Am Fam Physician. 2006;73(4):687-688
Synopsis
Nesiritide (Natrecor) is a recombinant form of human brain natriuretic peptide, which causes venous and arterial vasodilation. It does not affect cardiac contractility.1 Nesiritide is approved by the U.S. Food and Drug Administration (FDA) for use in the short-term treatment of hospitalized patients with acutely decompensated heart failure characterized by dyspnea at rest or by clinical evidence of fluid overload.1,2
| Name | Dosage | Dose form | Approximate cost* |
|---|---|---|---|
| Nesiritide (Natrecor) | 2-mcg-per-kg intravenous bolus followed by 0.01 mcg per kg per minute; 24 to 48 hours’ duration | Single-use, 1.5-mg vial | $530 per day |
Safety
Initial data from moderately sized controlled trials and large prospective registries suggested that nesiritide is safe.3–5 However, nesiritide has been associated with a transient and significant increase in serum creatinine.1–4 In a pooled analysis,3 nesiritide was associated with an increase in mortality within 30 days of treatment, although the difference was of borderline statistical significance (7.2 versus 4.0 percent; P = .059). Nesiritide has not been compared with vasodilators or diuretics in an adequately powered, randomized clinical study of long-term mortality.3,4 Nesiritide is FDA pregnancy category C.1
Tolerability
The most commonly occurring side effect of nesiritide is symptomatic hypotension.1–6 Nesiritide has been studied in comparison with inotropic agents (primarily intravenous dobutamine [Dobutrex]), noninotropic agents (primarily intravenous nitroglycerin), and placebo. It was associated with significantly fewer arrhythmias than dobutamine7 and with significantly fewer reported headaches than nitroglycerin.6 There were no reported increases in heart rate.7
Effectiveness
Pulmonary capillary wedge pressure decreases within one hour of treatment initiation, is maintained for at least six hours, and returns to preexisting levels when the infusion is discontinued. The effects of nesiritide are additive to the effects of loop diuretics and beta blockers. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be initiated or continued during nesiritide therapy.1 One study6 showed that nesiritide was similar to typical treatment (e.g., nitroglycerin, milrinone [Primacor], dobutamine) in its effect on symptoms.
Although nesiritide has not received indication for outpatient treatment from the company that developed the product, it has been used for weekly outpatient infusions. A single, nonblinded trial8 comparing this approach with usual care revealed no symptomatic benefit for patients receiving nesiritide. Hospitalizations were less common in the nesiritide group, but this may be because these patients were evaluated weekly by a physician whereas the usual care patients were not.
Price
Nesiritide costs approximately $530 per vial and most patients will need one vial per day for two days. The cost is similar to milrinone (a phosphodiesterase inhibitor), but more expensive than dobutamine, nitroprusside (Nitropress), and nitroglycerin.
Simplicity
Nesiritide is administered as an initial 2-mcg-per-kg intravenous bolus followed by an infusion of 0.01 mcg per kg per minute.4 Dosages greater than 0.01 mcg per kg per minute are associated with hypotension and elevated serum creatinine.1,2 Blood pressure should be monitored closely during nesiritide administration, but an intensive care setting is not mandatory.1,2
Bottom Line
Nesiritide improves short-term hemodynamics in hospitalized patients with acute decompensated heart failure who have not benefited from aggressive treatment with standard care.1,2,5 However, nesiritide may cause renal function to worsen and may increase the risk of death within 30 days.3 Patients should be notified about the potential risks of treatment; nesiritide is not indicated for serial treatments in the outpatient setting.