Elsevier

American Heart Journal

Volume 243, January 2022, Pages 158-166
American Heart Journal

Prevalent pharmacotherapy of US Fontan survivors: A study utilizing data from the MarketScan Commercial and Medicaid claims databases

https://doi.org/10.1016/j.ahj.2021.09.012Get rights and content

Background

Survivors of Fontan palliation are at life-long risk of thrombosis, arrhythmia, and circulatory failure. To our knowledge, no studies have evaluated current United States pharmaceutical prescription practice in this population.

Methods

A retrospective observational study evaluating the prevalent use of prescription medications in children and adolescents with hypoplastic left heart syndrome or tricuspid atresia after Fontan completion (identified using ICD9/10 codes) was performed using data contained in the MarketScan Commercial and Medicaid databases for the years 2013 through 2018. Cardiac pharmaceuticals were divided by class. Anticoagulant agents other than platelet inhibitors, which are not uniformly a prescription medication, were also studied. Associations between increasing age and the likelihood of a filled prescription for each class of drug were evaluated. Annualized retail costs of pharmaceutical regimens were calculated.

Results

A cohort of 4,056 subjects (median age 12 years [interquartile range: 8-16], 61% male, 60% commercial insurance) was identified. Of the cohort, 50% received no prescription medications. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (38%), diuretics (15%), and mineralocorticoid receptor antagonists (8%) were prescribed with the highest frequency. Pulmonary vasodilators were received by 6% of subjects. Older age was associated with increased likelihood of filled prescriptions for anticoagulants (P = .008), antiarrhythmic agents, digoxin, ACEi/ARB, and beta blockers (each P < .0001), but also lower likelihood of filled prescriptions for pulmonary vasodilators, conventional diuretics (both P < .0001), and mineralocorticoid receptor antagonists (P = .02).

Conclusions

Pharmaceuticals typically used to treat heart failure and pulmonary hypertension are the most commonly prescribed medications following Fontan palliation. While the likelihood of treatment with a particular class of medication is associated with the age of the patient, determining the optimal regimen for individual patients and the population at large is an important knowledge gap for future research.

Section snippets

Data source

The Truven Health MarketScan Claims and Encounter Database contains insurance claims data. For this project, modules containing data from both commercial insurers and Medicaid programs were used, as described previously.11., 12., 13., 14., 15., 16., 17., 18. This database provides in-depth, cross-sectional, and longitudinal patient-level data. Subjects are identified by both a longitudinal enrollee and plan identification number. Previous analyses using the same data set in which continuous

Study population

There were 4,056 children and adolescents included in the analysis of whom 39% were female (Table I). The median age was 12 years (interquartile range: 8-16 years), with 11% (n = 461) between the ages of 2 and 6 years, 40% (n = 1,626) between 7 and 12 years, and 49% (n = 1,969) between 13 and 19 years. Commercial insurance was used by 60% (n = 2,445) while 40% (n = 1,611) received Medicaid. Of the Medicaid recipients, 51% (n = 826) were white, 18% (n = 283) black, and 7% Hispanic (n = 105).

Distribution of pharmaceuticals

Discussion

In this retrospective observational study, the prevalent use of medications in children and adolescents after Fontan palliation was evaluated. Despite the risk of morbidity and mortality associated with the Fontan circulation, the slight majority of this cohort received no prescription cardiac medications. While older patients were more likely to be treated with medications used to treat systolic heart failure, antiarrhythmics, and anticoagulants, they were less likely to be treated with

Conclusion

The current study demonstrates the prevalent patterns of pharmaceutical utilization in children and adolescents after Fontan palliation. While the slight majority of subjects did not receive any cardiac drugs, there were differences in the odds of treatment with particular classes of medications in different age groups, suggesting a possible era effect in the approach to pharmaceutical regimens across the cohort. Understanding contemporary patterns of pharmaceutical use in patients who have

Funding

Dr. O'Byrne and Dr. Lemley received support from the National Institute of Health/National Heart Lung and Blood Institute (K23 HL130420-01 and T32-HL007915, respectively). The funding agencies had no role in the planning or execution of the study, nor did they edit the manuscript. The manuscript represents the opinions of the authors alone.

Conflict of interest

No relevant financial conflicts of interest to disclose.

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