Polypharmacy in Heart Failure with Reduced Ejection Fraction
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The widespread availability of life-prolonging therapies has been met with slow uptake in clinical practice, and many eligible patients are not prescribed optimal guideline-directed medical therapies (GDMT). The recent introduction of ARNI and SGLT2i continues to face the same barriers of clinical inertia.

Patients with HF often have other comorbidities, and the number of prescribed medications increases with age, yet use of guideline-directed medical therapies remains low in the elderly population.10 Most older patients hospitalized with heart failure are prescribed greater than 10 medications at discharge and this rate has increased from 41% in 2003–2006 to 68% in 2011–2014. Polypharmacy is generally described as taking at least 5 medications, and it has several downsides including increased risk for drug-interactions, risk for adverse events, difficulties with adherence, and costs.

With increasing availability of evidence-based options for HFrEF treatment, there is a perceived risk for increasing rates of adverse events, especially among older patients. While this may be true, it is not universally relevant and alternate scenario of avoiding optimal therapy definitely poses an increased risk for worse quality of life, recurrent hospitalizations, and mortality.

Risks and benefits of polypharmacy thus need to be weight against the risk of growing polymorbidity and its subsequent impact. We therefore strongly contend that availability of multiple medications provides the clinicians and patients with potent therapeutic options and that the negative connotations around polypharmacy needs to be curbed to appropriate proportion.

Patients with HFrEF may have various comorbidities that may prohibit their eligibility for morbidity- and mortality-reducing therapies, such as chronic kidney disease, and orthostatic hypotension. An example as such includes progressive renal disease where ACEi, ARB, ARNI, or MRA may not be suitable; yet providers may still provide beta blockers and SGLT2i due to their cardiac and/or renal protective effects in HFrEF.

Alternatively, a patient with orthostatic hypotension may have increased adverse symptoms to beta blockers, ACEi, ARB, or ARNI, but may tolerate MRA and SGLT2i due to their lower hemodynamic profile. While such medication sequencing or prioritizing among certain HFrEF subtypes are lacking, the growing arsenal of HFrEF therapies warrants a tailored approach in such vulnerable subpopulations. Additionally, as there are no new pharmaceutical agents or classes in advanced stages of investigation in chronic stable HFrEF, now is the time to balance implementation of maximally prescribing existing guideline-directed medical therapies that work with minimizing patient intolerances or adverse symptoms.

Source: https://www.amjmed.com/article/S0002-9343(21)00280-1/fulltext?rss=yes