A new paper in the January 2025 issue of Pharmacotherapy outlines the use of prescription medications known to exacerbate heart failure (HF) in adults with this condition.
More than 6 million of adults in the United States have heart failure, a condition associated with significant morbidity, mortality, 1 million annual hospitalizations, substantial economic burden and poor quality of life. While several medications are known to exacerbate heart failure and/or increase the risk of decompensation, prevalence of utilization of these agents in patients with HF is unclear.
Researchers from Northwestern University, University of Utah, Johns Hopkins University, University of Michigan, and Ann Arbor Veterans Administration analyzed data from 687 United States adults who responded yes to the question “Has a doctor or other health progressional ever told you that you have heart failure?” in the National Health and Nutrition Examination Survey (NHANES) from 2011-2020. Participants were a mean age of 66.1 years old and 50.4% female. Medications known to exacerbate HF and specifically identified in this study included:
Overall, nearly 15% (1 out of 7) of study participants were prescribed at least one medication listed above, associated with exacerbating heart failure. Of these, nearly 22% had level A evidence warning against use in HF and 78% had v. Use of these agents did not vary significantly by sex, race, or ethnicity.
This represents an opportunity to identify and address modifiable risk factors such as deprescribing medications known to exacerbate HF. Suggestions include utilizing thiazide diuretics, ACE inhibitors or angiotensin receptor blockers as alternatives to diltiazem and verapamil in patients with HF and hypertension, or topical NSAIDs instead of oral NSAIDs in patients with HF and arthritis.
Healthcare providers are reminded to assess appropriateness of medications at every visit for patients with heart failure, and look for opportunities to identify and deprescribe inappropriate medications in order to reduce risk for heart-failure associated morbidity.
The Food and Drug Administration (FDA) issued a press release regarding a proposed rule change that would reduce allowed nicotine levels in cigarettes and some other combustible tobacco products. The proposed reductions would result in nicotine levels that are felt to be minimally or nonaddictive altogether. If ultimately successful, the United States would become the first country to take such a significant action. It’s important to note that this rule change is still only in the “proposal” stage, however the FDA highlights that this is the next step after the idea was first proposed in 2018. The FDA will now seek input and public comment, which started January 16, and will continue through September 15, 2025.
The rule change that the FDA is seeking would not ban cigarettes, however it would limit nicotine levels to no more than 0.7 mg per gram of tobacco in cigarettes and other specified tobacco products. Items to be included in this rule involve cigarettes, cigarette tobacco, roll-your-own tobacco, most cigars, and pipe tobacco. The rule would not impact e-cigarettes, nicotine pouches, noncombusted cigarettes, water pipe tobacco (ex. hookah), smokeless tobacco, or premium cigars.
Through the proposed changes, the FDA is hoping to prevent initiation of use among young people while promoting cessation in all groups. In addition, the FDA notes that the changes would reduce nicotine levels low enough “to no longer create or sustain addiction.” It may also help individuals who smoke change to lower-risk alternatives.
Currently, cigarette smoking causes what is estimated to be half a million deaths in the U.S. annually, while costing more than $600 billion in annual healthcare costs and lost productivity. Through FDA population health models, it is felt that the proposed changes by the year 2100 would help approximately 48 million U.S. youth and young adults from starting smoking in the first place. In addition, they predict that 12.9 million smokers would cease use within one year of the proposed change; they do note that this number includes those that may switch to noncombusted tobacco products. By 2060, they estimate that 1.8 million tobacco-related deaths would be avoided, with this number further rising to 4.3 million by the end of the century. Through these saved lives and a decrease in medical issues requiring treatment, $1.1 trillion dollars could be saved over the first four decades; this number could rise when including other medical costs, productivity gains, and other unspecified costs.
It is important to understand that this is not yet an official rule change, however the FDA notes it is a critical next step necessary in the sequence of events required for this proposal to ultimately be successful. Continue to promote overall tobacco and nicotine cessation in all your patients in the interim. In addition to interventions you can provide, referral to the Wisconsin Tobacco Quit Line is an additional resource for your patients.
Question from the clinic: The Glucagon-like-peptide-1 Receptor Agonists (GLP1-RA) are getting confusing with
all of the different names, indications, and dosing. Can you please give me a tool to simplify this?
Clinical Pharmacy Practitioner in Primary Care
Mike Grunske, PharmD, BCPS
Mike Grunske is a Board-Certified Pharmacotherapy Specialist (BCPS). Mike transitioned his practice to the Clement Zablocki VA Medical Center where he has since practiced in the Primary Care Clinics as a Clinical Pharmacist Practioner. Within this role, his practice involves direct care and management of patients’ medication regimens. He has worked as an active preceptor for both pharmacy students and residents throughout his entire career. Mike is also Past-President and former Foundation Chair of the Pharmacy Society of Wisconsin (PSW).
Mike is married to a fellow PharmAid contributor (Vanessa Grunske). Together they have a teenage daughter and son. He enjoys traveling with his family, attending his kid’s cheer, baseball, and basketball events, and spending any available leftover time running and hunting.
Pharmacist at Advocate Aurora Health
Vanessa Grunske, PharmD, BCACP
Vanessa practices with Advocate Aurora Health in Milwaukee, where she sees patients at Aurora Sinai Medication Management Clinic and maintains a dispensing practice at St. Luke’s Medical Center. Board-certified in ambulatory care pharmacotherapy, her practice interests include diabetes, hypertension, smoking cessation, geriatrics, improving health literacy, and medication adherence. She particularly enjoys and spends a good share of her work hours teaching and mentoring pharmacy students, family medicine residents and pharmacy residents.
She and her husband, Mike, live in the Milwaukee area with their two teenage children. In her free time, she enjoys cooking, baking, visiting our national parks with her family or relaxing on a beautiful Caribbean beach.
Professor at Concordia University Wisconsin School of Pharmacy
Beth Buckley, PharmD, CDCES
Beth Buckley, PharmD, CDCES (Certified Diabetes Care and Education Specialist), is a Professor of Pharmacy Practice at the Concordia University Wisconsin School of Pharmacy, where she has a teaching role within all years of the curriculum with a focus on Applied Patient Care Skills Lab, Diabetes Pharmacotherapy, and electives in the areas of diabetes and wellness. Her current role is ambulatory care pharmacist where she works with a Collaborative Practice Agreement to provide chronic disease state management within a primary care clinic.
When not working, she enjoys reading, gardening, traveling with her husband, volunteering within the community, and active fun: hiking, biking, dog walking, practicing yoga, mindfulness, and living with intention and gratitude.
Disclaimer: The Wisconsin Academy of Family Physicians (WAFP) has entered into a business relationship with Pharm Aid to offer our members discounts and exclusive savings. This or other affinity program relationships presented by the WAFP in no way implies a WAFP endorsement of the program, supplier, or vendor.
