Patiromer Promising in Optimizing HF Treatments for Patients with Hyperkalemia, DIAMOND Trial Reveals

The study, published in the Journal of the American College of Cardiology, revealed that in individuals with heart failure with reduced ejection fraction (HFrEF) and a history of hyperkalemia (HK), the addition of patiromer facilitates the optimization of renin-angiotensin system (RAS) inhibitors and mineralocorticoid antagonists (MRAs), which are essential components of heart failure management.

Hyperkalemia, characterized by elevated potassium levels in the blood, poses significant challenges in managing patients on RAS inhibitors and MRAs. These medications are crucial for treating heart failure, as they help improve heart function and reduce the risk of hospitalization and mortality. However, the occurrence of hyperkalemia often leads to the discontinuation or dose reduction of these therapies, undermining their benefits.

Against the above background, Bertram Pitt, Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA, and colleagues aimed to evaluate the characteristics and usage of RAS inhibitors and MRAs in patients receiving patiromer during the run-in phase of the DIAMOND study (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure).

Patients with HFrEF and hyperkalemia (HK) or a history of HK participated in a run-in phase of up to 12 weeks, during which patiromer facilitated the optimization of RAS inhibitors and MRAs to reach at least 50% of the recommended RAS inhibitor dose, 50 mg/day of MRA, and normokalemia. Those who met these criteria and entered the randomized group were compared with the run-in failure group, consisting of patients who did not meet the randomization criteria.

Based on the research, the following findings were revealed:

• Of 1,038 patients completing the run-in, 878 were randomized, and 160 were run-in failures.
• 40.7% of patients had HK entering run-in with a similar frequency in the randomized and run-in failure groups (40.3% versus 42.5%).
• From the start to the end of the run-in, in the randomized group, there was an increase in target RAS inhibitor and MRA use in patients with HK (RAS inhibitor: 76.8% to 98.6%; MRA: 35.9% to 98.6%) and past HK (RAS inhibitor: 60.5% to 98.1%; MRA: 15.6% to 98.7%).
• Despite not meeting the randomization criteria, there was an increase after run-in in the run-in failure group in target RAS inhibitor (52.5% to 70.6%) and MRA use (15.0% to 48.1%).
• This increase was observed in patients with HK (RAS inhibitor: 51.5% to 64.7%; MRA: 19.1% to 39.7%) and past HK (RAS inhibitor: 53.3% to 75.0%; MRA: 12.0% to 54.3%).

In their analysis during the run-in phase of the DIAMOND trial, the authors found that most patients with HFrEF and hyperkalemia or a history of HK could rapidly and safely optimize their RAS inhibitor and MRA therapy while achieving or maintaining normokalemia with the help of patiromer. Notably, neither hypotension nor worsening kidney function posed significant barriers to the optimization of these therapies in this high-risk population. Furthermore, among patients who were unable to be randomized in this uncontrolled segment of the study, the majority were still able to initiate, maintain, or uptitrate their RAS inhibitor and MRA doses alongside patiromer.

"These findings suggest that patiromer could play a vital role in enhancing and sustaining the use of RAS inhibitors and MRAs in patients with HFrEF and HK or a history of HK," the researchers concluded.

Reference:

Pitt, B., Anker, S. D., Lund, L. H., Coats, A. J., Filippatos, G., Rossignol, P., Weir, M. R., Friede, T., Kosiborod, M. N., Metra, M., Böhm, M., Ezekowitz, J. A., Bayes-Genis, A., Mentz, R. J., Ponikowski, P., Senni, M., Piña, I. L., Pinto, F. J., Van der Meer, P., . . . Butler, J. (2024). Patiromer Facilitates Angiotensin Inhibitor and Mineralocorticoid Antagonist Therapies in Patients With Heart Failure and Hyperkalemia. Journal of the American College of Cardiology, 84(14), 1295-1308. https://doi.org/10.1016/j.jacc.2024.05.079