10 Nov Most Heart Failure Patients on Mineralocorticoid Receptor Antagonist Don’t Receive Recommended Laboratory Tests
Dr. Cooper
MedicalResearch.com Interview with:
Lauren Cooper, MD
Fellow in Cardiovascular Diseases
Duke University Medical Center
Duke Clinical Research Institute
Medical Research: What is the background for this study? What are the main findings?
Dr. Cooper: Heart failure guidelines recommend routine monitoring of serum potassium and renal function in patients treated with a mineralocorticoid receptor antagonist (MRA). Specific monitoring recommendations include: within 2-3 days of initiation of the drug, again at 7 days, monthly for at least 3 months, then every 3 months thereafter. However, no large studies had evaluated compliance with these safety recommendations in routine clinical practice. Using Medicare claims data from 2011, we evaluated monitoring of serum creatinine and potassium levels among patients with heart failure initiated on an MRA.
After MRA initiation, rates of guideline-recommended laboratory monitoring of creatinine and potassium were low. Of 10,443 Medicare beneficiaries included in this study, 91.6% received pre-initiation testing; however, only 13.3% received appropriate testing in the first 10 days after drug initiation and 29.9% received appropriate testing in the first 3 months. Only 7.2% of patients received guideline-recommended laboratory monitoring both before and after MRA initiation. Chronic kidney disease was associated with a greater likelihood of appropriate testing (relative risk, 1.83; 95% CI, 1.58-2.13), as was concomitant diuretic use (relative risk, 1.78; 95% CI, 1.44-2.21).
Medical Research: What should clinicians and patients take away from your report?
Dr. Cooper: Reasons for the discrepancy between the efficacy of mineralocorticoid receptor antagonist therapy in heart failure proven in clinical trials and the effectiveness observed in clinical practice are unclear. One possible explanation is laboratory monitoring during MRA initiation may be less rigorous outside clinical trial settings, and morbidity and mortality associated with abnormal laboratory results may offset the benefits of therapy. In order to close the gap between efficacy and effectiveness of mineralocorticoid receptor antagonist therapy in heart failure, treatment providers must start by addressing these issues.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Cooper: Quality improvement initiatives focused on improving appropriate laboratory monitoring are needed. In addition, further study is warranted to examine whether patients who receive appropriate laboratory monitoring after MRA initiation achieve greater benefits from mineralocorticoid receptor antagonist use than those who do not.
Citation:
Lauren B. Cooper, Bradley G. Hammill, Eric D. Peterson, Bertram Pitt, Matthew L. Maciejewski, Lesley H. Curtis, Adrian F. Hernandez.Consistency of Laboratory Monitoring During Initiation of Mineralocorticoid Receptor Antagonist Therapy in Patients With Heart Failure. JAMA, 2015; 314 (18): 1973 DOI:10.1001/jama.2015.11904
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Lauren Cooper, MD (2015). Most Heart Failure Patients on Mineralocorticoid Receptor Antagonist Don’t Receive Recommended Laboratory Tests
Last Updated on November 10, 2015 by Marie Benz MD FAAD