Additional costs are likely to be incurred in the first year of initiation due to up- titration. These costs are presented in Table 44. Table 43: Unit costs of Mineralcorticoid receptor antagonists Drug Mg/unit Units/day Units/pack Cost/pack ( ) Cost/unit ( ) Cost/year ( ) Source: NHS Drug Tariff, May 201793, 239, 240 , Table 44: Unit costs of up-titration Description Unit cost Source Nurse specialist appointment in community setting (a) 91 per hour of client contact Phlebotomy (b) 3 NHS Reference costs 2014/15242 (a) 30 minute appointment occurring every 4 weeks until maximum tolerated dose achieved. (b) Direct access service (community). In addition, the unit costs of all cause hospitalisation and acute kidney injury are presented in Table 45 below. The GC agreed that the cost of acute kidney injury treatment would be typical for a chronic heart failure population experiencing hyperkalaemia or worsening renal function. Table 45: Unit costs of clinical outcomes Description Code Unit cost Source All-cause hospitalisation (non-elective) - 2,930 NHS Reference costs Acute kidney injury (with and without interventions) LA07H-P 2,337(a) NHS Reference costs (a) Weighted using the activity reported for each of the included HRG codes. 6.2.3.5 Evidence statements Clinical Two studies (reported in 11 publications), comparing MRAs with placebo in people with heart failure with preserved ejection fraction on current standard first line treatment, were identified for inclusion within the review. Both studies compared spironolactone with placebo. The quality of the evidence ranged from high to very low. Evidence was downgraded due to a number of contributory factors including risk of bias, imprecision due to wide confidence intervals surrounding the effect estimate Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 and indirectness of the reported outcomes. 