NAPLEX Question of the Week: Heart Failure Handoff

Heart failure medication management is the subject of our question of the week.
NAPLEX Question of the Week: Heart Failure Handoff
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JS is a 67-year-old male who is a loyal customer of your community pharmacy. He walks in with a new written prescription from his new primary care provider. The prescription is for sacubitril/valsartan 49/51 mg by mouth twice daily.

Past Medical History:

Diabetes mellitus (Type 2)

CKD (estimated eGFR 40mL/min/1.73 m2)

HFrEF (EF 35%)

Hyperlipidemia

Hypertension

Depression

Current Medication List:                                                                                                                 

Zebeta 10 mg PO QD

Lasix 80 mg PO QD

Jardiance 25 mg PO QD

Vasotec 10 mg PO BID

Livalo 2 mg PO QD

Zoloft 50 mg PO QD 

Regarding the new prescription, which of the following would be correct?

A. The sacubitril/valsartan prescription should not be filled due to JS's CKD.

B. Sacubatril/valsartan can be safely initiated after stopping Vasotec for 2 days.

C. Sacubitril/valsartan should be taken with food to increase absorption.

D. The patient should continue to take Vasotec for the first two weeks after starting sacubitril/valsartan to reduce risk of a heart failure exacerbation.

Answer with Rationale:

Heart Failure is a common and debilitating condition. Heart failure is a syndrome where enough blood cannot be provided to tissues and organs.  It can be split into two main categories: heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Other recent categories include heart failure with improved ejection fraction (HFimpEF) and mid-range or mildly reduced heart failure (HFmrEF). HFrEF is when the left ventricle cannot contract normally causing the heart to not be able to pump with enough force to provide adequate blood circulation. HFpEF is when the left ventricle loses the ability to relax normally, leading to the heart not properly filling with blood between heartbeats. Common symptoms of heart failure are shortness of breath, chest pain, fatigue, and fluid retention.

Entresto (sacubitril/valsartan) is a combination neprilysin inhibitor/angiotensin receptor blocker that is a frontline medication for the management of HFrEF due to its ability to decrease morbidity and mortality. Let's go through each answer to address why they are correct or incorrect. 

Answer A is incorrect: Sacubitril/valsartan can be used in patients with CKD.  A dose reduction to 24mg/26mg BID would be needed if the eGFR is less than 30ml/min/1.73m2

Answer B is correct: There should be a 36-hour washout period between discontinuing ACE inhibitors, such as Vasotec (enalapril), and starting sacubitril/valsartan to reduce the risk of angioedema. A 2-day period would give enough time for safe initiation of Entresto. 

Answer C is incorrect: Sacubitril/valsartan can be taken with or without food as clinical outcomes are not different with either administration technique.

Answer D is incorrect: Sacubitril/valsartan should not be initiated within 36 hours of taking an ACE inhibitor, such as Vasotec (enalapril), due to the increased risk of angioedema. 

Brand/Generics Covered: Entresto (sacubitril/valsartan), Zebeta (bisoprolol), Lasix (furosemide), Jardiance (empagliflozin), Vasotec (enalapril), Livalo (pitavastatin), Zoloft (sertraline) 

Naplex Competencies Covered:

Area 1 – Obtain, Interpret, or Assess Data, Medical, or Patient Information

  • 2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
  • 4 – From medical records: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
  • 5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology

Area 2 – Identify Drug Characteristics

  • 1 – Pharmacology, mechanism of action, or therapeutic class
  • 2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
  • 3 – Boxed warnings or REMS

Area 3 – Develop or Manage Treatment Plans

  • 2 – Therapeutic goals or outcomes and clinical endpoints
  • 3 – Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions
  • 4 – Drug dosing or dosing adjustments; duration of therapy
  • 6 – Drug contraindications, allergies, or precautions
  • 8 – Drug interactions

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