Are Tesslon Perles (Tris-acryl microspheres) safe for patients with Heart Failure (HF)?

Safety of Tessalon Perles in Heart Failure Patients

Tessalon Perles (benzonatate) should be used with caution in heart failure patients due to potential cardiac risks, including reported cases of cardiac arrest with overdose, though they are not specifically contraindicated in current heart failure guidelines.

Medication Safety in Heart Failure

• Current European Society of Cardiology (ESC) guidelines do not specifically list benzonatate (Tessalon Perles) among medications contraindicated in heart failure patients 1
• Several medication classes are explicitly contraindicated in heart failure due to increased risk of worsening heart failure and hospitalization:
  • NSAIDs and COX-2 inhibitors (Class III recommendation, Level B evidence) 2, 1
  • Thiazolidinediones/glitazones (Class III recommendation, Level A evidence) 2
  • Calcium channel blockers like diltiazem and verapamil in HFrEF patients 2

Potential Risks of Tessalon Perles

• Benzonatate is structurally similar to local anesthetics including tetracaine and procaine, which may have cardiovascular effects 3
• Case reports document cardiac arrest with residual complications following benzonatate overdose 3
• The rapid onset of life-threatening adverse events with limited treatment options in overdose settings raises concerns about its use in vulnerable populations 3

Clinical Decision-Making Algorithm

1. Assess necessity of cough suppression:

   • Determine if cough is related to heart failure itself or another condition 1
   • Consider if cough could be a side effect of heart failure medications (e.g., ACE inhibitors) 4

2. Consider non-pharmacological approaches first:

   • Proper positioning, adequate hydration, and addressing underlying causes of cough 1

3. If medication is necessary:

   • Use lowest effective dose of benzonatate
   • Monitor for signs of cardiac decompensation
   • Avoid in patients with severe or unstable heart failure

4. Medication monitoring:

   • Regular assessment of heart failure symptoms
   • Monitor for potential adverse effects
   • Discontinue if any signs of worsening heart failure

Important Considerations and Pitfalls

• Failing to recognize that persistent cough might be a symptom of worsening heart failure rather than an independent condition requiring treatment 1
• Not considering potential drug interactions between benzonatate and standard heart failure medications 5
• Overlooking the risk of overdose, especially in patients with cognitive impairment or depression 3
• Not educating patients about proper dosing and potential risks of benzonatate 3

Alternative Approaches

• Optimize guideline-directed medical therapy for heart failure to reduce symptoms including cough related to pulmonary congestion 2, 5
• Consider addressing underlying causes of cough rather than symptomatic treatment 1
• If cough is ACE inhibitor-related, consider switching to an angiotensin receptor blocker (ARB) as an alternative 4