How to manage heart failure treatment with Sacubitril Valsartan (Entresto) while minimizing costs?

Managing Heart Failure Treatment with Sacubitril/Valsartan (Entresto) While Minimizing Costs

For this patient, switching to a full tablet of sacubitril/valsartan 24/26mg once daily is recommended instead of splitting tablets, as this maintains therapeutic benefit while addressing cost concerns and ensuring proper dosing.

Understanding the Issue

The pharmacy has raised two important concerns:

1. Cost barrier: Even generic sacubitril/valsartan costs $70 (vs $325 for brand)
2. Dosing concern: Manufacturer advises against splitting tablets due to uneven distribution of the two active ingredients

Rationale for Recommendation

Medication Efficacy and Safety

• Sacubitril/valsartan should not be split as it contains two active ingredients that aren't evenly distributed in the tablet 1
• Splitting could lead to inconsistent dosing and unpredictable therapeutic effects
• Maintaining the patient on some form of sacubitril/valsartan is important as it significantly reduces mortality and heart failure hospitalizations compared to ACE inhibitors 2

Cost-Effectiveness Considerations

• The 2022 ACC/AHA/HFSA guidelines acknowledge that "in patients in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value" 2
• However, sacubitril/valsartan has demonstrated superior outcomes in reducing heart failure hospitalizations (8.0% vs 13.8% with enalapril) 2
• Long-term use of sacubitril/valsartan (>270 days) has been shown to decrease healthcare costs by 22%, primarily through reduction in hospitalizations 3

Options for This Patient

1. Recommended: Switch to whole tablet once daily

   • Use a full 24/26mg tablet once daily instead of splitting tablets
   • This maintains the patient on ARNI therapy while addressing cost concerns
   • The lower dose may still provide clinical benefit while minimizing financial toxicity

2. Alternative: Consider ACEi/ARB substitution

   • If cost remains prohibitive, switching to a generic ACEi or ARB is considered acceptable by guidelines 2
   • This would be a step down in therapy but provides "high economic value" when ARNi is not feasible

3. Explore assistance programs

   • Pharmaceutical company copay assistance programs for sacubitril/valsartan may help reduce costs 2
   • Patient may qualify for assistance if meeting income thresholds 2

Implementation Steps

1. Prescribe sacubitril/valsartan 24/26mg once daily (lowest available dose)
2. Monitor blood pressure closely, especially given the patient is also on metoprolol and midodrine
3. If patient tolerates this regimen, consider gradual titration to twice daily dosing if clinically indicated and financially feasible
4. Schedule follow-up within 1-2 weeks to assess tolerance and effectiveness

Important Considerations

• Blood pressure monitoring: The patient is on multiple medications that can lower blood pressure (metoprolol, sacubitril/valsartan) as well as midodrine which raises it
• Renal function: Monitor closely as the patient is on apixaban and sacubitril/valsartan
• Financial toxicity: Studies show that out-of-pocket medication costs can lead to non-adherence and worse outcomes 2
• Avoid abrupt discontinuation: Sudden withdrawal of RAAS inhibition can lead to clinical deterioration 2

This approach balances the clinical benefits of maintaining the patient on some form of ARNI therapy while addressing the practical concerns of cost and proper medication administration.