 Treatment Algorithms --
March 2007
 In This Issue...
Introduction:
Despite the availability of a high number of treatment
options for chronic heart failure (CHF), current CHF therapies are often not
used optimally (i.e., they are underprescribed and/or underdosed) and the
prognosis for CHF patients remains poor. However, increasing physician
awareness of the strong evidence for the morbidity and mortality benefits of
drugs that act on the renin-angiotensin-aldosterone system (i.e.,
angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor
blockers [ARBs], and aldosterone antagonists), as well as the 2005 American
College of Cardiology and American Heart Association (ACC/AHA) recommendations
for expanded beta-blocker use in patients with stable CHF, has influenced U.S.
physician prescribing patterns. Longitudinal patient claims data reveal that
aside from loop diuretics, which are employed to reduce fluid overload, ACE
inhibitors and beta blockers are the most frequently prescribed first-line
therapies in newly diagnosed CHF patients. Physicians surveyed see a
continuation of this trend, and they note that the most likely near-term
prescribing change among both cardiologists and PCPs will be the further
expansion of their use of beta blockers as adjuncts to ACE inhibitors in
patients with stable CHF. Additionally, cardiologists will increase use of
aldosterone antagonists for symptomatic CHF, while PCPs will increase both the
use of polypharmacy at the first-line level and the use of ARBs.
Questions Answered in This Report:
- Lines of therapy: ACE inhibitors are considered the
cornerstone of CHF therapy for their ability to prolong survival in CHF.
Lisinopril (AstraZeneca’s Zestril/Merck’s Prinivil, generics) is the most
commonly used first-line ACE inhibitor among newly diagnosed CHF patients
thanks to its availability in cheap, generic form and support from mortality
and CHF hospitalization data from the Assessment of Treatment with Lisinopril
and Survival (ATLAS) trial. How much patient share of first-line therapy do
ACE inhibitors take relative to other CHF agents? Given the protocol for
adding certain CHF therapies (e.g., aldosterone antagonists, digitalis) as
patients become increasingly symptomatic, how much patient share do add-on
therapies receive in second- and third-line therapy?
- Pathway to key therapies: Physicians surveyed prefer
Coreg, which is commonly used as second- or third-line therapy, to Toprol-XL
because they believe Coreg is more efficacious for patients with advanced CHF.
As physicians’ comfort level with Coreg increases, its use will increase. This
trend is supported by survey data, which reveal that physicians anticipate an
increase in the proportion of Coreg prescriptions going to first-line treatment
between 2007 and 2009. How much of agents’ total use is devoted to
first-line treatment, and will it change in the near future? How long do
patients take to progress to key therapies, and what treatments precede them?
- Physician behavior: Furosemide is by far the most
frequently prescribed first-line agent for CHF; approximately 50% of patients
receive the drug as part of initial pharmacotherapy. Although most
cardiologists surveyed prefer furosemide for its fast onset of action, the greatest
percentage of PCPs surveyed cite its better efficacy at relieving congestive
symptoms and their familiarity with the drug as key to its use. What is the
make-up of patients by severity in the practices of PCPs and cardiologists, and
at what stage are patients most likely to receive furosemide? Are the drivers
behind other drug choices aligned by cost, efficacy, or safety? Do these
different physician types expect their practices to change in similar ways over
the next two years?
- Forecast: Longitudinal patient claims data reveal that
nearly 50% of newly diagnosed CHF patients prescribed furosemide as first-line
treatment progress to second-line therapy within a year. Representing an
alternate means of promoting diuresis, Otsuka’s arginine vasopressin (AVP)
receptor antagonist tolvaptan is in Phase III development in the United States
for CHF. What line of therapy will tolvaptan hit first? What attributes does
tolvaptan have that physicians surveyed believe may provide significant benefit
over existing diuretics? Will cardiologists and PCPs embrace tolvaptan equally,
and what will be the fate of loop diuretics and aldosterone antagonists against
this new competitor?
Includes:
Primary research: Quantitative results from our
survey of more than 153 physicians (77 cardiologists and 76 PCPs):
- Physician opinion on how drug use differs by patient severity.
- Most influential drug attributes when physicians choose between
agents.
- Anticipated changes in the line of therapy in which physicians
use key agents.
Primary patient-level data: Quantitative findings
from our analysis of data covering 55 million lives from more than 80
geographically dispersed U.S. HMOs:
- Quantified lines of therapy analysis showing exact share of
each agent in each line of therapy, including rate of progression between lines
and length of time patients are on each line.
- Progression flow charts through one year of treatment for newly
diagnosed patients receiving each of the following first-line agents: enalapril,
ramipril, lisinopril, captopril, Diovan, Cozaar, Avapro, other ARBs, Coreg,
Toprol-XL, bisoprolol, other beta blockers, torsemide, furosemide, other loop
diuretics, spironolactone, and digoxin.
- Flow charts tracking the preceding therapy patterns for
patients taking each of the following key therapies: enalapril, ramipril,
lisinopril, Aceon, Diovan, Cozaar, Avapro, Atacand, Coreg, Toprol-XL,
spironolactone, Inspra.
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