEF).

AREAS COVERED

The authors outline the regulatory history, pharmacokinetics, pharmacodynamics, and risk-benefit profile of sacubitril/valsartan in HFrEF and HFpEF. A critical cross-trial comparison is presented, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), together with an insight into the latest European Society of Cardiology guidelines, where the new category of heart failure with mildly reduced ejection fraction is introduced.

EXPERT OPINION

Sacubitril/valsartan is a foundation of the pharmacological armamentarium in HFrEF to counteract the neuro-hormonal changes and reverse cardiac remodeling, together with beta-blockers, SGLT2i and mineralocorticoid receptor antagonists. The optimal sequence algorithm is an evolving issue, and the authors provide the reader with their personal perspective. A multidisciplinary management is encouraged to minimize the therapeutic inertia and manage tolerability issues, thus supporting adherence. Pragmatic trials, pharmacovigilance, and high-quality real-world evidence are crucial toward personalized safe prescribing of sacubitril/valsartan.

Effect of Sacubitril/Valsartan on Neurocognitive Function: Current Status and Future Directions

Sacubitril/valsartan is a new medication approved for the treatment of heart failure with reduced ejection fraction. While the drug failed to meet the primary endpoint in patients with heart failure with preserved ejection fraction in the PARAGON-HF trial, improvements were noted in several secondary endpoints. Valsartan is an angiotensin receptor blocker and sacubitril is a neprilysin inhibitor. Neprilysin is postulated to have a role in the degradation of beta-amyloid in the brain; therefore, sacubitril could theoretically increase beta-amyloid plaque deposition in the brain and potentially increase the risk of Alzheimer's disease. Although pre-clinical and clinical studies have shown promising safety results, those studies have been heavily criticized for short monitoring time and targeted populations. In accordance with the requirements of the US Food and drug Administration (FDA), the ongoing Prospective Evaluation of Cognitive Function in Heart Failure: Efficacy and Safety of Entresto compared to Valsartan on Cognitive Function in Patients with Chronic Heart Failure and Preserved Ejection Fraction (PERSPECTIVE; NCT02884206) multicenter, randomized, double-blinded trial is assessing the long-term neurocognitive effects and safety of sacubitril/valsartan, and results are expected in early 2022.