The Editor-in-Chief of Medpage Today – whatever that is – asks:
Entresto: Why Is There Silence? We’re Not Selling iPhones; The drug hailed as a true PARADIGM shift, is slow out of the gate.

She’s a bit undercut by her staff, who wrote: Novartis is pushing a hard sell for Entresto — the “miracle” heart failure drug that is struggling to catch fire in the U.S. — at the American College of Cardiology meeting in Chicago. Here’s a MedPage Today video with Milton Packer and Clyde Yancy weighing in on the issue.

The “hard sell” documentation points back to the EIC’s editorial! It appears that there’s no separation between the drug company’s pitch through MedPage Today, and the “opinion” of the Editor-in-Chief.

There’s no pretense anymore. The drug companies run medicine now.

Entresto is a twofer-drug, which always makes me suspicious. I don’t like driverless cars, or cocktail medication. Its website offers “ENTRESTO reduced the risk of death and hospitalization in people with Heart Failure with reduced ejection fraction (HF).”

Its parts are sacubitril and valsartan. Afterload inhibitors, including the ARB’s, will improve the numbers of death and hospitalization in people with HF and reduced EF. It’s up to the company to show that:

  1. The combo works better than just an ARB.  You can add cream-cheese to the ARB and it will improve these measures.
  2. The combo works synergistically.  If they are just apples-and-oranges, who cares that they are a combo?  Atenolol/HCTZ is a dual acting agent that has two powerful parts – but who cares if they are bundled into one pill?

Ads used to answer the obvious, because they were targeted at doctors.  Now, no more!  They are targeted at pharmacy managers, RPh MBA characters, who look over the Statistics on Heart Failure, and frown.  Let’s get those better!  How can we do it?  Get the Entresto people out for the dog’n’pony show!

 Randomized to receive either ENTRESTO (n=4209) or enalapril (n=4233) Published in the NEJM.  The effect of adding a BNP agonist is about a 5% improvement on the endpoints.  But the link to the NEJM doesn’t work.  Absolute risk reductions are around 3% for death and rehospitalization.

The real point is not the “new-old” BNP agent – that’s been kicking around the labs for 20 years.  The point is that natriuretics help.  The patients are all on beta-blockers and other cardio-agents.

“ENTRESTO is indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II‐IV) and reduced ejection fraction.”

References: 1. McMurray JJV, Packer M, Desai AS, et al. Angiotensin–neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371(11):993‑1004. 2. ENTRESTO [prescribing Information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; August 2015.

This is definitely a may-use agent, not the Second Coming agent like the HCV medications.  But beat the drums, it’s the Heart Transplant in a Pill! sez the druglords.  They are talking to the low-information-voters in the Medical Retail system, who make the big decisions.  low-level PCP + drug=cardiologist level management.  Who needs expensive minds when we have expensive drugs?  That’s the equation they work on, and it’s measured in DOLLARS, CHUMS.

Anyone who gets it, understands that multidisciplinary management of heart failure with lower EF needs attention.  I do that, and get tune-ups with drugs over sixty years old.  The point is not some “the heck with the newfangled!” because HCV drugs changed the whole game there.  The point is that the slot for Game-Changer shouldn’t be cluttered with admen/women pitching their snake oil.