Cardiologists' Perspectives on Race-Based Drug Labels and Prescribing Within the Context of Treating Heart Failure

Abstract

Purpose: Cardiologists are known to consider patients' race when treating heart failure, but their views on the benefits and harms of this practice are largely undocumented. We set out to explore cardiologists' perspectives on the benefits and harms of race-based drug labels and guidelines. Specifically, we focused on isosorbide dinitrate and hydralazine hydrochloride (sold in a patented form as BiDil), a combination of drugs recommended for the treatment of black patients receiving optimal medical therapy for symptomatic heart failure and reduced ejection fraction. Methods: We conducted 81 semistructured interviews at an American College of Cardiology Annual meeting to assess cardiologists' and cardiology fellows' attitudes toward the use of race in drug prescribing. Investigators reviewed and coded the interviews using inductive qualitative analysis techniques. Results: Many participants believed that race-based drug labels might help doctors prescribe effective medications to patients sooner. More than half of the participants expressed concerns, however, that considering race within the context of treating heart failure could potentially harm patients as well. Harms identified included the likelihood that patients who could benefit from a drug may not receive it because of their race; insufficient understanding about gene–drug–environment interactions; and simplistic applications of race in the clinic. Conclusions: Few participants expressed approval of using race in drug prescribing without recognizing the potential harms, yet most participants stated that they continue to consider race when prescribing isosorbide dinitrate and hydralazine hydrochloride. Within the context of treating heart failure, more open discussions about the benefits and harms of race-based drug labels and prescribing are needed to address cardiologists' concerns.

Attitudes and beliefs regardingrace‐targetedgenetic testing of Black people: A systematic review

“…We do not know whether this discomfort is specific to RTGT or whether these same physicians also are uncomfortable using algorithms or other decision tools that rely on race in medicine. Some evidence suggests that clinicians see the use of race in medical decision‐making both positively and negatively and have varying levels of comfort with collecting and using race information (Bonham et al, 2017; Callier et al, 2019). This discomfort aligns with other stakeholders' views that reliance on race is a barrier to RTGT (Bevan et al, 2003; Gordon, Amórtegui, et al, 2019; Gordon, Amόrtegui, et al, 2019; Gordon, Wicklund, et al, 2019; Miller, 2020).…”

Health equality, race and pharmacogenomics

“…It is no surprise that BiDil (isosorbide dinitrate/hydralazine), the only drug tested and approved for use solely in African Americans, and motivated by commercial interest, sparked distrust and has become a cautionary tale 6–8 . There is evidence of physician concern that racial categories used to determine treatment strategy in heart failure could prevent patients from receiving medication that would in fact benefit them 9 . Race is currently deeply entrenched in clinical practice, with differences in therapeutic algorithms for example in treating hypertension or heart failure, as well as diagnostic thresholds such as renal or lung function parameters 5…”

“…[6][7][8] There is evidence of physician concern that racial categories used to determine treatment strategy in heart failure could prevent patients from receiving medication that would in fact benefit them. 9 Race is currently deeply entrenched in clinical practice, with differences in therapeutic algorithms for example in treating hypertension or heart failure, as well as diagnostic thresholds such as renal or lung function parameters. 5 How then can the scientific and medical community go about extricating discussions of race from genetically derived ancestry?…”

Race and Drug Toxicity: A Study of Three Cardiovascular Drugs with Strong Pharmacogenetic Recommendations

“…The use of race and ethnicity in medicine is controversial due to the large variability amongst different racial/ethnic groups, lack of detailed ethnic information, the co-existence of social and environmental determinants of health, and the broad geographic categorization of "racial" groups (i.e., Asian, African). Yet, race and ethnicity are still employed as surrogate biomarkers in clinical practice [13,14] including in many US FDA prescribing guidelines [15]. For each of the drugs described above, considerable variability amongst different ethnic/ancestral/racial populations [16][17][18][19][20] exists within their respective pharmacogenes covered in the CPIC guidelines.…”