Shared Decision-Making in Transthyretin Amyloid Cardiomyopathy Care

Announcer:
You’re listening to Heart Matters on ReachMD. On this episode, we’ll hear from Dr. Ahmad Masri, who will be discussing the role of shared decision-making in the management of transthyretin amyloid cardiomyopathy, or ATTR-CM. Dr. Masri is an Associate Professor of Medicine in the Division of Cardiovascular Medicine at Oregon Health and Science University. Here he is now.

Dr. Masri:
Deciding on the treatment option initiation in a naive patient, for example, is really individualized. We discuss all the options with the patient, and there are unique characteristics about each of the options that allow the physician and the patient to come up with a plan as to which medication they would start on. So that’s for the naive patients. Some drugs are older; some drugs are injectable; some drugs are daily or twice a day; some medications are once-every-three-month injections. So there are enough individual variations between all of these medications that you can actually talk to the patients about them and have them decide or have a shared decision-making approach in this.

In terms of patients who are already on a therapeutic agent, there is also a chance there for shared decision-making where, if the patient is perceiving they’re not doing as well as they used to or if they have progressive heart failure symptoms, a need for diuretics, or an admission or something like, it creates an opportunity to do what we call switching over to a different agent. And we’re very clear and very transparent about the fact that we do not know if a switch over to a different agent will be beneficial for that specific patient, but it’s a chance to have discussion about the new or available therapies and if the switch is indicated or not in that scenario. 

So it is really important to take the time to sit down with the patients—especially the newly diagnosed patients who all of this is coming new to them—to have them really understand the underlying disease process, the drugs that we use, and the benefit of each individualized medication. It is very important to be able to secure that time in a busy clinic to do that and reiterate it, sometimes even multiple times. And so what we do is that we have an introductory talk with the patient about what transthyretin cardiomyopathy is. Then we go through all the medication classes and whatnot. We together have a shared decision-making about it, but a lot of the times, we actually have a follow-up with a phone call, or we have our pharmacist—who’s very experienced with these medications—also perform a follow-up phone call so that we can communicate with the patients again and make sure they really understand one, the rationale for doing this, and two, what the expectations are. And I think that is extremely important as part of this process. 

I think there are some barriers to prescribing, obtaining and having patients continue on these therapies for transthyretin amyloidosis. One obvious barrier is the ability of the patient and the physician to have the time and the place to discuss these in detail. It is a lot to talk about, and so one, it’s a barrier of communication—you need to be able to secure the time to do this in, again, busy practices—and the second thing is the barrier of making sure that you are not choosing only one option and running with it. And then finally, an important barrier is related to obtaining these medications for the patients. You have to invest and be willing to work with these payer and insurance companies to get the medication for the patient. It is not always an easy process or a straightforward process, but it’s a good reminder that if you don’t do this and you don’t get this drug to the patients, they’re going to do worse, and they’re not going to do well over the following years.

And so those are some of the barriers and the challenges, but I do believe that we can overcome all of these.

Announcer:
That was Dr. Ahmad Masri talking about how we can optimize communication when treating transthyretin amyloid cardiomyopathy. To access this and other episodes in our series, visit Heart Matters on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!