2) This program is intended for healthcare professionals and is supported by educational grants from AstraZeneca, Bayer, Chiesi, and NovoNordisk. See archived programs, all by expert authors, still available for credit at https://t.co/U6Mo1oSwIh
— cardio-met (@cardiomet_CE) August 24, 2021
Poll:
— cardio-met (@cardiomet_CE) August 24, 2021
A. Stop dapaglifozin
B. Stop both ARNI and spironolactone
C. Continue ARNI at current dose, but stop spironolactone and do not attempt again
D. Start potassium binder, check K levels in 1 week, restart spironolactone and increase ARNI doses if K remains ≤ 4.9
— cardio-met (@cardiomet_CE) August 24, 2021
5) Ms. SG has HFrEF. So what target doses of GDMT should we be aiming for?
— cardio-met (@cardiomet_CE) August 24, 2021
A. Spironolactone 12.5-25 mg/d (or eplerenone 25 mg/d) with Sacubitril/Valsartan 24/26 mg twice day
B. Spironolactone 25-50 mg/d (or eplerenone 50 mg day) with Sacubitril/Valsartan 97/103 mg twice day
6) The correct answer is B. The steroidal MRAs, spironolactone and eplerenone, have been shown to be effective in reducing hospitalizations for HF and mortality in patients with chronic HFrEF and also are likely effective in appropriately-selected patients with chronic HFpEF. pic.twitter.com/fZwH4ZyK2W
— cardio-met (@cardiomet_CE) August 24, 2021
7) In patients with HF, submaximal RAASi does not provide same degree of benefit as max RAASi. And lower doses of ACEi/ARB have also not been shown to be effective in slowing #CKD progression.
— cardio-met (@cardiomet_CE) August 24, 2021
9) As many of 47% of patients stop or reduce their RAASi after a moderate to severe hyper-K+ event, and those that discontinue RAASi experience worse outcomes. pic.twitter.com/YbVTghv5aD
— cardio-met (@cardiomet_CE) August 24, 2021
11) Among 39518 patients initiating MRA, 18% developed hyperK+ (>5) of which 30% stopped the MRA. Over 2yr f/up, stopping the MRA was associated with decreased risk of recurrent hyperK, but 10% increase risk of MACE [HR 1.10 (1.06-1.14)]. Now that is something to “scream” about. pic.twitter.com/BlyGfGTrJE
— cardio-met (@cardiomet_CE) August 24, 2021
13). But hyperK+ is not a good thing either. We know this. As serum K+ levels increase above normal levels, rates of MACE and mortality increase. That’s bad news. pic.twitter.com/8wzZsS8PIz
— cardio-met (@cardiomet_CE) August 24, 2021
14) Risk factors for hyperK+ are predictable, we know what they are. Advanced CKD (frequency up to 40-50%), chronic HF (up to 30%), DM (up to 17%), resistant #hypertension w/ MRA Rx (up to 8-17%), advanced age & drugs that interfere w/ kidney K+ excretion (especially in combo). pic.twitter.com/kH4x0P98za
— cardio-met (@cardiomet_CE) August 24, 2021
16) Furthermore, correcting the dyskalemia can mitigate the risk pic.twitter.com/FrxJuYZJBb
— cardio-met (@cardiomet_CE) August 24, 2021
18) There’s MUCH more to the story! Return tomorrow to discuss new therapies that DWARF the impact of doing without bananas! @nephondemand @drpaddymark @CardioAcademic @michellebr00ks @LTummalapalli @TChanMD @FZores @Shahed__Ahmad @baileyannRN @DrRoderickTung @ISNWCN @CardioKp
— cardio-met (@cardiomet_CE) August 24, 2021
19) Welcome back! I am @ErinMichos and we are talking 'bout managing #hyperkalemia in pts who would benefit from #RAASi/#MRA. You are earning FREE CE/#CME! Nod to @EveKerrMD @JTLLERGO @EileenEReynolds @ProfMartinCowie @VietHeartPA @EzequielZaidel @NeilSkolnik @kidney_colloq
— cardio-met (@cardiomet_CE) August 25, 2021
21) Good news! New potassium binders can help w/ RAASi initiation & up-titration to max doses. Both Patiromer and Sodium Zirconium Cyclosilicate (SZC) have demonstrated clinical efficacy in reducing serum K+, good safety profiles, and are approved by FDA and EMA.
— cardio-met (@cardiomet_CE) August 25, 2021
23) Let’s look at HARMONIZE, which enrolled patients w/ hyperK+. After an open label phase using SZC 10 mg TID, 237 patients who achieved normoK+ (3.5-5.0 meq/L) were randomized to SZC 5, 10 or 15g, or placebo daily for 28 days https://t.co/W2pIGIJwNO
— cardio-met (@cardiomet_CE) August 25, 2021
25) 28 days is good, but we need to use RAASi long-term. So what about long-term SZC use? Well a subsequent phase 3 study enrolled 751 outpatients w/ hyperK+. After acute K+ correction, those back to normoK+ were enrolled in maintenance of SZC 5 mg, titrated as needed, for 12 mos
— cardio-met (@cardiomet_CE) August 25, 2021
27) And patiromer? The OPAL-HK trial enrolled pts w/ CKD who were receiving RAASi and who had hyperK+ (5.1-6.5). After initial treatment, pts were randomized to patiromer vs placebo for 4 wks. Patiromer tx was associated with decrease in serum K & reduction in recurrent hyperK+ pic.twitter.com/dPyvyyKIfD
— cardio-met (@cardiomet_CE) August 25, 2021
29) Patiromer resulted in statistically significant decreases in serum potassium level after 4 weeks of treatment, lasting through 52 weeks. And was safe, effective, and well tolerated in older patients too. pic.twitter.com/M3ZnDX6s81
— cardio-met (@cardiomet_CE) August 25, 2021
30) Spironolactone is effective Tx of Resistant HTN; many of these pts also have CKD & hyperK+ risk. Can K+ binders help here too? That is what AMBER trial studied. At 12 wks, 66% of placebo vs 86% of patiromer remained on spiro, w/ less hyperK+. Similar for eGFR 25-30 & 30-45 pic.twitter.com/g2VhWMTOZq
— cardio-met (@cardiomet_CE) August 25, 2021
31) Back to our case patient. Well she has a guideline-directed indication for both RAASI & MRA but her K 5-5.5 puts her at risk. What to do? After reviewing diet & other meds, let’s try a potassium binder and see if we can re-initiate MRA, uptitrate RAASi, & monitor that K. pic.twitter.com/iu2zz3PqVa
— cardio-met (@cardiomet_CE) August 25, 2021
32) That's it! I am @ErinMichos and you made it! FREE CE/#CME! Claim your 0.5h at https://t.co/uSsZpc959x. And follow us as your only source of accredited serialized #tweetorials in the #cardiometabolic space. Peruse our roster of expert authors at https://t.co/a4vil8xXva. pic.twitter.com/zgRBDlpJyM
— cardio-met (@cardiomet_CE) August 25, 2021