NICE changes mind on GP prescribing of heart failure drugs in final guidance

NICE has removed a requirement in its updated guidance on chronic heart failure for GPs to seek specialist advice before prescribing a sodium-glucose cotransporter-2 (SGLT2) inhibitor.

It comes after several stakeholders noted that GPs have long-held experience with the class of drugs and seeking extra advice would delay care.

An overhaul of the guidance published in its final version this week will see GPs initiating a wider range of drugs for heart failure.

Under the update, GPs are advised to prescribe four classes of at once rather than waiting for the dose of each to be titrated.

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.

This approach could save around 3,000 deaths and 5,500 hospital admissions through drugs being started earlier in the heart failure pathway, NICE has estimated.

However, a previous recommendation that GPs should only initiate SGLT2 inhibitors under advice from a specialist has been removed after pushback at the consultation stage.

In response to the draft document published in June, several stakeholders including NHS England and the Primary Care Cardiovascular Society (PCCS) noted that GPs have more experience in doing so than heart failure specialists in use of SGLT2 inhibitors.

Consultation responses published on the NICE website showed several organisations, including NHS trusts asking for the wording to be changed.

NHS England told NICE in its response: ‘GPs have been prescribing SGLT2i far longer and have greater experience with this class of medication than HF specialists.

‘The current recommendation will lead to delays and under-treatment of this prognostically beneficial class of medication but also potentially lead to more referrals to heart failure clinics and greater waiting times.’

Likewise, the PCCS pointed out that general practice should be able to initiate SGLT2 inhibitors without other input.

‘They are already doing this for patients with [type 2 diabetes] and/or CKD. The need to seek specialist advice will build in delays whilst specialist contacted whilst awaiting a reply and then the need to another contact with the patient.’

NICE confirmed to Pulse that the wording of the guidelines had been amended in response to feedback.

For people on the maximum tolerated dose of the four classes of drugs 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 guideline continues to recommend that primary care prescribers consider seeking advice from a heart failure specialist before starting an ARNI’, a NICE spokesperson confirmed.

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.

There is also new guidance on monitoring of renal function after starting an ACE inhibitor, ARNI, ARB or MRA.

It states that renal function and electrolyte levels should be measured one to two weeks after starting treatment, one to two weeks after each dose increment, every three to six months once the maximum tolerated dose has been established and any time renal function may be compromised.