Q&A column, 5/16

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Editor: Frederick L. Kiechle, MD, PhD

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Q. What laboratory test should be used to monitor the effect of the heart failure medication Entresto (sacubitril/valsartan)?

A. There is no consensus at this time about which biomarkers should be measured once a patient is treated with Entresto. On the one hand, the simplistic argument would be to simply measure NT-proBNP, as this biomarker is not adversely affected by the drug and monitoring of the benefit of Entresto is possible. While the most straightforward approach, this may not be practical for institutions that do not run NT-proBNP, so clinicians are faced with either not measuring a natriuretic peptide in their patients or measuring BNP and trying to interpret it. Unfortunately, we do not know if the effect of Entresto extends to all BNP assays, and if it does, whether they are affected the same.

Also, in order to interpret BNP in a patient taking Entresto, it’s important to emphasize we do not yet know how much of an increase in BNP to expect from Entresto treatment, or the durability of such a rise. It is clear that in the PARADIGM-HF trial, patients showed an approximate 25 percent increase in their BNP concentrations (measured using the Siemens BNP method) after initiation of the drug. This rise seems to be relatively durable, suggesting that the effects of Entresto on BNP do not “wear off.”

Lastly, much as a fall in NT-proBNP may indicate benefit, it has been suggested by some that measuring BNP might be done to look for the rise in the marker to suggest effectiveness of the drug. I believe this latter approach is foolish and not advisable because a rising BNP might very well indicate a decompensating patient, and such decompensation would be missed if it was assumed the rise in BNP is due to Entresto.

James L. Januzzi Jr., MD
Hutter Family Professor of Medicine

Senior Faculty, Harvard Clinical Research Institute, Boston