From the Guidelines
For a patient with anasarca, heart failure with preserved ejection fraction (HFpEF), and sarcoidosis, I strongly recommend initiating diuretic therapy with loop diuretics, such as furosemide, and adding an SGLT2 inhibitor, like empagliflozin, to manage HFpEF, alongside treating sarcoidosis with prednisone. The treatment approach should prioritize addressing both the fluid overload from heart failure and the inflammatory process of sarcoidosis. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, diuretics are recommended as needed for HFpEF, and SGLT2 inhibitors are suggested for symptomatic HF with LVEF ≥50%. For the sarcoidosis component, corticosteroid treatment, such as prednisone 20-40mg daily, is typically the first-line treatment, with gradual tapering based on response, as suggested by Bozkurt et al 1. In cases of steroid-resistant disease or significant side effects, consider alternative immunosuppressive therapies. Regular monitoring of fluid status, renal function, electrolytes, and cardiac function is crucial to adjust the treatment plan as needed. Key aspects of management include:
- Diuretic therapy with loop diuretics, such as furosemide 40mg twice daily, potentially increasing to 80-120mg daily if needed
- Addition of an SGLT2 inhibitor, like empagliflozin 10mg daily, for HFpEF management
- Blood pressure control, targeting <130/80 mmHg, with medications like ACE inhibitors or ARBs if ACE inhibitors aren't tolerated
- Treatment of sarcoidosis with prednisone 20-40mg daily, with gradual tapering based on response
- Consideration of alternative immunosuppressive therapies, such as methotrexate or mycophenolate mofetil, in cases of steroid-resistant disease or significant side effects.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Heart Failure with Preserved Ejection Fraction (HFpEF)
- Mineralocorticoid receptor antagonists (MRAs) have been studied as a potential treatment for HFpEF, with spironolactone being one of the most researched MRAs 2, 3, 4, 5.
- The TOPCAT trial, a randomized, double-blind clinical trial, demonstrated that spironolactone decreases heart failure hospitalizations in patients with HFpEF, although the primary outcome was not significantly reduced 2, 4.
- Post hoc analysis of the TOPCAT trial identified certain HFpEF phenotypes that responded favorably to spironolactone, suggesting potential for personalized MRA therapy 3.
- MRAs have been shown to improve diastolic function and induce beneficial remodeling through a reduction in myocardial fibrosis in patients with HFpEF 5.
Considerations for Patients with Sarcoidosis and Anasarca
- There is limited research specifically addressing the treatment of HFpEF in patients with sarcoidosis and anasarca.
- However, the use of MRAs such as spironolactone may be beneficial in reducing heart failure hospitalizations and improving symptoms in patients with HFpEF, regardless of the underlying cause 2, 4.
- Close monitoring of potassium and renal function is necessary when using MRAs, as they can increase the risk of hyperkalemia and renal retention of potassium 2, 4, 5.
Future Directions
- Further research is needed to fully understand the role of MRAs in the treatment of HFpEF, particularly in patients with sarcoidosis and anasarca 3, 6.
- The concept of phenomapping presents an encouraging avenue for investigating different intervention targets and novel therapies for HFpEF 3.
- Non-steroidal MRAs and sodium-glucose co-transporter 2 (SGLT2) inhibitors may emerge as promising treatment options for HFpEF in the future 3.