Heart Failure

Pharmacological Management of Heart Failure

Sodium Glucose Co-Transporter 2 Inhibitors (SGLT2i) for Management of Heart Failure

This information is intended for primary and secondary care clinicians in NHS South West London (NHS SWL) managing patients with heart failure (HF) with reduced ejection fraction (HFrEF).

Summary

  • It covers the use of sacubitril valsartan (Entresto®) in patients with HFrEF and should be utilised in conjunction with the NHS SWL HF pathway and SWL pharmacological management of HF guidance.
  • Sacubitril valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI). It is licensed and approved by NICE in technology appraisal 388 (TA388) for use in the management of HF in patients with reduced left ventricular ejection fraction (LVEF less than or equal to 35%) who remain symptomatic despite a stable dose of angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB).

Recommendations

  • Sacubitril valsartan is to be initiated by the patient’s specialist HF team (AMBER 2 on NHS SWL formulary). The patient will be monitored by the HF team until titrated to the maximum tolerated dose. Prescribing of sacubitril valsartan will then transfer to primary care once stabilised on the dose.
  • Transfer of prescribing responsibility is to be communicated to primary care via clinic letter or discharge letter including an individual management plan (this replaces transfer of care forms).

Roles and responsibility

HF specialist team responsibility

  • Following a shared decision by a heart failure specialist (nurse, pharmacist or doctor) with the patient, considering benefits and risks, contra-indications and side effects (see Summary of Product Characteristics (SmPC) and SWL pharmacological management of HF) initiate sacubitril valsartan for symptomatic chronic HFrEF according to NICE TA388.
  • Monitor patient at initiation and following dose changes until up-titrated to the highest tolerated dose of sacubitril valsartan on which the patient is stable (stable renal function and blood pressure (BP), no side effects), prior to transfer of prescribing responsibility to primary care.
  • Complete discharge letter or outpatient letter requesting transfer of prescribing responsibility, which should include:
    • Indication for therapy, dose.
    • Individual management plan.
    • Plans for follow up.
    • Assessment results upon stabilisation on maintenance dose: renal function and electrolytes and BP.
    • Details of HF specialist team for advice/support.
  • Secondary care HF team to support community HF nursing team with clinical advice regarding dose titration and prescriptions as appropriate
  • Supply at least 4 weeks of sacubitril valsartan at transfer of prescribing (exception applies for patients requiring blister packs; primary care may be asked to prescribe earlier).
  • Continue to follow up the patient for further optimisation of HF management as clinically indicated.

Primary care responsibility

  • Continue prescribing sacubitril valsartan at the recommended maintenance dose after initiation and stabilisation and following communication from the heart failure team as above (AMBER 2 on SWL formulary – transfer of care via clinic or discharge letter, to include individual management plan).
  • Remove ACEI or ARB from repeat prescriptions, add sacubitril valsartan to repeat prescriptions and communicate changes with the patient’s community pharmacy especially for blister pack patients to reduce the risk of co-prescribing errors and potential acute kidney injury (AKI) and/or hyperkalaemia.
  • Review medication and seek HF specialist advice if concerned about:
    • Systolic BP less than or equal to 95 mmHg with symptomatic hypotension
    • Angioedema (stop sacubitril valsartan)
    • Pregnancy/breastfeeding (sacubitril valsartan is contra-indicated)
    • Serum potassium more than 5.4mmol/L (may need to consider discontinuation or dose reduction)
    • Severe hepatic impairment, biliary cirrhosis or cholestasis (contraindicated with Child-Pugh C cirrhosis)
    • Estimated glomerular filtration rate (eGFR) declines to less than 30ml/min or increased serum creatinine by more than 50% or creatinine clearance reduced by more than 50% from baseline
    • Dehydration, worsening HF symptoms, fluid overload or weight gain
    • The patient is experiencing psychiatric events as an adverse effect
  • Follow up in primary care with 6-monthly medical review recommended by NICE CG106 for stable HF patients.

Prescribing and monitoring guidance

  • Recommended initial dose is 49/51 mg twice daily and the dose is doubled at 2 to 4 weeks to the target dose 97/103 mg twice daily if tolerated.
  • An initiation dose of 24/26 mg twice daily is indicated in patients with hypotension (systolic blood pressure 100 to 110 mmHg), moderate renal impairment (eGFR 30 to 60 ml/min) or moderate hepatic impairment (alanine aminotransferase or aspartate aminotransferase more than or equal to two times the upper limit of normal).
  • Never prescribe an ACEI or ARB at the same time as sacubitril valsartan.
    • If the patient is already taking an ACEI: STOP ACEI therapy for 36 hours before starting sacubitril valsartan.
    • Patients already taking ARBs may start sacubitril valsartan on the day after stopping ARB therapy.
  • The monitoring requirements of sacubitril valsartan are the same as an ACEI or ARB. Baseline blood pressure, heart rate and a renal profile will be checked prior to initiation and at 2 to 4 weeks following each dose change.
  • See SWL pharmacological management of HF guidance and SmPC for further prescribing and monitoring information.

References/resources

V1.0 Approved by Integrated Medicines Optimisation Committee (IMOC) February 2025 (Acknowledgement South East London ICB)