EU-RICA - ARNI

Summary

The presentation 'Early and Upfront: Rapid Initiation Campaign for Iron' discusses guidelines for heart failure treatment, emphasizing the importance of early recognition and rapid initiation of the 'Fantastic Four' therapies—iron, beta-blockers, MRAs, and SGLT2 inhibitors. It highlights the benefits of these treatments, including reduced hospitalizations and improved heart function, and addresses the management of patients with varying ejection fractions. The talk also covers recent trials and the significance of the unique formulation of sacubitril/valsartan in improving cardiovascular outcomes for heart failure patients.

Takeaways

• 📚 The presentation focuses on the rapid initiation campaign for iron in heart failure treatment, emphasizing early intervention with directed medical therapy.
• 💊 The 'Fantastic Four' of heart failure treatment includes iron, beta blockers, MRA (mineralocorticoid receptor antagonists), and SGLT2 inhibitors, which are crucial for disease management.
• 🚑 Early and upfront initiation of these four medications is recommended for better outcomes in heart failure patients, regardless of ejection fraction levels.
• 📉 There is no fixed order for the sequence of therapies; the priority is to start and observe the application of the medications as quickly as possible.
• 🔍 Benefits of the combined therapy include rapid improvement in health, reduction in hospitalizations, and better quality of life for patients.
• 📈 The 2022 AHA/ACC Heart Failure Society of America guidelines suggest starting these medications simultaneously at low doses, especially for patients with heart failure.
• 🌟 Subcutaneous sacubitril/valsartan has shown significant benefits in reducing cardiovascular and renal events in patients with heart failure, including those with mild reduced or preserved ejection fraction.
• 📊 Cost-effectiveness analysis indicates that rapid initiation of therapy, either pre-discharge or early post-discharge, is supported by Class 1 evidence.
• 🔬 Recent trials, such as the PIONEER and VITALEAN trials, have demonstrated the efficacy of sacubitril/valsartan in reducing cardiovascular death and rehospitalization in heart failure patients.
• ⚠️ Sacubitril/valsartan is not to be halved due to its unique formulation, and patients should be enrolled in a hard care program for better access and adherence.
• 📝 The importance of early recognition and treatment of heart failure, including the management of diuretics and the initiation of MRA and SGLT2 inhibitors, even in areas with limited lab access, is highlighted.

Q & A

What is the main topic of the presentation?

The main topic of the presentation is the 'Early and Upfront, Rapid Initiation Campaign for Iron' in the context of directed medical therapy for heart failure.

What are the primary goals of the guideline Director Medical Therapy for heart failure?

The primary goals are to prevent disease progression and improve the patient's clinical status.

What are the 'Fantastic Four' in the context of heart failure treatment?

The 'Fantastic Four' refers to Iron, Beta Blockers, Mineralocorticoid Receptor Antagonists (MRA), and SGLT2 inhibitors, which are key components of heart failure treatment.

According to the 2022 AHA/ACC Heart Failure Society of America guidelines, how should medications for heart failure be initiated?

The guidelines suggest that medications should be started simultaneously at low doses, especially for patients with heart failure, or alternatively, started sequentially with the sequence guided by clinical or other factors.

What are the benefits of using the combination of Iron, Beta Blocker, MRA, and SGLT2 inhibitor in heart failure treatment?

The benefits include rapid improvement in health, reduction in heart failure hospitalizations, improvement in symptoms, and better quality of life for patients.

What is the recommended starting dose for Iron in the context of rapid initiation?

The recommended starting dose for Iron is 50 mg once or twice daily.

What is the significance of the term 'EF' in the context of heart failure?

EF stands for Ejection Fraction, which is a measure of how well the heart is pumping blood and is a key factor in determining the type and severity of heart failure.

What is the rationale for the 36-hour washout period when switching from an ACE inhibitor to an ARNI?

The 36-hour washout period is necessary to prevent angioedema, a potentially serious side effect that can occur when transitioning from an ACE inhibitor to an ARNI.

What does the term 'subcubital' refer to in the context of Vasartan?

Subcubital refers to a unique formulation of Vasartan that combines a sacubitril and valsartan in a specific 1:1 molar ratio, enhancing vasodilation and inhibiting vasoconstriction.

What is the significance of the term 'LVEF' in heart failure treatment?

LVEF stands for Left Ventricular Ejection Fraction, which is a measure of the heart's ability to pump blood from the left ventricle and is crucial in assessing heart function and treatment outcomes.

What is the role of diuretics in the management of heart failure according to the script?

Diuretics are a cornerstone in the management of heart failure, helping to reduce fluid overload and symptoms, but their use should be reassessed post-discharge to allow newer medications to work effectively.

How does the script address the management of patients with unknown eGFR when considering the use of SGLT2 inhibitors?

The script suggests that SGLT2 inhibitors can be initiated regardless of eGFR, with monitoring of renal function to ensure there is no worsening of kidney function.

What is the importance of early recognition and treatment in heart failure management as emphasized in the script?

Early recognition and treatment are key to preventing disease progression and achieving better outcomes in heart failure patients, including the use of the 'Fantastic Four' medications.

Outlines

00:00

💊 Rapid Initiation of Heart Failure Medication

The script discusses the importance of early and upfront treatment for heart failure, focusing on the 'Fantastic Four' therapies: iron, beta blockers, MRA, and SGLT2 inhibitors. It emphasizes the 2022 AHA/HFSA guidelines that recommend starting these medications simultaneously or in rapid sequence without waiting to achieve target doses. Benefits include rapid symptom improvement, reduced hospitalizations, and improved quality of life. The script also covers the correct dosing and titration of these medications, highlighting the significance of early intervention in managing heart failure.

05:03

📊 Clinical Trials and Heart Failure Management

This paragraph delves into recent clinical trials that have shaped the approach to heart failure treatment. It mentions studies like the Pioneer Heart Failure Trial and the Vericiguat Heart Failure Trial, which have shown significant benefits in reducing hospitalizations and cardiovascular deaths. The discussion also touches on the use of sacubitril/valsartan, a novel medication that has demonstrated positive outcomes in patients with reduced, mildly reduced, and preserved ejection fractions. The importance of early recognition and treatment, including the use of EP device therapies and transplant considerations, is also highlighted.

10:06

🛑 Subcubital Vasartan's Role in Heart Failure

The script provides an in-depth look at subcubital vasartan, a unique formulation that combines sacubitril and valsartan, and its role in improving cardiovascular outcomes for heart failure patients. It discusses the benefits of this medication in reducing the risk of symptomatic hypotension and worsening renal function compared to other treatments. The paragraph also summarizes the results of the PIONEER and VIALITE-HF trials, emphasizing the significant risk reduction in cardiovascular events and the importance of early treatment initiation.

15:07

🚑 Early Recognition and Treatment in Heart Failure

This paragraph underscores the importance of early recognition and treatment in managing heart failure, focusing on the 'Fantastic Four' therapies. It discusses the stages of heart failure and the different types, including the newly recognized improved ejection fraction category. The script also addresses practical considerations in clinical practice, such as the management of diuretics and the challenges of initiating therapy when lab results are not readily available. It concludes with the message that early and upfront treatment can lead to better outcomes in heart failure patients.

20:07

💡 Managing Heart Failure Medications in Clinical Practice

The final paragraph addresses common clinical questions and considerations when managing heart failure patients. It discusses the use of diuretics, the importance of not reducing the dose of sacubitril/valsartan, and the challenges of initiating medications like MRAs and SGLT2 inhibitors when eGFR levels are unknown. The script emphasizes the need for proper patient assessment and the importance of continuing medications to prevent relapse, while also acknowledging the financial considerations and the role of healthcare programs in facilitating access to these treatments.

Keywords

💡Heart Failure

Heart failure is a medical condition in which the heart is unable to pump enough blood to meet the body's needs. In the video, heart failure is the central theme, with discussions focusing on its treatment and management strategies. The script mentions various aspects of heart failure, including its symptoms, progression, and the importance of early diagnosis and treatment.

💡Ejection Fraction (EF)

Ejection fraction is a measure of how much blood the heart pumps out with each beat, expressed as a percentage. It is a key indicator in assessing heart failure. The script discusses different categories of heart failure based on EF: mildly reduced EF, severely reduced EF, and preserved EF. These categories help in determining the appropriate treatment strategies.

💡Directed Medical Therapy

Directed medical therapy refers to a treatment plan specifically tailored to address the needs of a patient with a particular condition. In the context of the video, this term is used to describe the approach to treating heart failure, emphasizing the importance of a personalized treatment plan that considers the patient's specific health status and needs.

💡Rapid Initiation Campaign

The rapid initiation campaign is a strategy discussed in the video that aims to quickly start and adjust medications for patients with heart failure. This approach is highlighted as beneficial for improving patient outcomes, with the script mentioning its effectiveness in reducing hospitalizations and improving heart function.

💡Fantastic Four

In the video, the 'Fantastic Four' refers to a combination of four key medications used in the treatment of heart failure: angiotensin receptor neprilysin inhibitors (ARNIs), beta blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors. These medications are emphasized as crucial components of a comprehensive treatment plan for heart failure.

💡Angiotensin Receptor Neprilysin Inhibitors (ARNIs)

ARNIs are a class of medications that combine the effects of angiotensin receptor blockers and neprilysin inhibitors. They are used to manage heart failure by reducing the strain on the heart and improving its function. The script discusses the benefits of ARNIs, such as rapid improvement in heart function and reduction in hospitalizations.

💡Mineralocorticoid Receptor Antagonists (MRAs)

MRAs are medications that block the effects of aldosterone, a hormone that can cause fluid retention and high blood pressure. In the context of the video, MRAs are part of the 'Fantastic Four' and are discussed as important in managing heart failure by reducing symptoms and improving patient quality of life.

💡SGLT2 Inhibitors

SGLT2 inhibitors are a class of drugs that reduce glucose levels by causing the kidneys to remove sugar from the body through urine. The script mentions their role in heart failure treatment, highlighting their benefits in reducing heart failure hospitalizations and improving patient outcomes.

💡Renal Function

Renal function refers to how well the kidneys are working. In the video, renal function is discussed in relation to heart failure, as kidney health is closely linked to heart health. The script mentions the importance of monitoring renal function when using certain medications, such as SGLT2 inhibitors.

💡Cardiovascular Outcomes

Cardiovascular outcomes are the results or consequences related to heart and blood vessel health. The video discusses the impact of various treatments on cardiovascular outcomes in patients with heart failure, emphasizing the goal of improving these outcomes through effective medical therapy.

💡Diuretics

Diuretics are medications that increase urine production, helping to reduce fluid buildup in the body. In the video, diuretics are mentioned as a cornerstone in the management of heart failure, used to alleviate symptoms like fluid retention. The script also discusses considerations in their use, such as the potential for overuse and its impact on kidney health.

Highlights

Topic of the presentation is 'Early and Upfront, Rapid Initiation Campaign for iron' in heart failure treatment.

Guidelines focus on directed medical therapy for heart failure, emphasizing rapid initiation of treatment.

Discusses treatment strategies for patients with varying levels of ejection fraction (EF).

Primary goal of treatment is to prevent disease progression and improve patient quality of life.

Introduction of the 'Fantastic Four' in heart failure treatment: iron, beta blockers, MRA, and SGLT2 inhibitors.

There is no fixed order for the sequence of therapies; prioritization and observation are key.

2022 AHA/HFSA guidelines recommend simultaneous initiation of medications at low doses for heart failure patients.

Benefits of the 'Fantastic Four' include rapid health improvement and reduced hospitalizations.

Initiation of medications can be done simultaneously or through rapid sequencing.

Example dosing for iron, beta blockers, MRA, and SGLT2 inhibitors in heart failure treatment.

Special considerations for patients transitioning from ACE inhibitors to ARNI.

Recent trials show the effectiveness of sacubitril/valsartan in acute heart failure.

Cost-effectiveness analysis supports rapid initiation of iron therapy in heart failure patients.

Subgroup analysis of heart failure patients with improved EF shows benefits of sacubitril/valsartan.

PIONEER-HF trial results indicate a significant reduction in cardiovascular death and rehospitalization with sacubitril/valsartan.

VICTORIA trial demonstrates the efficacy and safety of sacubitril/valsartan in patients with mild reduced EF.

Subcubital valsartan's unique formulation enhances vasodilation and inhibits vasoconstriction.

Early recognition and treatment of heart failure are crucial for better patient outcomes.

Management of diuretic use in heart failure treatment, emphasizing the importance of reassessing patients post-discharge.

Discussion on the management of patients with unknown eGFR when considering the use of MRA and SGLT2 inhibitors.

Transcripts

topic for tonight is entitled early and Upfront

Rapid Initiation Campaign for iron

okay so the outside of the presentation are as follows

are the giving the guideline

directed medical therapy for heart failure

how do we treat patients with hephra

and how do we initiate rapidly

how do we initiate rapidly the design mine

so particularly

how do we treat patients for who have more than 40% EF

we have mildly reduced EF

we serve EF and those with include EF

so in the guideline Director Medical Therapy

our primary general Sarah Stylos

prevent disease progression

and improve the patient child status

so this was discussed by Doctor Richard Bruce earlier

the most common signs and symptoms of heart failure

so again the primary treatment

goals is to prevent the disease progression

so how do we do this so specially for your arrhythmias

you will have our heart transplant now

and then

we decrease

the recompensated state of our heart failure patients

and for the improvement of patients and status

who want to lessen the symptoms

improve the quality of life of these patients

so this was discussed as a fantastic four

so of course you have your irony

your beta blocker the MRA

and then the accidental

medicine for your heart failure

as TLDP inhibital

so in the order of sequence of therapies of this cast

there is no fixed order

or no preference for the sequence used

so he prioritize administration

and observe application of the

those and speed matters of course

so in the 2022 ahacc

Heart Failure Society of America guidelines

it was stated that we need to start this medicine

simultaneously at no doses

especially for your health breath patients

alternatively

this medications will be started sequentially

with sequence guided by clinical or other factors

without the need to achieve target nursing

before initiating your medication

so

here are the benefits of your irony plus beta blocker

plus MRA and then your SG and T2 in medical

so first

would be a rapid improvement in health

as early as 8 weeks

rapid reduction in your heart failure

hospitalizations within 2 to 4 weeks

so we would not want our patients to be visiting

the emergency room

rapid reduction in your mentality

as early as 2 to 4 weeks

rapid improvement in your LV

ejection production within 12 weeks

rapid reduction in your heart failure

rehauspitalization and improve use tolerability

adherence persistence and overcoming ineration

so this is your comprehensive

disease modifying medical therapy

wherein we start simultaneously

or rapid sequencing of your fantastic 4 medicines

so an example is a pre one for your irony beta blocker

MRA and s G l t t inhibitor

we start them at a low dose or your illustration

so say for example your iron knee

you can start them at D1 with 50 mg once

twice daily dosing low dose of your makeup locker

low dose of your MRA and your s G L D2 inhibitor

so it is stated that for

if you want to convert creatency detour to your army

so

you need to wait for 36 hours as you wash out period

so that dose of your self

VARs or pivotal

vasartar should be doubled after 2 to 4 weeks

to target dose of 200 mg twice daily dose

so uh for your beta blockers

so you also start low low and slowly

so you have your examples of esoperolol or vadiloyal

no acting metoporolol succinate and your medievalol

so on the deep 7 to 14 which is yourself

uh first to

to second with to continue your medications

they treat them as tolerate them

so here we optimize our uh medicines

now as long as their patients

tolerate the effects of this medicines

so on the end of your first month to your uh

third month

maintain this an additional type of titration

however for patients who want to uh lessen the death

we consider EP device therapies

or transplatory micro valve repair

so

the recent trials for hospitalised patients as emerged

particularly your pioneer heart failure trial

your Fireglide heart failure trial were in secumetal

Vasal Tan was used

so in here the undertakens in the previous inhibitor

irony as used in your acute

the compensating heart failure

has shown to decrease as much as 71%

in the outcomes of these patients

with regards to their tolerability

worsening renal function hyperkalimia

symptomatic hypertension and

and Angie edema were all compatible with the placebo

so with regards to

the patients hospitalized with heart failure

those who are symptomatic and show if fluid overload

especially

for those patients who have reduced ejection fraction

it has shown that there

has 46% relative breast reduction

so with regards to a rapid illustration

for your eye knee

it has shown 42% relative risk reduction

with regards to the cardiovascular death or hospital

readmissions due to your heart failure

so moving on so

the cost effectiveness analysis was examined for

patients who are on rapid initiation of your ironing

so the intensive in

the intensive strategy of initiation of rapid

up titration

are shown to have a class 1 evidence already

when initiated on pre discharge

or early post discharge fails

so what about your heart failure

patients with improved EF

mild reduced EF or to serve ejection production

so for this patient

especially for your improved ejection fraction

so this is defined as a baseline EF of 40%

an increase of 10 points from your baseline LVEF

honor

the second measurement of your LVEF to be more than

40% already

so with this regards

it has shown that subcubital Vasar Tan

reduce total heart failure

hospitalizations in cardiovascular death

and 25% related risk production

in total heart failure patients

versus your Vasar Tan alert

so comparing your paradigm heart failure

with a paradigm heart failure trial

so your therapeutic benefits of yourself

while with respect to heart failure patients on

has shown robust evidences that may extend

the patients to be

the use of your subcrimetal vasar tan

for below normal Egyptian fraction

so moving on the pirate line heart failure trial

so in the pirate line to heart failure trial

this aims to show the efficacy

safety and tolerability of subterminal Vasar Tan

for those patients of mild

reduced EF episode

ejection fraction

with patients with a recent worsening heart failure

even

so this was their status design

with the primary employment of time

average proportional change of your NP

Pro BNP from this line from width 4 to eight

so it has shown that there was 15% greater adoption

with your security advisor

done with regards to the change of your NP Pro bnb

which is arrogate marker for your heart failure

so a pre specified participant level

food analysis was also used for this study

so in the Pirate Light heart failure trial

there's a million follow up here of top six months

and went for a part ago on heart failure

triangles of median follow up of almost three years

so this showed to us of a primary code analysis

for in your total worsening heart failure events

and cardiovascular debt

there was a 22% relative risk reduction

and for your report analysis of all participants

there was 14% relative risk reduction

favored in your secretary field via site plan

so in summary security

Vasar Tan reduced cardiovascular and renal events

compared with Vasar Tan

among patients with heart failure

with mild reduced or preserved ejection fracture

so benefits appeared to up uh

who rapidly

with statistically

significant reductions in cardiovascular events

first observed within the first 2 weeks of treatment

initiation and cardiovascular benefits

most apart in patients with an LVEF below normal

so this is an important uh

sentence here that's accumulated

bicyrtan increased risk of symptomatic hypotension

but reduced risk of

worsening renal function when compared with bicyrtan

so again

the unique formulation of a saccubutal Vasor

done consistently improves the cardiovascular outcomes

with R B E

for your hospitalized patients across the spectrum

so for your pioneer heart failure

it has shown red

31% reduced cardiovascular death and reignation

for patients with reduced EF

so that's less than 40%

and the viral glide heart failure

and part of one heart failure

which consisted of your mildly reduced EF

and preserved ejection fraction at 22%

reduce hospitalization and cardiovascular death

for those patients for symptomatic ambulatory patients

the paradigm heart failure is proven

for patients reduce ejection fraction

will have a reduction as much as 20%

for the reduced total heart failure

hospitalizations and cardiovascular death

as well as a 22% relative risk reduction

for those patients who have more than 40% rejection

fraction

so why is subcubital vasartan verifications

so this is the molecule of sectorbital

vasartan is designed to be different

so this is a combination of your subcubital and your

so arresting hibitor and your neprelacene inhibitor

so your LCC696 so the active molecule of your uh

occubital valsar Tan

simultaneously delivers your succubital and valsar tan

in a specific one is to 1 molar ratio

so you enhance your vassal relaxation

and you inhibit your vassal construction

so the power of subcubital vasircan is

with its unique forulation

so

it has shown robust evidences for both outpatient and

uh

admitted patients

so with regards to the cardiovascular outcome trials

so the rapid initiation campaign for irony

has shown to be very efficacious

and has been already recommended by your aha

ACC and Heart Failure Society of America

so the uh in conclusions

early recognition of the patient

with heart failure is key to early treatment

the rapid initiation of the Fantastic Four

which consists of your army as United inhibitor

MRA and beta blocker

is key to early and maximum benefits

in heart failure patients

and army in the full spectrum of heart failure

and we used

early and upfront initiation

leads to better heart failure outcomes

so uh this is make ways so you recover

so the early and upfront use of iron in heart failure

is exception to the rule so with that

thank you

before shifting your or your age or your vision or any

what's the rationale of the time

of course aside from the overlapping effect of your

ace inhibitor in your irony

which may affect your lemodynamic status

we want to prevent the

the effect of andro edema

now for patients who are

initially on your ace inhibitor

and to be shifted on your army

so that is a seat window

period at 36 to 48 hours to prevent anti

edema for these patients

thank you

uh requests from the audience uh

make for those so

um Madam President

thank you very much Doctor Zan

so we both listen to the two speakers

uh they emphasize

early recognition is the key to prevent heart failure

so we really have to encourage our patient at risk

those who are on stage a

who are those patients

those are newly diagnosed diabetes

and controlled hypertensive patient

whether they are old or young

um those have recent MRI

recent stroke so as to avoid

to have a structural abnormality in the future

because once they develop it

they would really develop symptoms later on

they also emphasize that we have to remember

the four pillars of management

the army use

if it's the patients are not do not tolerate the army

we can ship it to ace inhibitor or Arbs

the importance of a better blocker

the mineral corticoid antagonist and the SCL2 inhibitor

we um

they also emphasize uh

Doctor Richie emphasize that there is a new type of um

heart failure uh

we we knew only the preserve EF

reduce EF the mid range EF

but now there is an improved EF they want

these are the patients who have

at first 40% less of ejection fraction

and then after treatment

has an improvement of 10% from the baseline

the message

is to continue the medications to avoid relapse

Redell

it's a magic four

by the magic number for tonight is four

so there are four pillars

the treatment of hearts filler

there are four stages there are

those are two ways

stage B is a pretty heart failure

stage C is those who are symptomatic

and stage d is the advanced heart failure

another four is the four types of heart failure

so for our residence for the younger colleagues

so please take note of those things

and of course

the recent trials mentioned by the third time

so it's very helpful actually in our practice

hi okay

so there's a question Doctor Radelle about um

diuretic use

so let me ask you Doctor Radelle in your practice

um how do you manage your patient

uh we know that the diuretic is a cornerstone um

in the management of heart failure

how do you manage with the use of the diuretic

because they give

they have given the emphasis on their lecture

as much as possible of course India

it's it depends on the clinical picture of the patient

if the patient is about to be discharged

well you have been really assessed the patient

so sometimes I still feel for oral diabetics uh

post discharge

but I have to reassess the patient at least 5 days

for maximum plan for 1 week

for me to know if I'm going to take out the diuretic

already because of us

what Doctor Richards mention

uh we do not give uh

whom they read it as maintain and stuff

we we have to give way to the newer uh

medications for them to work

so we really uh it's a case to case basic statues

and we really have the assessment patient here

because sometimes we over diabetes our patient

which is also what is harmful to the kidneys

I think we

are

I have a um doctor that I have a question

there's a question in the check box

they uh

they would like to ask the how do you um manage do

are we allowed to lessen the dose of the interest tone

because you mentioned that ideally

that should be 50 milligram twice a day now

so is there an incense that most of that time

patient become hypotensive

so so what can you say about this

so in the landmark trial of interests of occupital

balcytan so we're only allowed

actually it was not mentioned

if we're allowed to lessen or decrease the dose

no so

as low as the patient has not presented symptomatic

hypertension and so

you can still use the full dose of your 50 mg

twice a day

those things

now with regards to the common questions

and since seccupital website

and interest is relatively expensive now

so a common question is

are we allowed to uh half the the tablet

no so actually no

no because as I have discussed no

so uh the subcubitrial and then the uh

pulsite time is integrated as one molecule

so once you uh half if no

so

you might disintegrate the full effect of the medicine

so anyway I think know why this

Philippines has a hard care program

no where in they give back uh

so the number of tablets now to the patients

once enrolled to this program

so that makes it easier for the patients also

and the family

anyway so the question was

these medications are elite effective

other options for patients who are illegal

guy for in there

actually

so it's a manner of delivering it to the patient now so

if you tell them the landmark trials

and the possible benefits of these medicines so

we have to remember that this 4 medicines already

the mainstream

or the four pillars of your heart failure

it's the aim to have our

okay then okay let me keep the question

may I ask regarding the use of MRA

in SGLT2 inhibitors among patient with unknown EGFR

uh

financial consult where labs are not easily accessible

can we still initiate this class of labs

or wait for it

for labs to be done prior to its initiation

okay so definitely need this line laboratories now

so we need to establish the uh

kidney function of the patient

the urinal function of the patient

so that includes your BRP as well as your electrolytes

if you are considering to use also your MRI

so emerging studies for the s G

L T 2 inhibitor a show that irregardless of the EGFR

so you may still use or initiate your s G

L t to inhibitor then just monitor their

renal function

so to see if there is work

but

recent studies of your SGLB to inhibitor has

established that there is a beneficial impact

on the worsenic kidney function of the patients