Cardiomyopathy Management: NSAID Options

John L. Berk, MD: Let me ask for your individual experience with diflunisal, a drug that was taken through an international randomized trial for neuropathy and actually performed quite well. Do you ever use it for cardiomyopathy, Dr Desai?

Akshay S. Desai, MD, MPH: Yes. So, I think you know 1 of the challenges. Diflunisal is a nonsteroidal anti-inflammatory drug that at higher doses is used for treatment of inflammatory disorders and at lower doses seems to have efficacy, certainly in amyloid polyneuropathy and then perhaps, based on single-center sort of uncontrolled trials in TTR [transthyretin] amyloidosis. I think that the challenge, as with all NSAIDs [nonsteroidal anti-inflammatory drugs] in patients with heart failure is the fluid retention that is possible, particularly in patients with more advanced renal dysfunction.

I think that there is a role for diflunisal in some patients with early TTR amyloid cardiomyopathy where it could be used safely and at low cost because it is far cheaper than the alternative. But we tend to reserve it for patients who don’t have very symptomatic heart failure, who have reasonable renal function, and who have adequate platelet counts so that they’re not at high risk for thrombocytopenia or bleeding.

John L. Berk, MD: Dr Hanna, any difference?

Mazen Hanna, MD: Yeah, I completely agree. The same thing with us. We actually published a paper looking at a couple dozen patients’ experience with cardiomyopathy. And in that experience, we looked for worsening renal dysfunction, GI [gastrointestinal] bleeding, worsening heart failure. And with careful monitoring of these patients, a couple of patients had some full retention that we could deal with. Everybody got a PPI [proton pump inhibitor], so we’re being very careful, and I think patients can tolerate it. But I would say again, to echo Dr Desai’s comments, that it wouldn’t be more than an NY222 patient. We would avoid people on high-dose diuretics. We’d like to see the GFR [glomerular filtration rate] above 50 mL/min. Very elderly patients on anticoagulation, we would avoid. So … you’re looking at the risk-benefit ratio and we have the same experience, so we reserve it for someone whose renal function and heart failure is still reasonably intact.