Transitions in heart failure therapy prior to acoramidis use in transthyretin cardiomyopathy: real world insights from the german starttr cohort

Background

Acoramidis, a transthyretin stabilizer, was only recently approved for treating amyloid transthyretin cardiomyopathy (ATTR-CM) in Europe. Beyond clinical trials, little is known about who receives this therapy and how their heart failure medications evolve in the lead up to treatment.

Purpose

To map the changing pattern of heart failure medications in German patients with ATTR-CM who initiate acoramidis, to better understand how real-world practice adapts around this new therapy.

Methods

We used the IQVIATM LRx database, which contains longitudinal prescription data covering roughly 80 % of Germany’s statutorily insured population. Patients with at least one acoramidis prescription between April and September 2025 were identified. For this analysis, we selected those with at least twelve months of observable data before initiation of acoramidis as a first line treatment and at least three months of follow-up thereafter. Assuming the first prescription signaled a new ATTR-CM diagnosis, we described demographic and clinical characteristics and tracked drug use across five periods: 10–12, 7–9, 4–6, and 1–3 months before acoramidis initiation, and 1–3 months afterwards.

Results

During the 6-month period following the launch of acoramidis in April 2025, 128 patients with first-line acoramidis initiation were identified: median age 82 years (Q1-Q3: 78-85), 14% women. Most prescriptions originated from hospital outpatient departments (91%).

In the twelve months preceding acoramidis initiation, use of renin-angiotensin system inhibitors (56% à 60%), betablockers (44% à 52%), and calcium channel blockers (16% à 16%) remained fairly steady (Table). As the initiation date approached, there was a marked rise in prescriptions for mineralocorticoid receptor antagonists (14% à 31%), loop diuretics (34% à 56%), direct oral anticoagulants (29% à 46%), and sodium-glucose cotransporter 2 inhibitors (SGLT2i, 22% à 65%). These patterns suggest intensifying heart failure treatment in the months leading up to acoramidis use. During the 3-month period following acoramidis initiation, these trends continued.

Conclusion

Our real-world data reveal that patients initiating acoramidis therapy as a first-line treatment often experience escalating heart failure symptoms and increasingly complex medication regimens in the year beforehand. The findings highlight three key points: 1) many patients’ heart failure worsens before their ATTR-CM is recognized, underscoring the need for earlier diagnosis; 2) heart failure therapy is actively intensified at specialized centers making the diagnosis; and 3) large scale prescription databases (like LRx) offer a valuable lens through which to monitor the adoption and impact of new treatments.tableFor image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.