CEimpact Podcast

The Impact of Timing on Heart Failure Treatment Success

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Heart failure remains a leading cause of hospitalization, prompting ongoing research into treatment strategies that improve outcomes for patients. A recent study explores the potential of combining an MRA agent and SGLT2 inhibitor, showing meaningful clinical benefit while also reinforcing the need for thoughtful patient selection and safety monitoring. Tune in to explore how this evidence may shape pharmacist-driven care and contribute to more confident, individualized treatment decisions.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Zachary Cox, PharmD
Professor
Lipscomb University College of Pharmacy

Joshua Davis Kinsey has no relevant financial relationships to disclose. 

Zachary Cox is a consultant for Roche, Reprieve Cardiovascular, Abiomed, Vectorious, Kestra Medical Technologies, and WhiteSwell. He was also a consultant for Lexicon Pharmaceuticals (ended 2025) and conducted research for AstraZeneca (ended 2024). All relevant financial relationships have been mitigated.  

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the clinical evidence supporting the use of multiple drug classes in combination therapy for heart failure.
2. Identify pharmacist considerations for evaluating patient-specific factors related to efficacy and safety of combination treatment approaches.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-299-H01-P
Initial release date: 10/20/2025
Expiration date: 10/20/2026
Additional CPE details can be found here.

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SPEAKER_02:

ACE Impact subscribers, welcome to the Game Changers Clinical Conversations Podcast. I'm your host, Josh Kinsey, and as always, I'm excited about our conversation today. As evidence for heart failure treatment continues to develop, pharmacists are uniquely positioned to address care gaps and improve patient outcomes through evidence-based therapy choices. In this episode, we review recent data and clinical insights that help pharmacists confidently support emerging guideline-driven heart failure management. And it's great to have Zach Cox as our guest for today. Zach, welcome.

SPEAKER_01:

Thank you so much for having me. It's a pleasure to be here.

SPEAKER_02:

Yeah, we really appreciate you giving us some of your time this afternoon. For our listeners that may not know you, Zach, go ahead and take a couple minutes to tell us a little bit about yourself.

SPEAKER_01:

Sure. I am a pharmacist in Nashville, Tennessee. I work at Lipscomb University College of Pharmacy, where I'm a professor of pharmacy and I teach cardiology to pharmacy students. I also work at Vanderbilt University Medical Center where I work every day. I see patients that are hospitalized with heart failure with an interdisciplinary team of physicians and nurses, and we care for those that are hospitalized with heart failure. And then I also participate in acute heart failure research at Vanderbilt University Medical Center, where we have a number of ongoing clinical trials that I help manage and oversee.

SPEAKER_02:

Great, great. Well, again, you're very busy, you wear many hats. So thank you for giving us some of your time this afternoon. We really appreciate it. So one thing I like to always do in the beginning, Zach, is just kind of lay the foundation for our listeners and just kind of let's set the stage. What is it we're talking about today? Let's discuss the actual disease state that we're discussing and just kind of go from there. So if you don't mind, just remind us, you know, be as clinical as needed, but remind us what heart failure is and maybe some of the specifications there. So like classifications, clinical burden, things like that.

SPEAKER_01:

Sure, yeah. Heart failure summarized is the failure of the heart to meet the metabolic demands of the body. And that's either due to it not pumping out enough blood, either because its pumping function, its contractility is weak, or because it's impairment in filling with blood due to sort of a diastolic. So when the heart is relaxing, dysfunction. And so we have a wide range of classifications of heart failure here. But before we jump into those, I think what's really important for us to recall is that heart failure is one of the number one causes for morbidity and mortality among Americans. It is, it carries a prognosis that's worse than most cancers. Uh, if we look at the five-year survival rate. And then when we look in the Medicare population, it's the number one reason that patients with Medicare are hospitalized in the United States. And so we have both, you know, a high disease burden and we have a high disease morbidity and mortality. And the number one way that we can reduce those things for our patients is through medicine. So pharmacists are uniquely poised here, regardless of what type of heart failure people have, to really make massive impacts on their life. And so the key, you know, classification that I think is most relevant to the article we're going to discuss today is based on the ejection fraction of the left ventricle. So when the left ventricle squeezes to pump blood to the body, what percent of the blood is ejected? And we're going to be really dealing with people in the study we're going to talk about who have close to a normal or preserved ejection fraction. Sometimes this is called HEF PEF, heart failure with preserved ejection fraction. This means that they pump out greater than 50% of the blood that was in their left ventricle whenever they squeeze. And this means for our current guideline recommended therapies, that they need to be on a couple of classes of medications that have been demonstrated in clinical trials to reduce the risk of heart failure hospitalization and reduce the risk of dying from heart failure, which we just mentioned. So those are going to be the two classes we're going to discuss: sodium glucose, co-transporter 2 inhibitors, SGLT2 inhibitors, like the flosins, and mineralicorticoid receptor antagonists, sometimes also called aldosterone antagonists. So things like Spronolactone, E. clailerone, phenerinone.

SPEAKER_02:

Great. That's a great review. Takes me back to 20 something years ago sitting in the classroom. So thank you. That's great. One thing that I would question is on the ejection fraction, since we're going to focus on that. Remind us what like what where does it have to be in order to be diagnosed with heart failure? Yeah.

SPEAKER_01:

That's a great question. You can have heart failure at any ejection fraction. And so we divide people with heart failure with a reduced ejection fraction less than 40%, heart failure with a preserved ejection fraction greater than 50%. And that leaves this sort of small sliver of people who have an ejection fraction of 40 to 50%, which have not been well represented in many clinical trials, but they're called heart failure with mildly reduced ejection fraction. Thankfully, our newer agents and SGLT2 inhibitors and MRAs have included them in some of their studies. So for these two classes, we do have a lot better idea of therapy. So any range of ejection fraction can develop heart failure, but that does respond differently to medications depending on which class we have. And you know, the number one barrier to getting these medicines on patients, unfortunately, in studies, is what we call clinical inertia, meaning they're doing okay. Why rock the boat? Why add another medicine? Why titrate the dose? And so there's been a really big push recently. And pharmacists in studies have been shown to be statistically significant movers of the needle of getting people on the right medicine and not just saying everything's okay, let's wait till something's not. And we try and liken this to cancer a lot, since it has a similar prognosis. No one would be diagnosed with cancer and say, well, just give me the bare minimum. And then if it gets worse, we'll really ramp up the treatment, right? Everyone would want the best treatment from day one. And that's really where we need to be placing our focus with heart failure as well.

SPEAKER_02:

Yeah, that's such a great point. I mean, you could compare that to a lot of disease states in the sense of, you know, like, oh, we're just waiting on the blood sugar to get over 300 instead of 250 or something like that, which is just it's wild, especially like you said, when you compare it back to, you know, like cancer, which we're all, as soon as it's identified, get rid of everything in every way possible, you know. So um, yeah, it's a great point. Thanks for sharing that. So you mentioned a couple of the medication classes that we will specifically talk about today, because it's kind of what the study that we're gonna reference today was based on. But what are some of the other medication classes that are out there that are currently treating heart failure?

SPEAKER_01:

Yeah, most patients with heart failure, again, regardless of their ejection infraction, need a loop diuretic. This would be medicines like furosamide or bumepinite or torsamide to help keep fluid off. That's the number one sort of driver of symptoms for them. Those medicines importantly don't decrease the risk of dying. It sort of just treats the symptom of the disease, but most need those. When we talk about heart failure with reduced ejection fraction, we call it the core four. They need to be on a beta blocker, a RAS inhibitor, like an ACE or an ARB, like you know, PRILLS and RTNS, and then an MRA, which we're gonna talk about today, like uh Sprintolactone, and then an SGLT2 inhibitor, and we're gonna specifically mention Dagliflows in today. As we go to that upper end of the ejection fraction, the preserved or normal ejection fraction, which is the population we're gonna specifically focus in on today, not all of those medication classes have been shown to have benefits. And so our guideline recommended therapies for FPEF are an MRA again, an SGLT2 inhibitor again, and then beta blockers haven't shown to be helpful. They're not recommended. And then RAS inhibitors like ACEs and ARBs are really only recommended if there's hypertension that also needs to be treated. But in the absence of hypertension, they haven't been demonstrated to have as great an impact.

SPEAKER_02:

I was just gonna question if if another comorbid disease would indicate that those would stay on. Um, and then so in addition to those core four, and then in the in the upper that we're gonna talk about today, the two that we're gonna really discuss, everyone is on the loop diuretic, right?

SPEAKER_01:

Yes. In America, 90 plus percent of people still require loop diuretic. If if there are patients that don't need them, that's wonderful. Unfortunately, it's just a need in most people.

SPEAKER_02:

Got it. So it's kind of core four plus one. That's always a lot of things.

SPEAKER_01:

Yes, symptomatic driver, yes.

SPEAKER_02:

Got it. Okay, great. Okay, so obviously the goal of our podcast every week is to show pharmacists how they can be involved in this in in whatever it is that we're talking about. You know, what are some of the ways that they can ensure that they are prepared for the changes or for recommendations or education or whatnot. So I want to go ahead and jump into the actual article that kind of spurred the conversation for today. And I'll just kind of set the stage and then let you run with your clinical expertise to kind of give us the rundown and you know, maybe how it's truly applicable to practice. And so basically what we're looking at is a med brief online from Medscape. And it was basically a study that found that adding sperm lactome and an SGLT2 inhibitor, in this case the Pagliflososin, I'm gonna completely butcher it. Not great with getting all those out of my mouth when I'm nervous, sorry. And then it led to greater reductions in the nitritic peptide, which also reduced concern. It also raised concerns about reducing kidney function and hyperkalemia. So that's what I really want to dig into today is does the benefit outweigh the risks, I guess basically, is kind of the point. So I'll let you kind of take it from there and tell us a little bit about the findings here and then how they really kind of uh are applicable to everyday practice.

SPEAKER_01:

So sure. Thanks so much for that great introduction there to the study. Uh yes, I think that the key message that we want to start with is patients with heart failure should be on an MRA and an SGLT2 inhibitor, in this case, sporonolactone and daptamycin. And that's sort of guideline recommended. What this study really looked at to try and overcome the clinical inertia we were just talking about, where people will only get started on one and then maybe go a few years before they get started on another, they looked at a strategy of simultaneously starting both these medicines at the same time versus starting one and then adding the other. And they did this in a in sort of a crossover design style. And so this was really important because it sort of addresses a need of could we speed this up by starting multiple things simultaneously? Because both these drugs have independently, or both these drug classes have independently demonstrated in very large clinical trials that they're beneficial on all the important outcomes here. So they were sort of looking to see, could we do this? And they they looked at 12-week intervals with a washout period in between in the same people. And so it's really about a strategy as opposed to should this be done. I think another quick nugget to recall is that this is not like a new combo pill, and we're used to like a lot of our blood pressures may be combo pills. This isn't you know a combination pill that's going to come to market. That there could be, and there are in the pipeline, other combinations, but specifically to this study, this was just looking at taking two individual meds that are indicated and starting about the same time.

SPEAKER_02:

Sure. So we're not looking at decrease in the pill burden and all that kind of stuff. It's more, yeah, got it. Understood.

SPEAKER_01:

That's exactly right. It's about sort of streamlining the goals into one visit. Got it. So I think the good news that we should take away is that there was a reduction in NT pro BMP, which is a measure of the stress that your heart is under. And when it goes lower, that's a positive thing. The higher it is, the worse the prognosis for patients. And so that was reassuring in that this was just like in the large studies where these were studied individually, that these improved heart function and that there was additive benefit yet again when combining these medications. So that really reinforced what had been seen in other studies. The probably the more concerning thing is what you just said. There was raised concerns about hyperkalemia, so serum potassium getting too high, and kidney function, specifically retinine clearance or EGFR estimated glomerular filtration rate decreasing. And, you know, these are real problems now, not only because those are concerning things, but because more and more patients have on their phone, you know, a portal where they can directly see their labs. And when those labs turn red or worsen, you know, they're they they want to ask their health care provider, as they should, what's going on with these? Are these medicines hurting me? Right? Like what? And so we have to be more poised to sort of interpret data than maybe we have been in the past, where patients would just be reassured with everything's going great.

SPEAKER_02:

Everything looks good. Yeah.

SPEAKER_01:

Now it's I can see these numbers, uh, but it's just like, you know, when I do my taxes, I need someone to help interpret them for me. Um so I think that's another big role for pharmacists here. And so I think particularly in this study, that's probably the most important nugget is the conversation we're about to have, which is how do we interpret these things? Um, so let's maybe just take them one at a time and let's talk about hyperkalemia first. We know that our MRAs, like speronolactone, raise potassium. That is just a function of how they work, and that's why it's specifically monitored. And it's really important to get laboratory monitoring because the dose may need to be adjusted like it was in the study, or maybe we need to stop those potassium supplements that they've been on with their loop diuretic, you know, to make room. The interesting finding here is in the past, adding a drug like dapogleplosin to this drug class has slightly lowered the potassium or had no effect sort of in that range. Whereas here there was a very small but significant increase in the serum potassium. And so honestly, you know, the authors themselves and the people that wrote the editorial noted this, but didn't really have, you know, a mechanism by which this was seen in this population. It could be that, you know, I think about three-fourths were already on an Acer and ARB. And so again, adding an MRA to an Acer and ARB that already increases potassium could be this. So it could just be a function of sort of differences in this population versus others. But I think the take-home nugget for us there is uh it's not safe to not monitor an MRA when we add it for a potassium perspective, regardless of the other medicine, that we still need to really be closely watching the serum potassium in these patients. That's sort of a reinforced measure so that we can continue to get them the benefit, but without, you know, the risk as much as we can mitigate it.

SPEAKER_02:

Yeah, it makes sense. And so as we're monitoring those, you know, the potassium levels and and those numbers, what are what sort of action options do we have to take if it is high? So you mentioned adjusting sperno lactone, potentially looking at are they on a potassium supplement? Yeah. So I'll let you kind of speak to that.

SPEAKER_01:

Yeah, you you outlined it well there. Uh in this article and in practice and in the guidelines, you know, if that if they're having high potassium to a dose, we can decrease the dose of the MRA to sperno lactone. They can even take it every other day. And that's been done in clinical trials and still has benefit. Uh, we can certainly stop other potassium supplements, and and that would be a nice way of reducing pill burden while keeping them on the really important medicine. And then, of course, if it is high, we can also uh use potassium binders either temporarily or chronically to help people stay on these medications. And so it's a lot of good therapeutic options. The key is to be sure we're monitoring it and keeping people safe. And generally, a potassium greater than 5.5 is in the concerning range. These mild elevations of 5.1, 5.2, 5.3, et cetera, can sometimes be tolerated and sometimes just be a little bit of normal fluctuation.

SPEAKER_02:

Sure, sure. Now, I've another point I would like to make is that it's really important and critical for pharmacists in this space to look beyond what maybe is a prescription, a potassium supplement, and make sure that they're not taking something over the counter. So I think that's a great question to ask. And then my question would be: does diet really come into play here? Are they getting too much, like, is there, would there ever be a reason that we would some try to get a decrease the amount of potassium that they're intaking, or is that really negligent as far as causing any of the increased potassium?

SPEAKER_01:

It's such a good point that you raised there, because it absolutely can be dietary potassium can significantly take someone who is doing fine and make them hyperchelemic, particularly with these medicines. And I'll tell you the scenarios we run into are people who have the lower kidney function can be very sensitive to this. And then particularly because there's such a focus on reducing sodium in heart failure patients. One of the things that they may do is switch to a salt substitute. They get the salt taste, but not the sodium. And those are potassium chloride. So all your salt substitutes, if it's salt, low salt, no salt, all those sort of strategies are potassium chloride. And so again, they can all of a sudden be taking in copious amounts of potassium chloride. So dietary questions, particularly are you using a salt substitute or things like that, can be really helpful in unmasking the cause around this.

SPEAKER_02:

Yeah, makes sense. Okay, good, good deal. So then the other concern that we want to talk about, things that we would need to monitor is the kidney function. Um you mentioned a couple of those kind of labs that we would that we would uh focus on. So go ahead and let's review those again and kind of talk about those in greater detail.

SPEAKER_01:

Yeah, so the serum creatinine will be our lab, and then we'll use that to calculate their uh EGFR or their creatinine clearance, where lower EGFR, lower creatinine clearance indicate less filtration function by the kidney. And so I think what's really important as we start out here is to quickly note that guidelines and best practice documents say that a decrease in the EGFR is to be expected when we start either one of these medications. And so one is setting proper expectations for our patients, and then to say the magnitude that's generally accepted is a 30% decrease from wherever they start. So that sort of allows you to individualize the amount of magnitude that's sort of quote normal from the patient's baseline kidney function. It's up to a 30% decrease in EGFR is is expected. What's really key about how these medicines do that is that it's completely reversible and it's completely functional, meaning you stop the drug and it goes right back up to the baseline. So this is not damaging the kidneys in any way, it's not injuring the kidney. Sometimes people will call this acute kidney injury, which is a mislabel when we're talking about these medicines because the kidneys aren't actually injured. You are actually removing the workload from the kidney and so that they're filtering a little less, but you're doing that because over the long run, this is how we preserve kidney function, is by helping it work a little bit less, but preserving it so that it's not getting burnout and the nephrons are dying. And that's what chronic kidney disease is. Nephrons are dying rapidly over time, and we progress to where there's none left to work. This we're offloading the work, and that's why it's reversible and not injury. And so that's a really big distinction for patients. And actually, both these classes of medications are actually FDA approved to treat chronic kidney disease and to slow the decline of chronic kidney disease. So we have massive studies on the safety and efficacy of these classes, and so I think we can also leverage that to really help our patients say, hey, these have been extensively studied and people across the entire spectrum of kidney function, and we know that these actually help people long term. So it's to be expected when you start them that we can see a little bit of a decrease, but that's actually the medicines working, and that's gonna help your kidney over the long haul. Sometimes I use the analogy to help patients with where I say if you're really stressed at your job and everyone hates working at your job, there's gonna be burnout and you guys are gonna quit, right? And quit working. Whereas if the employer just asked you to do 80% of your work a day, all of a sudden there was a reasonable expectation, you would probably stay at that job longer because you weren't under such stress. And that's essentially what these medicines are asking the kidney to do.

SPEAKER_02:

Yeah, I think that's key because I think it's important to note that the pharmacist's role here is education and providing the information to the patient. And like you said, because you know, everything you immediately get pinged on your phone as soon as your new labs are updated, you know, to your online portal or whatever. And so patients are more apt these days to immediately look at it. You're exactly right. They they see the red and they they think, oh gosh, something is wrong, there's a problem. So I think it's important to note that one of the key things here that a pharmacist can do is simply educate and explain that this is expected, it's okay, you know, whatever, and then just to continue monitoring it. Obviously, don't just miss it completely, but just to continue monitoring. So yeah. So as far as what is, I guess, the the overall plan of action after you know talking about this editorial and really kind of seeing what it is, because it as you mentioned, it's not really changing a guideline or changing the way that we do something. It's really just about a proper initiation of both of these medications. So who I guess my question is, who is this really affecting? Like who, what population are we? Is this new patients who are newly diagnosed and we're gonna immediately start them out with both? Or is it, is there some patients who have constantly been on something and is there a way to kind of go back and start over, if that makes sense?

SPEAKER_01:

Yeah, I think I think you that's a great question. I think it really affects all patients with heart failure that are not currently receiving these medication therapies and don't have an absolute conjurnication, you know, to these. So the vast majority here. And so I think you're right. New patients certainly directly affects because it helps us understand that we could potentially start both these medicines at the same time. Patients who've had the disease and maybe aren't on these therapies and need to be optimized, or they've been stopped because of some, you know, issue, and now we need to restart them rather than drawing that out for longer periods of time and and leaving them at greater risk, we can do this in a more expedited fashion.

SPEAKER_02:

Sure.

SPEAKER_01:

I think we've learned that this is safe in most patients. However, as you mentioned, the monitoring, particularly of the basic metabolic panel where we get the potassium and the kidney function is really key because we saw, you know, about one in five patients who did this sort of strategy of starting a both at the same time had an increase in their, or excuse me, a decrease in their EGFR greater than 30%. That would sort of be the normal, you know, line at which we would say this requires some additional thought and consideration. Not every one of those had their medicine stopped. Many were able to continue, but it required some, you know, thought interpretation, questioning, and and follow-up monitoring. So I think those are the people that are affected and the pharmacist can help, as we said, in interpretation and expectation setting, and then encouraging on the importance of monitoring so that the patients can get maximum benefit with minimum risk because it's being monitored appropriately.

SPEAKER_02:

Yeah, that makes sense. So in our last few minutes here, I just wanted to kind of basically it's going to be reiterating the facts that we've already kind of gone over, but what are some of the opportunities here for pharmacists? As I mentioned, you know, the goal of this episode of our episode each week is to make sure that our pharmacists leave with actionable items or things that they can do. So I think the first thing is the importance of just staying up to date on any kind of changes that are happening in heart failure treatment. Are is there anything else that you know of? Are guidelines about to change or be updated or anything like that that you would share?

SPEAKER_01:

Uh probably not at this time in uh in terms of a guideline update. There's been one fairly recently from the American Art Association in in 2022, and the European guidelines followed a year later. Uh, so I don't know that there'll be anything majorly different there. There are more drugs being added to these classes. Phener Renone is a new mineralicorticoid receptor antagonist that is now approved for chronic kidney disease and for heart failure. So you might see some new faces in the class, if you will, but no sort of recommendation changes uh to date on how we should change these classes in a big way.

SPEAKER_02:

I like that. New faces in the class, but no new classes quite yet. So yeah, okay, interesting. Okay, and then another opportunity for pharmacists here is to, as we kind of already touched on just a few minutes ago, is identifying the appropriate patients. So again, those patients who were nudely diagnosed, also those patients who have not been optimized on both therapies, or for whatever reason the therapy was stopped or changed or something like that, and maybe assessing to see whether or not they can be added back to the patient's therapy regimen.

SPEAKER_01:

Yeah, I think that's such a, I'll just be very brief, but that's such a key point because uh the pharmacist just asking the question, why isn't this person on these therapies has been shown in clinical trials to dramatically improve the number of patients who are on these medications. And so just the prompting question why is often enough to break inertia, either to the patient or to the provider. And so I think asking the question why is is so powerful.

SPEAKER_02:

Yeah. And I mean, you know, we I recently talked about with another guest on another episode the importance of, you know, sometimes things get lost in when they're dismissed from the hospital or, you know, thing and and you're you're not sure in that transition of care if they're supposed to continue on this medication. And it wasn't something that they had previously, and so they're like, yeah, I don't think I'm supposed to. And and you know, just so it's really important to ask those questions and to never assume that, oh, I don't see a spironalactone. So they must not have tolerated it well, and that's why they're not on it anymore. So it's key to make sure that we are the medication experts that we're asking the right questions, we're doing the reconciliation properly, and we're making sure that patients are optimized in their therapy.

SPEAKER_01:

So absolutely.

SPEAKER_02:

Yep. And then of course the other thing that we mentioned was education. So I think it's important to not only educate about the medications, but as we have talked about at length, the continued monitoring of different things and the follow-up care that's that's required for these medications sometimes. And then some of the challenges that we face, it's not always green and grassy everywhere. So some of the challenges that we face when there are contraindications, you know, we do have patients that can't tolerate something. And if that's the gold guideline standard, then you know we have to put our thinking caps on sometimes. So, and then as you mentioned, sperm lacton at times, based on potentially hyperkalemia, it may need some dose tritose titration and then monitoring of any other adverse effects. So are there any other things that you can think of in that space where it's kind of hard to navigate sometimes?

SPEAKER_01:

Yeah, I'll quickly say, you know, the the number one reason that SGLT2 inhibitors tend to be interrupted or discontinued as a class tends to be around the concern around urinary tract infections. They're extremely common as we know, uh, and there's concerns that SGLT2 inhibitors, because of the way that glucose exits the urine from the way that they work, could contribute to this. And there have been numerous articles written about this problem that I'll just briefly summarize, which is you know, the benefit far outweighs the risk, uh, not minimizing, you know, the you know, discomfort of a UTI, but it is less severe of a disease that's more easily treated than heart failure. And so if we do need to temporarily interrupt that, we want to really rapidly start the SGLT2 inhibitor back. And so you might find patients like that who've had it interrupted and has just sort of fallen through the cracks. Uh and also if people are having, you know, infrequent UTIs, we would definitely consider this therapy. If someone's having very frequent UTIs, you know, multiple a year, and this is a real quality of life issue, then we may need to interrupt the therapy, but we may also, again, need to go back into detective mode as to, well, what's the driver behind this? And and, you know, there are a lot of things that can be done to decrease the frequency of UTIs. And so uh that that would just be another area, you know, that both monitoring in this study, but also addressing so that patients can potentially receive the therapies that they can't tolerate.

SPEAKER_02:

Yeah, yeah, that's great. I used to always tell my students, I mentioned it before on the podcast, that pharmacists are like sleuths. You know, we have to constantly be digging deep and asking all the questions and putting the facts together and determining, you know, what they are. So I'm a I'm a big murder mystery buff and I love those kind of things. And so I love sleuthing and and but I I think it's it's key for a lot of the things that we do in practice as well. And then another challenge that we may have is patient concerns. Obviously, we talked about how they could see their in the red lab sometimes and and are immediately concerned and wonder about something. Adherence. I mean, you know, what if what if they don't mention that they saw that their labs are bad and they think that it's important for themselves just to take the to just take themselves off medication? And so it's important that we're continuously educating and advocating for adherence and staying on the schedule. And then I don't I have been out of practice for a little bit, but I don't think spirolactone is a cost concern anymore. It shouldn't be, right? But some of the some of the SGLT2s could be potentially still, right?

SPEAKER_01:

Correct. Many of them are still branded. Many are coming off patent in in the next year. And so that will help. And then this has also been a class that's specifically addressed by some of the new Medicare legislation where they can Medicare can specifically negotiate prices. And so these will change in the next coming year, the next calendar year in terms of our Medicare population. So classically has been a class where cost has been a real barrier for many people. I think we're sort of moving out of that. But for the present, there are still cost concerns with SGLT2 inhibitors.

SPEAKER_02:

Great. And we know that that is another challenge for pharmacists and pharmacy staff, but it is also an area where we can shine and we can make sure that we are connected to the appropriate resources and helping them gain access to the medication that they need. So okay, well, I think that that touches on the different challenges and opportunities and the outcomes of this editorial and kind of talking through some of that. So, Zach, is there anything else that I missed that you wanted to be sure that you shared on this topic? No, you summarized me. Okay. Yes. All right, perfect. So as I'd like to do with every episode at the very end, I'd just like to give it back to you and say, what's the game changer here? Uh, you know, what's our big take-home point? What exactly do pharmacists need to know from this topic that we've been discussing today?

SPEAKER_01:

Yeah, I think the game changer here is that for heart failure, we have multiple medications that we want patients to be on. And historically, this has been a very slow sequential addition process. And now we have yet another study, in addition to some other recent literature, that is showing that for many patients, simultaneous addition of multiple medication classes is safe, and we already know that they're effective. And so it reminds us that we can often make multiple medication changes, particularly additions in one setting. And yet it also reminds us that for some patients, this will not maybe not be tolerated as well. And so it reinforces the importance of basic monitoring, particularly here around laboratory monitoring of the basic metabolic panel and appropriate interpretation and expectation of what we're gonna find.

SPEAKER_02:

Yeah, that's great. That's a great summary. And, you know, would be remiss if we didn't mention that collaboration is also key here because obviously this involves multidisciplinary team with different providers and you know, patients who have heart failure, that's likely not the only comorbid disease that they have. Uh so it, you know, they're typically going to have a lot of specialists and a lot of other people on the team. So it's key that pharmacists are making sure that they're continuously collaborating and sharing uh their findings and and their recommendations.

SPEAKER_01:

So that's such a great point. Yes, yeah.

SPEAKER_02:

Well, Zach, this has been great. Thank you so much again for giving us your time and for talking this through with us. We really appreciate it.

SPEAKER_01:

Thank you so much for having me. I really enjoyed it. Thank you.

SPEAKER_02:

If you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.