Curr Heart Fail Rep DOI 10.1007/s11897-014-0186-8

MANAGEMENT OF HEART FAILURE (TE MEYER, SECTION EDITOR)

Polypharmacy in Heart Failure Patients Vittoria Mastromarino & Matteo Casenghi & Marco Testa & Erica Gabriele & Roberta Coluccia & Speranza Rubattu & Massimo Volpe

# Springer Science+Business Media New York 2014

Abstract In heart failure (HF), the progressive use of multiple drugs and a complex therapeutic regimen is common and is recommended by international guidelines. With HF being a common disease in the elderly, patients often have numerous comorbidities that require additional specific treatment, thus producing a heavy pill burden. Polypharmacy, defined as the chronic use of five or more medications, is an underestimated problem in the management of HF patients. However, polypharmacy has an important impact on HF treatment, as it often leads to inappropriate drug prescription, poor adherence to pharmacological therapies, drug-drug interactions, and adverse effects. The growing complexity of HF patients, whose mean age increases progressively and who present multiple comorbidities, suggests the need for newer models V. Mastromarino : M. Casenghi : M. Testa (*) : E. Gabriele : R. Coluccia : S. Rubattu : M. Volpe Cardiology Department, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Ospedale Sant’Andrea Via di Grottarossa 1035-1039, 00189 Rome, Italy e-mail: [email protected] V. Mastromarino e-mail: [email protected] M. Casenghi e-mail: [email protected] E. Gabriele e-mail: [email protected] R. Coluccia e-mail: [email protected] S. Rubattu e-mail: [email protected] M. Volpe e-mail: [email protected] S. Rubattu : M. Volpe IRCCS Neuromed, Pozzilli, IS, Italy

of primary care to improve the management of HF patients. Self-care, telemonitoring, and natriuretic peptide-guided therapy represent promising new HF care models to face the complexity of the disease and its therapeutic regimen. Keywords Adherence . Brain natriuretic peptide . Comorbidities . Heart failure . Polypharmacy . Self-care

Introduction Heart Failure (HF) is a leading cause of morbidity, hospitalizations, and death, and is responsible for a large part of the economic burden for health care budgets. HF affects almost 5.1 million Americans [1] and about 15 million patients in more than 51 countries of the European Society of Cardiology, with an overall population of approximately 900 million people [2]. Its prevalence is reported to increase dramatically, especially among older people [1]. Indeed, the increase in life expectancy related to an improved treatment of acute coronary syndromes or valve diseases, and to an earlier diagnosis and better treatment of HF is leading to a progressive aging of HF population [3]. In the last three decades, the list of medications for HF expanded considerably. Unlike in many other diseases, medical therapy in HF has been largely an “add-on” phenomenon and, therefore, optimal HF therapy has become increasingly complex. Furthermore, with HF being a common syndrome in the elderly, it is often accompanied by several comorbid conditions. The most typical ones are chronic pulmonary disease, atrial fibrillation, obstructive sleep apnea, renal impairment, diabetes mellitus, systemic infections, thromboembolism, anemia, and cachexia, any of which may unfavorably affect HF patient prognosis [4]. Patients with multiple comorbidities require the adoption of a complex therapeutic scheme with several medications, thus leading to polypharmacy,

Curr Heart Fail Rep

which is an underestimated problem. Although there is no generally accepted definition of polypharmacy, it is often identified by cut-points based on the number of medications, usually more than five [5]. According to a more detailed definition, a distinction could be made between minor (2-4 drugs) and major (five or more drugs) polypharmacy [6]. Its prevalence has been reported to increase with age and is associated with an increased risk of inappropriate drug prescription, underuse of effective treatment, medication errors, poor adherence to pharmacological therapies, drug-drug and drug-disease interactions, and adverse effects [7]. In this article, we provide an overview of current knowledge on the role of polypharmacy in HF, propose a critical analysis of the open issues, and discuss possible solutions.

Treatment of HF: ATypical Paradigm of Add-on Therapy Medical therapy for HF, based on current evidence and recommended by guidelines, has become complex. Typically, guidelines for HF management propose a stepwise approach based on the severity of the disease, which almost unavoidably ends up involving multiple drugs. Angiotensinconverting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and β-blockers play an important role in modifying the course of HF and should be considered in every patient. In addition, diuretics and often anti-aldosteronic drugs are mandatory in order to relieve symptoms and signs of congestion, as well as to attenuate or delay the clinical progression of the disease [8]. Simultaneously, HF therapy also includes the treatment of underlying causative factors, such as hypertension, myocardial ischemia, atrial fibrillation, diabetes, and dyslipidemia, resulting in an increase in the number of prescribed drugs [9, 10]. In addition to these medications, many others have shown benefits in terms of symptom reduction and HF hospitalization, and represent either useful alternatives or additional treatments in patients with HF (for example, digoxin [11], ivabradine [12], and others still under investigations [3]). However, the use of additional drugs exacerbates the problem of polypharmacy.

Comorbidities in HF Besides treating HF and related cardiac conditions, the treatment of comorbidities is often necessary. In 2003, Havranek et al. showed that among 34,587 older Americans who were admitted to the hospital with HF, diabetes (38 %), chronic lung disease (33 %), atrial fibrillation (30 %), and prior stroke (18 %) were very frequent [13]. More recently, Braunstein and colleagues demonstrated that among 122,630 individuals aged ≥65 years with chronic HF, identified through a 5 % random sample of all US Medicare beneficiaries, nearly 40 % of

patients had ≥5 noncardiac comorbidities. Most frequently, noncardiac comorbidities were chronic obstructive pulmonary disease (COPD; 26 %) osteoarthritis (16 %), thyroid disease (14 %), Alzheimer’s disease/dementia (9 %), depression (8 %), chronic renal failure (7 %), asthma (5 %), and osteoporosis (5 %) [4]. In 2011, data from the National Health and Nutrition Examination Survey (NHANES) were analyzed across three survey periods (1988–1994, 1999–2002, 2003– 2008) in a sample of 1,395 patients with HF, and confirmed that the phenotype of patients with HF has changed substantially over the last two decades, as more recent HF patients are older, have more comorbidities, and use more medications [14••]. Indeed, the age-adjusted proportion of patients with HF who had ≥5 or more comorbidities increased from 42 % in 1988–1994 to 58 % in 2003–2008. The mean number of prescribed drugs increased markedly, from 4.1 to 6.4 [14••]. Recently, Ather and colleagues showed that patients with HF with preserved ejection fraction (HFpEF), accounting for nearly 40 % of HF patients, were older and had higher prevalence of COPD, diabetes, hypertension, psychiatric disorders, anemia, obesity, and cancer compared to patients with HF with reduced ejection fraction (HFrEF). The higher number of comorbidities produced more frequent non-HF hospitalizations in patients with HFpEF; mortality, however, did not differ between the two groups [15]. Several studies have shown that comorbidities have a negative prognostic role in HF [4, 16]. They are associated with a worse clinical status and frequently precipitate, complicate, or contribute to hospitalization, thus being an important predictor of hospitalization and mortality in HF. Moreover, the presence of comorbidities may raise the number of medications up to 10 per patient, increasing the risk of polypharmacy, and consequently, of drug interactions and side effects.

Polypharmacy in HF: An Under-recognized Problem In a retrospective study of 116 elderly patients with HF (median age 86; range 65–98), Lien and colleagues found that nearly 90 % of patients were taking four or more different medications [17]. The analysis of medication profiles upon admission and discharge of 91 consecutive patients admitted to the hospital for HF showed that polypharmacy increased from less than five medications per patient on admission to an average of 6.6 per patient on discharge, with median values of five medications [18]. Also Masoudi et al. investigated the chronic drugs prescribed at hospital discharge to elderly patients (≥65 years) hospitalized for HF in two cohorts separated by 27 months (April 1998–March 1999, n=31,602; July 2000–June 2001, n=30,774). They found that between the two time periods, there was an increase in the mean number of chronic medications prescribed (from 6.8 to 7.5, 11 % relative

Curr Heart Fail Rep

increase; P

Polypharmacy in heart failure patients.

In heart failure (HF), the progressive use of multiple drugs and a complex therapeutic regimen is common and is recommended by international guideline...
251KB Sizes 2 Downloads 0 Views