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Tan YJ, Ong SC, Low JZ. Budget Impact Analysis of Dapagliflozin in Treating Patients With Heart Failure With Reduced Ejection Fraction From the Perspective of Malaysian Public Healthcare System. Clin Ther 2024:S0149-2918(24)00217-0. [PMID: 39261261 DOI: 10.1016/j.clinthera.2024.08.008] [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: 05/02/2023] [Revised: 08/09/2024] [Accepted: 08/10/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE This is a budget impact analysis that compared the scenario of treating heart failure with reduced ejection fraction (HFrEF) using dapagliflozin plus standard of care (SoC) versus a scenario without dapagliflozin, from the perspective of Ministry of Health (MOH) Malaysia over a 5-year time horizon. METHODS A Microsoft Excel-based cost calculator was developed for such comparison. The estimated size of eligible population, uptake rates for dapagliflozin, as well as costs related to drugs, clinical events, and adverse events were based on published data, official tariffs, and databases, and expert opinion. Clinical data from the DAPA-HF trial were used to inform efficacy and safety inputs (i.e., hospitalization for heart failure (hHF), cardiovascular death, and adverse events). Results were reported as total annual and cumulative costs (in 2023 Malaysian Ringgits [RM], United States Dollars [USD], and European Union Euros, [EUR]; with exchange rates of 1 USD = RM 4.40 and 1 EUR = RM 4.90]), as well as the number of clinical events. Sensitivity and scenario analyses were also conducted. FINDINGS The base-case analysis estimated that over a five-year period, the adoption of dapagliflozin for HFrEF treatment would result in a cumulative cost-saving of RM 2.6 million (USD 0.6 million/EUR 0.5 million), representing a 0.3% reduction in costs, driven primarily by reduced expenditure on hHF. Moreover, dapagliflozin treatment would lead to 731 fewer hHF and 366 fewer cardiovascular deaths. Sensitivity and scenario analyses revealed that the results were most sensitive to assumptions regarding loop diuretic requirements and the cost of dapagliflozin. Although cost savings or a net-zero balance were projected for the first four years, an anticipated 2.5% annual increase in dapagliflozin uptake in the longer term would lead to additional costs for the MOH, starting from the fifth year. IMPLICATIONS Incorporating dapagliflozin into the SoC can improve health outcomes for HFrEF patients and may generate cost savings, potentially easing the economic strain of HFrEF management on Malaysia's public healthcare system in the short term. Nonetheless, a modest increase in budget should be anticipated as more patients gain access to the treatment over time.
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Affiliation(s)
- Yi Jing Tan
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Penang, Malaysia; Seri Manjung Hospital, Ministry of Health Malaysia, Seri Manjung, Perak, Malaysia
| | - Siew Chin Ong
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Penang, Malaysia.
| | - Joo Zheng Low
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Penang, Malaysia; Tuanku Fauziah Hospital, Ministry of Health Malaysia, Kangar, Perlis, Malaysia
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Biegus J, Cotter G, Metra M, Ponikowski P. Decongestion in acute heart failure: Is it time to change diuretic-centred paradigm? Eur J Heart Fail 2024. [PMID: 39169731 DOI: 10.1002/ejhf.3423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024] Open
Abstract
Congestion is a common cause of clinical deterioration and the most common clinical presentation at admission in acute heart failure (HF). Therefore, finding effective and sustainable ways to alleviate congestion has become a crucial goal for treating HF patients. Congestion is a result of complex underlying pathophysiology; therefore, it is not a direct cause of the disease but its consequence. Any therapy that directly promotes sodium/water removal only, thus targeting only clinical symptoms, neither modifies the natural course of the disease nor improves prognosis. This review aims to provide a comprehensive evaluation of the current decongestive therapies and propose a new (not diuretic-centred) paradigm of long-term congestion management in HF that attempts to correct the underlying pathophysiology, thus improving congestion, preventing its development, and favourably altering the natural course of the disease rather than merely treating its symptoms.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Gad Cotter
- Momentum Research, Inc., Chapel Hill, NC, USA
- U 942 Inserm MASCOT, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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van Poelgeest E, Paoletti L, Özkök S, Pinar E, Bahat G, Vuong V, Topinková E, Daams J, McCarthy L, Thompson W, van der Velde N. The effects of diuretic deprescribing in adult patients: A systematic review to inform an evidence-based diuretic deprescribing guideline. Br J Clin Pharmacol 2024. [PMID: 39117602 DOI: 10.1111/bcp.16189] [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: 03/21/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024] Open
Abstract
In this systematic review, we report on the effects of diuretic deprescribing compared to continued diuretic use. We included clinical studies reporting on outcomes such as mortality, heart failure recurrence, tolerability and feasibility. We assessed risk of bias and certainty of the evidence using the GRADE framework. We included 25 publications from 22 primary studies (15 randomized controlled trials; 7 nonrandomized studies). The mean number of participants in the deprescribing groups was 35, and median/mean age 64 years. In patients with heart failure, there was no clear evidence that diuretic deprescribing was associated with increased mortality compared to diuretic continuation (low certainty evidence). The risk of cardiovascular composite outcomes associated with diuretic deprescribing was inconsistent (studies showing lower risk for diuretic deprescribing, or comparable risk with diuretic continuation; very low certainty evidence). The effect on heart failure recurrence after diuretic deprescribing in patients with diuretics for heart failure, and of hypertension in patients with diuretics for hypertension was inconsistent across the included studies (low certainty evidence). In patients with diuretics for hypertension, diuretic deprescribing was well tolerated (moderate certainty evidence), while in patients with diuretics for heart failure, deprescribing diuretics can result in complaints of peripheral oedema (very low certainty evidence). The overall risk of bias was generally high. In summary, this systematic review suggests that diuretic discontinuation could be a safe and feasible treatment option for carefully selected patients. However, there isa lack of high-quality evidence on its feasibility, safety and tolerability of diuretic deprescribing, warranting further research.
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Affiliation(s)
- Eveline van Poelgeest
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Luca Paoletti
- Pharmacy Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Serdar Özkök
- Istanbul Medical Faculty, Department of Internal Medicine, Division of Geriatrics, Capa, Istanbul University, Istanbul, Turkey
| | - Ezgi Pinar
- Istanbul Medical Faculty, Department of Internal Medicine, Division of Geriatrics, Capa, Istanbul University, Istanbul, Turkey
| | - Gülistan Bahat
- Istanbul Medical Faculty, Department of Internal Medicine, Division of Geriatrics, Capa, Istanbul University, Istanbul, Turkey
| | - Vincent Vuong
- Trillium Health Partners, Mississauga, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Eva Topinková
- Department of Geriatrics, 1st Faculty of Medicine Charles University, Prague, Czech Republic
- General Faculty Hospital, Prague, Czech Republic
- Faculty of Health and Social Sciences, University of South Bohemia, České Budějovice, Czech Republic
| | - Joost Daams
- Medical Library, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lisa McCarthy
- Trillium Health Partners, Mississauga, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathalie van der Velde
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Cavagnini ME, Best EE, Skersick PT, Truitt KP, Musick KL, Mangum BR, Hollis IB, Rodgers JE. Impact of Inpatient Initiation of SGLT2 Inhibitors on Diuretic Requirements in Patients With Heart Failure. J Pharm Pract 2024; 37:683-689. [PMID: 37032494 DOI: 10.1177/08971900231159739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve outcomes in patients with heart failure (HF) and are now included in guideline-directed medical therapy. Trials reporting the change in loop diuretic dose following SGLT2i initiation have indicated conflicting results. There is no clear guidance on whether reducing loop diuretic doses following SGLT2i initiation is appropriate. Objective: The purpose of this study is to assess the impact of SGLT2i initiation on diuretic adjustment in hospitalized patients with known or new HF. Methods: This was a retrospective, single health-system study assessing the change in loop diuretic dose in the 60 days following discharge for patients with HF initiated on SGLT2i therapy during a hospital admission or upon discharge. Secondary outcomes assessed effect on renal function and discontinuation of SGLT2i within the 60 day follow up period. Results: Forty percent of patients required loop diuretic dose adjustment, with 29% requiring a dose reduction within the 60 days following discharge. There was minimal change in serum creatinine or blood urea nitrogen. The SGLT2i was discontinued in 6 patients. Conclusions: After inpatient initiation of SGLT2is, approximately one-third of patients required a reduction in loop diuretic dose within 60 days following hospital discharge. Further study is recommended to confirm if empiric diuretic dose adjustments are appropriate in this HF population.
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Affiliation(s)
| | | | | | | | | | - Blake R Mangum
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Ian B Hollis
- UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
- UNC Medical Center, Chapel Hill, NC, USA
| | - Jo E Rodgers
- UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
- UNC Medical Center, Chapel Hill, NC, USA
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Domingo M, Ruiz-Cueto M, Teis A, Lupón J, Alonso N, Bayés-Genís A. SGLT2i and loop diuretic withdrawal or downtitration in heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:943-945. [PMID: 37331585 DOI: 10.1016/j.rec.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Affiliation(s)
- Mar Domingo
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - María Ruiz-Cueto
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Albert Teis
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Josep Lupón
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Nuria Alonso
- Servei d'Endocrinología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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Hershkowitz I, Cahn A. Prescription patterns in people who are frail. THE LANCET. HEALTHY LONGEVITY 2023; 4:e522-e523. [PMID: 37734396 DOI: 10.1016/s2666-7568(23)00177-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Isca Hershkowitz
- Department of Medicine, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 91120, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Lee KS, Noh J, Park SM, Choi KM, Kang SM, Won KC, Cho HJ, Moon MK. Evaluation and Management of Patients With Diabetes and Heart Failure: A Korean Diabetes Association and Korean Society of Heart Failure Consensus Statement. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:1-20. [PMID: 36818141 PMCID: PMC9902644 DOI: 10.36628/ijhf.2022.0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 05/25/2023]
Abstract
Diabetes mellitus is a major risk factor for the development of heart failure. Furthermore, the prognosis of heart failure is worse in patients with diabetes mellitus than in those without it. Therefore, early diagnosis and proper management of heart failure in patients with diabetes mellitus are important. This review discusses the current criteria for diagnosis and screening tools for heart failure and the currently recommended pharmacological therapies for heart failure. We also highlight the effects of anti-diabetic medications on heart failure.
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Affiliation(s)
- Kyu-Sun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Junghyun Noh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Chang Won
- Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Hyun-Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Min Kyong Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Lee KS, Noh J, Park SM, Choi KM, Kang SM, Won KC, Cho HJ, Moon MK. Evaluation and Management of Patients with Diabetes and Heart Failure: A Korean Diabetes Association and Korean Society of Heart Failure Consensus Statement. Diabetes Metab J 2023; 47:10-26. [PMID: 36727161 PMCID: PMC9925146 DOI: 10.4093/dmj.2022.0420] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
Diabetes mellitus is a major risk factor for the development of heart failure. Furthermore, the prognosis of heart failure is worse in patients with diabetes mellitus than in those without it. Therefore, early diagnosis and proper management of heart failure in patients with diabetes mellitus are important. This review discusses the current criteria for diagnosis and screening tools for heart failure and the currently recommended pharmacological therapies for heart failure. We also highlight the effects of anti-diabetic medications on heart failure.
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Affiliation(s)
- Kyu-Sun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Junghyun Noh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Chang Won
- Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Hyun-Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Min Kyong Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - The Committee of Clinical Practice Guidelines
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Korean Diabetes Association and Committee of Clinical Practice Guidelines
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Korean Society of Heart Failure
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Lee S. Renal Effects of SGLT2 Inhibitors and Potential Clinical Implications: Beyond the Heart. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:177-179. [PMID: 36381015 PMCID: PMC9634024 DOI: 10.36628/ijhf.2022.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/25/2022] [Indexed: 02/25/2023]
Affiliation(s)
- Sunki Lee
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
- Division of Cardiology, University of California San Francisco Medical Center, San Francisco, CA, USA
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