MRA (spironolactone, eplerenone)

A prescription for spironolactone may highlight a heart failure patient, especially if prescribed in combination with other heart failure medicines. However, it has other indications as well (e.g. hypertension, management of ascites in liver disease). 

Eplerenone is only licensed for heart failure. Although these medicines are classed as diuretics, they have been shown in HFrEF to improve mortality and so are mainly prescribed for their prognostic benefit rather than diuretic effects.

Sacubitril + valsartan (Entresto) 

Entresto is only licensed for the treatment of heart failure. It is approved by NICE for specialist initiation/recommendation, so depending on local arrangements pharmacists may find that the prescription has been provided by the specialist team or from the GP on specialist advice. 

Importantly, sacubitril + valsartan is prescribed instead of an ACEi (risk of angioedema if given with an ACEi) or any other ARB (Entresto contains valsartan), so always check that the patient knows:

• To stop any ACEi at least 36 hours before commencing sacubitril + valsartan
• That the ACEi is permanently discontinued
• To stop any ARB before commencing sacubitril + valsartan. A wash-out period is not needed. The first dose of sacubitril + valsartan can be taken when the next dose of the ARB is due.

Sodium glucose co-transporter-2 inhibitors (SGLT2i)

SGLT2i medicines have been used in type 2 diabetes for several years. Recent trials with dapagliflozin and empagliflozin have shown that they reduce both symptoms and mortality in patients with heart failure, with or without diabetes. This has rapidly expanded the number of patients eligible for treatment, so pharmacists should not assume that a patient on these drugs has diabetes. However, if they have, their blood glucose medications may need to be reviewed.