Real-World Challenges to Prescribing Sacubitril/Valsartan for Patients with Heart Failure

SEPTEMBER 22, 2016
W. Todd Penberthy,PhD
At HFSA 2016, Eiran Z. Gorodeski, MD, MPH, director of the Center for Connected Care at the Cleveland Clinic, elegantly presented how his institution implemented the new heart failure therapy sacubitril/valsartan in the real world.
He started by noting that for, patients with chronic symptomatic heart failure with reduced ejection fraction (HFrEF) NYHA class II or III, who can tolerate an ACE inhibitor or angiotensin receptor blocker (ARB), the ACC/AHA/HFSA HF 2016 guidelines recommended replacement by an angiotensin receptor-neprilysin inhibitor (ARNI; sacubitril within entrust) to further reduce morbidity and mortality.
In the presentation, Gorodeski addressed the following questions: How do you implement these guidelines in the real world? How do you navigate the insurance barriers, which are very real? How do you up-titrate the medication?
He described the three packages of Entresto: (1) as 24/26 for 50 mg of sacubitril/valsartan respectively, (2) 49/51 for 100 mg, and (3) 97/103 for 200 mg total. Gorodeski reminded the audience that you can never cut the pills in half because these tablets are not proportionately the same.
Because it is common to switch a patient from an ACE inhibitor to an ARNI, it is important that physicians are aware that patients should never take an ARNI within 36 hours of taking an ACE inhibitor, as this can increase the risk for angioedema.
Gorodeski said cardiologists have been spoiled with powerful and cheap drugs. By making use of the GoogleRx database, he found that you can get furosemide for $4 per month in most places, valsartan for $10 per month, lisinopril for $3 per month, or spironolactone for $4 per month. However Entresto is $12 per day! Almost universally, patients will not be able to afford paying for this out of pocket. This introduces the insurance companies into the situation. Insurance coverage frequently requires prior authorization. He said the drug is 57% covered by Medicare part D and Medicare advantage plans. For those whose insurance does cover it, there tends to be a copay ranging from 0 to $200 per month. However, there are assistance programs available.

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