Gary Besinque, PharmD: We [at Kaiser Permanente] update our HF management guidelines every 2 years. Recognizing the impact of the various cardiovascular (CV) safety trials that the FDA [United States Food and Drug Administration] had asked for, and the quite impressive results that SGLT2 (sodium-glucose cotransporter-2) [inhibitors] emerged with after a good number of studies, we began to consider where SGLT2 [inhibitors] would be placed in heart failure (HF) management.
[The] decisions on whether to start or not start SGLT2 inhibitors in patients with HF was based on where patients are on the continuum of HF disease. We’re happy to recognize that presence or absence of diabetes was not material to the decision to [start an SGLT2 inhibitor].
Generally, when we're tweaking [Kaiser Permanente’s] National HF guidelines, we make incremental moves, and that's what happened [when we introduced SGLT2 inhibitors]. We still rely heavily on the β-blockers [that have demonstrated good safety and efficacy in HF]—carvedilol, bisoprolol, and metoprolol tartrate—for early initiation, especially in patients with HF after a heart attack. [After these have been initiated,] the next class [we recommend initiating] would be the ACE [angiotensin-converting enzyme] inhibitors or ARBs [angiotensin receptor blockers].
After that, we thought that SGLT2s would be good, because…we felt that the more myocardium there was to ameliorate any deficiencies, the better, because that should hopefully result in long term improvement in quality of life. The SGLT2 [inhibitors] came in [third], especially in the patients with better ejection fraction and better New York Heart Association (NYHA) [functional class for] HF. MRAs (mineralocorticoid receptor antagonists) and ARNIs (angiotensin receptor-neprilysin inhibitors) are definitely next [and last to be initiated, according to our recommendations].
The economics are the elephant in the room when you're talking about instituting newer therapies earlier, and of course, earlier means amongst a much larger cohort. It does make waves in terms of the finance folks; [they’re asking] whether you can keep the enterprise afloat. Our purchasing and contracting team does a stellar job. Kaiser's a large operation, so they can acquire some very favorable contracting. That was the case for our SGLT2 [inhibitors]. [This has made] it easier to explore the benefits and dimensions of SGLT2-inhibitor use in our program.
Of course, in the back of mind comes that 30-day readmission conundrum that everybody has been struggling with, and not getting very much traction. You can easily translate a reduction in number of hospitalizations over time into more than making up for the extra cost of instituting SGLT2 [inhibitors] early.
We certainly have struggled, especially with HFpEF (heart failure with preserved ejection fraction), and it may be that introducing SGLT2 [inhibitors] very early in the care of these patients could make a strong impact on the quality of life and other dimensions of health care delivery.
This transcript has been edited for clarity.
For other articles and videos in this AJMC® Perspectives publication, please visit “Implementing the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure: SGLT2 Inhibitors, Treatment Sequencing, and Value Statements.”