Should Entresto (sacubitril/valsartan), Xarelto (rivaroxaban), and Lasix (furosemide) be continued in a palliative care setting?

Management of Entresto, Xarelto, and Lasix in Palliative Care

In palliative care settings, Lasix (furosemide) should be continued for symptom management, while Entresto (sacubitril/valsartan) and Xarelto (rivaroxaban) should be evaluated for discontinuation based on the patient's goals of care, symptom burden, and life expectancy.

Medication-Specific Recommendations

Lasix (Furosemide)

• Continue furosemide as it provides direct symptom relief from congestion and edema
• Loop diuretics are considered essential medications in palliative care for managing dyspnea and fluid overload 1
• The European Society of Cardiology specifically identifies furosemide as a medication appropriate for anticipatory prescribing in palliative care 1
• For select patients with severe symptoms, home administration of IV or subcutaneous furosemide can be considered 1

Entresto (Sacubitril/Valsartan)

• Consider discontinuation as life expectancy shortens
• While Entresto can prevent heart failure hospitalization, its primary benefit is long-term rather than immediate symptom relief 1
• As patients approach end of life, angiotensin receptor-neprilysin inhibitors may become less tolerable and require downtitration for symptomatic hypotension 1
• Quality of life benefits from Entresto 2 must be balanced against:
  • Pill burden
  • Risk of hypotension
  • Limited time to benefit in palliative care context

Xarelto (Rivaroxaban)

• Consider discontinuation based on goals of care discussion
• The AHA guidelines specifically note that "in patients with ESCVD, the time to benefit may be longer than a patient's anticipated life expectancy; therefore, it may be practical to stop anticoagulation" 1
• Risk of bleeding increases in patients >75 years, those with renal impairment, and patients with frailty 1
• Abrupt discontinuation increases thrombotic risk, so careful consideration is needed 3
• Shared decision-making should include discussion of stroke risk versus bleeding risk and align with patient preferences 1

Decision-Making Algorithm

1. Assess life expectancy and goals of care

   • Weeks to days: Prioritize symptom management only
   • Months: Consider medication burden versus benefit

2. Evaluate symptom burden

   • Congestion/edema: Continue or increase Lasix
   • Hypotension: Consider reducing or stopping Entresto
   • Bleeding risk: Evaluate need for Xarelto

3. Consider medication burden

   • Reduce total pill count when possible
   • Prioritize medications that directly improve symptoms

4. Implement changes gradually

   • Taper medications rather than abrupt discontinuation
   • Monitor for symptom changes after medication adjustments

Important Considerations

• Symptom management is the priority in palliative care rather than disease modification or prevention 1
• Shared decision-making should incorporate benefits, risks, and patient preferences 1
• Monitor for hypotension which is more common with Entresto (15.9% vs 5.7% with conventional therapy) 4
• Avoid abrupt discontinuation of Xarelto due to increased thrombotic risk; consider bridging or gradual tapering 3
• Recognize that patient preferences may evolve as disease progresses, requiring reassessment of medication goals 1

By focusing on medications that provide direct symptom relief while reducing those primarily aimed at long-term outcomes, the medication regimen can be optimized to enhance quality of life in the palliative care setting.