GPs to start patients on heart failure drugs following updated NICE guidance

GPs can start treatment with certain heart failure drugs that previously had to be initiated by a specialist, NICE has said in updated guidance.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors and angiotensin receptor-neprilysin inhibitors (ARNIs) can for the first time be started by GPs, with advice from a heart failure specialist, potentially speeding up access, NICE said in a draft update to its 2018 guidelines.

It is part of an overhaul of recommendations which advises four classes of drugs are prescribed at once rather than waiting for the dose of each to be titrated.

NICE said the new recommendations, currently out for consultation, could save around 3,000 deaths and 5,500 hospital admissions through drugs being started earlier in the heart failure pathway.

The recommendations state that patients with chronic heart failure with reduced ejection fraction should be offered an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and an SGLT2 inhibitor together.

For people on the maximum tolerated dose of each who continue to have symptoms of heart failure, doctors can consider switching the ACE inhibitor to an angiotensin receptor-neprilysin inhibitor (ARNI), NICE added.

People who cannot tolerate ACE inhibitors, should be offered an ARNI, beta-blocker, MRA and SGLT2 inhibitor instead, the committee advised.

The update means earlier use of the SGLT2 inhibitors empagliflozin and dapagliflozin than NICE has recommended before.

It follows economic modelling from clinical trials and real-world data which suggests that early use of an MRA and SGLT2 inhibitor in combination with ACE inhibitor and a beta-blocker is cost-effective.

The committee said because the correct sequencing of medicines will vary between patients, the guidelines are moving away from introducing each medicine in turn to ‘treatment combinations for different scenarios’.

In those with preserved ejection fraction, the updated recommendations also advise considering an MRA and an SGLT2 inhibitor.

Deputy director at NICE’s Centre for Guidelines Eric Power said: ‘For this update we’ve been able to review the emerging evidence quickly to keep pace with changes in the treatment landscape and make recommendations that will widen access to effective treatments.

‘This should have a big impact on the lives of people living with heart failure as well as freeing up space in hospitals by reducing their risk of having to go to hospital for unplanned emergency treatment.’

Professor Bryan Williams, chief scientific and medical officer for the British Heart Foundation, said the updated guidance should ensure that people with chronic heart failure receive medication they need at an earlier stage.

‘It is also hugely helpful that NICE draft guidance would now allow GPs to prescribe some vital new highly effective medications as alternative treatments, rather than referring patients back to heart failure specialists, which wastes precious time.’      

NICE updated draft guidance on Chronic heart failure in adults: diagnosis and management is out for consultation until 8 July.