Vifor takes iron therapy expansion to heart


A win in a cardiovascular outcomes study is now pretty much a necessity for any diabetes or heart drug to avoid becoming an also-ran. But Vifor Pharma is hoping that three such trials will help broaden the use of its injectable iron therapy Ferinject to include heart failure patients with iron deficiency.

The product is currently approved for patients with iron deficiency anaemia, including those with chronic kidney disease – but there are signs that it could also improve heart failure outcomes. If Vifor can confirm this in larger studies sales could expand in an area where the company must believe there is underuse, and push Ferinject firmly into blockbuster territory.

Big in the US

EvaluatePharma sellside consensus already puts 2022 sales at just over $1bn. Over half of these revenues are forecast to come in the US, where Vifor is partnered with Daiichi Sankyo and the product is known as Injectafer.

Daiichi is carrying out the largest of the new studies, called Heart-FID, in 3,000 North American patients with stable heart failure with iron deficiency, who are receiving maximally-tolerated background therapy. Meanwhile, the Vifor-sponsored Affirm-AHF trial will focus on acute heart failure, while the Germany-based, investigator-led Fair-HF2 study is enrolling patients with systolic chronic heart failure.

Vifor appears to be covering all of its bases – Ferinject is already recommended in the 2016 European Society of Cardiology guidelines for symptomatic patients with systolic chronic heart failure and iron deficiency; meanwhile, a recent US guideline update included a new recommendation that intravenous iron replacement can improve exercise capacity and quality of life in heart failure patients with iron deficiency. 

However, perhaps these recommendations have not been enough to accelerate sales as fast as Vifor and Daiichi would like, providing a motivation for the companies to go to the expense of carrying out large outcomes studies.

The Swiss company will hope the results from the latest trials will build on data from three smaller previous studies, Confirm-HF, Fair-HF and Effect-HF, all in chronic heart failure, which showed benefits on surrogate endpoints including the six-minute walk test.

Heart failure trials of Ferinject
Study N Patient population Primary endpoint(s) Data ID
Confirm-HF 304 Chronic HF Change in 6-minute walk test at week 24 Reported NCT01453608
Fair-HF 459 Chronic HF Self-reported patient global assessment and NYHA functional status at week 24 Reported NCT00520780
Effect-HF 174 Chronic HF Change in Peak VO2 at week 24 Reported NCT01394562
Affirm-AHF 1,100 Acute HF HF hospitalisations and CV death after 52 weeks H2 2019 NCT02937454
Fair-HF2 1,200 Chronic HF HF hospitalisations and CV death after 52 weeks H2 2020 NCT03036462; investigator-sponsored study
Heart-FID 3,000 HF 12-month  death rate, hospitalisation rates, and 6-month change in 6-minute walk test 2021 NCT03037931; conducted by US partner Daiichi Sankyo

However, regulators and payers will be more interested in harder endpoints like hospitalisation and death, and this is what the new outcomes trials will be looking at.

Ferinject has also shown promise here, with the Confirm-HF trial finding a 61% reduction in re-hospitalisations, although this was not its primary endpoint. In addition, a meta-analysis of four trials – Confirm-HF, Fair-HF, Efficacy-HF and FER-CARS-01 – showed that Ferinject reduced recurrent heart failure hospitalisations and cardiovascular death by 47%.

This appears to compare favourably with the 20% reduction in heart failure hospitalisations and cardiovascular deaths seen in the Paradigm-HF trial of Novartis’s heart failure drug Entresto, Stifel analysts noted today. However, Paradigm-HF was much bigger, enrolling nearly 8,500 patients, and was not limited to iron-deficient patients. Entresto is forecast to sell $4bn by 2022.

Even so, the niche Ferinject will be targeting – if successful – should be a sizeable one: iron deficiency is present in around half of heart failure patients, according to the authors of the aforementioned meta-analysis. 

But outcomes studies are unpredictable, not to mention time-consuming and expensive. It is probably a risk Vifor has to take if it wants to inject new life into Ferinject – but it is a gamble nonetheless.

To contact the writer of this story email Madeleine Armstrong in London at or follow @ByMadeleineA on Twitter

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