Clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure

Abstract

Objective:The establishment of an optimal strategy for elderly patients with acute decompensated heart failure (ADHF) is currently an important issue. Particularly in very elderly (VE) patients, ADHF is associated with a poor prognosis. We therefore aimed to evaluate the efficacy and safety of the early use of tolvaptan (TLV) in VE patients.Methods:Of 245 patients with ADHF admitted between March 2013 and July 2014, we prospectively enrolled 111 patients with TLV first administered within 24 h of hospitalization. These were divided into two groups according to the age: VE (≥85 years, n=45) and not very elderly (NVE, <85 years, n=66). The endpoints were the incidence of worsening renal function, death by any cause, or the length of hospital stay.Results:There were no significant differences between the two groups in the incidence of worsening renal function (26.7% in VE vs. 25.8% in not VE, p=0.92), dose of TLV after hospitalization (7.4±0.7 vs. 7.5±1.3 mg/day, p=0.63), mean duration of the use of TLV (4.3±3.5 vs. 5.4±4.8 days, p=0.17), or mean length of hospital stay (16.5±7.8 vs. 15.7±8.0 days, p=0.64).Conclusion:TLV shows similar efficacy and safety in both VE and NVE groups. Even for VE patients with ADHF, initiation of TLV with standard diuretic treatment may have the potential not to increase the incidence of worsening renal function.

Update of acute and long-term tolvaptan therapy

“…Kinoshita and colleagues demonstrated that tolvaptan therapy in patients aged over 80 years old with repeated HF hospitalizations resulted in immediate decongestion and reduced hospitalization period with a lower incidence of worsening renal function [22]. In another study, patients aged over 85 years old had similar rate of worsening renal function and length of hospitalization stay compared with those aged under 85 years old during tolvaptan therapy [23].…”

Tolvaptan in the very elderly with acute decompensated heart failure- a therapeutic option worthy of consideration

“…The treatment of ADHF in the (very) elderly can be particularly difficult due to advanced age-related frailty and comorbidities increasing the odds for a poor outcome, deterioration of liver and kidney function predisposing to inadequate drug metabolism or elimination, reduced efficacy, and increased risk of drug toxicity, or other adverse events. In this regard, this study ( 11 ) is reassuring in that, regardless of age, tolvaptan represents a safe therapy for patients with ADHF. More specifically, tolvaptan use in doses and duration as used in the study performed by Niikura et al ( 11 ) does not increase the risk of WRF, a relatively common side effect of drug therapy in patients with ADHF that portends a poor prognosis ( 12 ).…”

“…In this regard, this study ( 11 ) is reassuring in that, regardless of age, tolvaptan represents a safe therapy for patients with ADHF. More specifically, tolvaptan use in doses and duration as used in the study performed by Niikura et al ( 11 ) does not increase the risk of WRF, a relatively common side effect of drug therapy in patients with ADHF that portends a poor prognosis ( 12 ). Moreover, the study may be unique in addressing the treatment of ADHF in such a high-risk and difficult to treat group of patients as are the very elderly.…”

“…In this issue of the Anatolian Journal of Cardiology, the article entitled “The clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure” by Niikura et al ( 11 ) assessed the safety and efficacy of early use (within 24 hours of hospitalization) of oral tolvaptan in very elderly (≥85 years of age; n=45) versus younger patients (<85 years; n=66) with ADHF. The primary outcome was WRF (creatinine increase >0.3 mg/dL from admission level) or severe WRF (creatinine increase >0.5 mg/dL from admission level).…”

Tolvaptan should be used very carefully in very elderly patients

“…We were very interested to read the article entitled ’The clinical utility of early use of tolvaptan in very elderly patients with acute decompensated heart failure’ by Niikura et al ( 1 ) recently published in the Anatol J Cardiol 2017; 18: 206-12 and the editorial comment entitled ’Tolvaptan in the very elderly with acute decompensated heart failure- a therapeutic option worth of consideration’ by Ndrepepa ( 2 ) in the same issue, which evaluated the safety and efficacy of tolvaptan, a selective vasopressin V2 receptor antagonist, in very elderly patients.…”