In a patient with heart failure and some degree of chronic kidney disease, is there a preferred choice between intiiating an ACEI/ARB versus Entresto?
In PARADIGM-HF, the baseline Cr was 1.1, and these authors found that sacubitril/valsartan was better than enalapril in terms of increasing Cr and potassium levels. It’s hard to know how safely we can extrapolate that observation to patients with heart failure and a Cr that’s elevated at baseline, though. The attached meta-analysis looked at exactly this population and found that sacubitril-valsartan did not change urinary albumin/creatinine ratios nor adverse events, but that it did result in better GFRs, blood pressures, and NT-proBNP levels, comparatively. I’m also attaching one of the analyzed articles, which was an RCT comparing sacubitril/valsartan to irbesartan in patients with chronic kidney disease alone. (It found that both of these drugs had similar effects on GFR and potassium levels, but that the former was more effective with respect to blood pressure and biomarkers. Its discussion section is worth a read.) Putting it all together, my take-home is that sacubitril-valsartan is safe to initiate in patients with heart failure and CRI, and that there may be some reno-protective effect here – as long as patients can tolerate the medication without getting hypotensive.
Kang H, Zhang J, Zhang X, et al. Effects of sacubitril/valsartan in patients with heart failure and chronic kidney disease: A meta-analysis. European Journal of Pharmacology. 2020;884:173444-173444. doi:https://doi.org/10.1016/j.ejphar.2020.173444
Haynes R, Judge PK, Staplin N, et al. Effects of Sacubitril/Valsartan Versus Irbesartan in Patients With Chronic Kidney Disease. Circulation. 2018;138(15):1505-1514. doi:https://doi.org/10.1161/circulationaha.118.034818
