Listening to patients’ questions: what the HEAR Project reveals about alirocumab use in routine care

This invited commentary refers to ‘Bridging InsigHts from the MEdical Information Department with Alirocumab Pen Use for a Better PAtient JouRney and HCP-Community Engagement (HEAR Project)’ by M. Barisone et al. https://doi.org/10.1093/eurjcn/zvag109 The HEAR Project offers a timely reminder that the effectiveness of lipid-lowering therapy depends not only on pharmacological efficacy but also on whether patients can use treatment confidently and correctly in daily life.1 By examining unsolicited questions about alirocumab pen use and storage, the study highlights a practical dimension of cardiovascular prevention that is highly relevant to routine care: the work required to translate a prescribed therapy into successful self-management at home.1 This matters because self-administered injectable therapies are increasingly used across cardiovascular prevention, yet successful adoption depends on patient understanding, practical skill, and emotional readiness.2,3 The HEAR Project is especially valuable because it captures concerns that arise after the clinic visit has ended.1 Among 1165 unsolicited questions concerning alirocumab received between June 2019 and October 2022, 297 related to pen use or storage, with most focused on pen handling or administration and the remainder on storage issues such as temperature stability or travel. Questions about the yellow window, administration errors, and uncertainty over whether the full dose had been delivered may seem simple, but they mark the points at which confidence falters, adherence becomes vulnerable, and efficacy could be compromised.1,4,5 However, it is worth noting that clinicians with first-hand experience in managing these therapies would argue that this (handling, administration, and storage of the injectable) is only a small part of the wide range of barriers and concerns that they experience in routine clinical practice both with alirocumab and other similar injectables.2,3,6,7 A notable strength of the study is its use of spontaneous enquiries rather than a structured questionnaire. This approach captures concerns that emerge naturally in routine care and may therefore provide a more authentic picture of support needs than formal surveys alone. It also extends the lens beyond patients by showing that pharmacists and other healthcare professionals often seek clarification on behalf of patients or in response to practical difficulties. That pattern matters because injectable-therapy support is distributed across the care pathway rather than confined to the prescribing consultation.1,2 For cardiovascular allied professionals and nurses, the practical implications are clear. Education at treatment initiation should not be limited to a single demonstration of injection technique. Patients need repeated, structured, and comprehensible information on how to use the device, how to interpret dose-completion indicators, what to do if the injection appears incomplete, and how to manage storage concerns during everyday life and travel. The European Society of Cardiology (ESC) and association of cardiovascular nursing and allied professions (ACNAP) educational initiatives on injectable cardiovascular therapies reinforce this same message by emphasizing that structured, accessible education for both clinicians and patients is essential to safe and effective use of these therapies in routine care.2,3,6–8 The emotional dimension identified in the HEAR Project deserves particular emphasis. Some patients experienced stress or anxiety when they were uncertain whether the medication had been administered correctly, and in some cases, this uncertainty was associated with use of anxiolytics. These responses show that self-injection problems are not merely technical failures but also psychological barriers to treatment continuation.1,3 Broader literature on injectable therapies similarly shows that acceptance and persistence are shaped by beliefs, confidence, previous experiences, and access to trustworthy information, not just by the mechanics of administration.2,3 Pharmacists and nurses are especially well placed to identify anxiety early, normalize common concerns, and use teach-back, return demonstration, and follow-up contact to improve confidence.2,3 Patients need the option to access support when concerns arise. A brief explanation at initiation may be insufficient, particularly for older adults, people with reduced dexterity, or patients who are new to self-injection.1,3 The HEAR Project therefore supports a model of care in which education is reinforced over time and tailored to the questions patients are most likely to ask when they return home.1 This aligns with contemporary cardiovascular practice priorities, which place increasing emphasis on patient engagement, self-management support, and individualized education throughout the care pathway.1–3 The study also highlights the importance of interdisciplinary consistency.1 A substantial proportion of questions came from healthcare professionals, especially pharmacists, alongside patients themselves.1,2 This suggests that nurses, pharmacists, and prescribers should work from shared educational messages and common troubleshooting advice to reduce confusion and ensure continuity across care settings.1,7 At the same time, the study’s limitations should temper interpretation. The dataset was derived from a pharmaceutical company’s internal medical information and device-call systems, so it includes only people who chose to seek help through those routes.1 Many patients may ask local clinicians, pharmacists, or caregivers instead of contacting the manufacturer directly, meaning the reported proportion of enquiries likely underestimates the full scale of device-related difficulties. In addition, the lack of patient-level demographic and clinical data prevents exploration of which groups are most vulnerable and whether these concerns are associated with non-adherence or discontinuation.1 The consistency of the themes gives the paper clear practice value. It identifies common points of confusion that can be addressed through better educational design, plain-language written materials, video demonstration, and early follow-up after treatment initiation, something that is reflected in the below ESC/ACNAP educational resources.1,6 The paper supports the argument that patient questions should be treated as meaningful clinical insight rather than peripheral service interactions.1 The ESC/ACNAP educational resources are relevant to this context because they frame injectable-therapy support as a professional capability that can be strengthened through structured learning rather than left to ad hoc experience alone, and they provide practical, stepwise educational materials in English, Italian, and French for healthcare professionals, patients, and caregivers.6 Please visit https://www.escardio.org/communities/associations/acnap/education/educational-resources-on-a-selection-of-injectable-therapies-with-cardiovascular/. Rani Khatib (Conceptualization, Writing—original draft, Writing—review & editing [lead]) and Emmanouela Kampouraki (Conceptualization, Writing—original draft, Writing—review & editing [supporting]) No funding was provided for this commentary. This commentary does not contain new data.