Managing medications in patients with heart failure

Patients with heart failure clearly need a medical home where medications and supplements are regularly assessed and managed, and that medical home is increasingly the office of the internist, according to experts.

Consider the recent release of the American Heart Association (AHA) Scientific Statement “Drugs That May Cause or Exacerbate Heart Failure,” which brings together in a single document critical information about classes of drugs that should be avoided or used with caution in patients with heart failure. According to the statement, patients with heart failure take an average of more than 10 doses of prescribed medications each day; visit from 15 to 23 different clinicians each year; have several comorbidities for which they are receiving treatment; and are self-prescribing over-the-counter medications, herbal supplements, and vitamins. This daily medication regimen most likely includes drugs or supplements that exacerbate heart failure, counteract the effects of necessary medications, and place the patient at risk.

“The primary care physician really does have to take charge as the overseer of the entire regimen because one specialist may prescribe a drug and the other specialist will prescribe another,” said William T. Abraham, MD, FACP, director of the division of cardiovascular medicine at Ohio State University in Columbus. “Before you know it, you have medications that are in opposition to one another because no one is looking at the big picture.”

What to use, avoid

The complete list of problematic drugs in patients with heart failure can be found in the AHA scientific statement, but some of those most commonly encountered in primary care include the following.

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Both prescription and over-the-counter forms of these drugs tend to interfere with the efficacy of heart failure drugs, particularly for patients with reduced ejection fractions. NSAIDs can affect the kidney, worsening fluid retention and exacerbating heart failure in patients with systolic and diastolic heart failure, according to Dr. Abraham. He also noted that many patients taking over-the-counter formulations of an NSAID sometimes take enough to equal a prescription-strength dose of the drug.
• Rheumatologic medications, such as tumor necrosis factor-alpha inhibitors: These are associated with new-onset or worsening heart failure. The American College of Rheumatology recommends that these drugs only be considered in patients with compensated heart failure if there are no other reasonable options available, according to the AHA statement.
• Antihypertensive drugs: For patients with hypertension and heart failure, calcium-channel blockers can exert a negative inotropic effect on the heart, exacerbating or worsening the condition, and should be avoided, Dr. Abraham said. Minoxidil, a vasodilator, can worsen clinical outcomes in patients with heart failure.
• Antidepressants/antipsychotics: Higher doses of tricyclic antidepressants can prolong the QT interval, particularly in heart failure, said Robert L. Page II, PharmD, MSPH, professor and clinical specialist in the division of cardiology at the University of Colorado Denver and chair of the AHA scientific committee that wrote the recent statement. The selective serotonin reuptake inhibitor (SSRI) citalopram in doses exceeding 40 mg can increase the risk of QT prolongation in patients with heart failure, leading to risk of torsades de pointes. Also, clozapine and lithium can be a major problem for patients with heart failure, Dr. Page noted.
• Alpha-blockers: These are prescribed for urologic conditions but can exacerbate heart failure, according to the AHA statement.
• Metformin: Metformin can be used in patients with stable heart failure but should not be used in those with an estimated glomerular filtration rate below 30 mL/min/1.73 m². The FDA recently updated this information in a drug safety communication. The American Diabetes Association still recommends that the drug not be used in patients who have recently been hospitalized with heart failure or those who are unstable with frequent hospitalizations and large fluctuations in renal function, according to the AHA scientific statement.
• Dipeptidyl peptidase-4 (DPP-4) inhibitors: These are prescribed for type 2 diabetes. The FDA issued a new alert this year about the potential increased risk for patients with heart failure who take saxagliptin and alogliptin. A recently released trial, published in JAMA Cardiology in 2016, found no increased risk for heart failure with sitagliptin, another DPP-4 inhibitor. Dr. Page, however, advised caution with use of sitagliptin as well until further trials are completed.
• Oncology drugs: The list of oncologic drugs included in the AHA scientific statement is the largest on the list, according to Dr. Page. “Many of these drugs come onto the market so quickly, and it's a moving target. The primary care doctor needs to consult with the oncologist and cardiologist about managing these drugs in a patient with heart failure,” he said.

Reconcile medications

Ileana L. Piña, MD, MPH, a heart failure specialist and professor of medicine and epidemiology and population health at Albert Einstein College of Medicine in Bronx, N.Y., said that medication reconciliation by primary care physicians can help patients remain adherent with therapy.

Patients released from the hospital with a diagnosis of heart failure often come home with instructions to take 13 pills each day, some 3 or 4 times daily, Dr. Piña said. That type of regimen is impossible for most patients, she noted.

Dr. Piña recommends that several medications be quickly eliminated from this posthospital regimen: the stool softener, the laxative, the sleeping pill, and the pain pill. In addition, she said, most patients do not need to take a vitamin, and those previously using an inhaler for what was believed to be asthma may not need it after an accurate diagnosis of heart failure. Physicians should help decrease the number of drugs and simplify the regimen so that necessary medications must be taken only once or twice daily, she said.

Dr. Page stressed that medication reconciliation should be an ongoing process. “Patients pick up an over-the-counter supplement or will have picked up another prescription medication on a recent trip to the emergency department. It's sort of like barnacles on a ship: Medications just keep building, particularly among patients older than 65,” he said. “It is critical that there be medication reconciliation at each visit.”

Patients should be encouraged to bring all their medications in a paper bag when they visit their doctor so that someone can look through them and evaluate the components of each, Dr. Page noted. “For example, in some glucosamine products there is a fair amount of sodium, and glucosamine is a very common supplement,” he said. “You have to look at the fine print; the devil is in the details.”

Dr. Piña also advises primary care physicians to consult with the patient's heart failure specialist. “The primary care physician can be the steward of medication management, but I also urge them not to touch the heart failure drugs that have been given by a heart failure specialist. Try very hard not to cut down or discontinue the critical drugs for heart failure. If you are planning to do so, talk to a heart failure specialist first,” she said.

Educate the patient

In the real world of primary care, physicians typically do not have the time to perform a comprehensive medication assessment at every office visit. Dr. Piña advised that a nurse practitioner, a nurse, a physician assistant, a qualified nonphysician, or a pharmacist on staff can talk to patients about their medications, supplements, and over-the-counter products, providing information about which ones to avoid and educating them about the effect of diet choices and unnecessary medications or supplements on their heart failure.

This assessment and patient education “should be reiterated at each visit so that it is the same message time and time again: Remember your weight, remember your diuretic dose, remember what you are eating, and remember to eat an equal amount of protein, some carbs, and some fats. That is much better than spending money in these health food stores because you don't know what you are getting there,” Dr. Piña added.

Educational material should also be given to patients during a medication assessment, Dr. Piña said. The American Heart Association and the Heart Failure Society of America have online materials for patients, with information about diet, heart failure medications, symptoms, treatment plans, and other topics. ACP's Center for Patient Partnership in Healthcare offers Patient FACTS on heart failure in English and Spanish.

“Patients need reinforcement. I believe that if they have a primary care doctor that they trust and someone they have a relationship with, then when that person tells them that they really need to take certain medications, they tend to believe them,” Dr. Piña said. “The reinforcement that they get from this doctor is so critical.”