Type of therapy | Role in therapy | Drug | Typical initial dose (oral) | Target dose | Minimum dose titration interval |
Renin-angiotensin system inhibitors/neprilysin inhibitors | Preferred | Sacubitril-valsartan (ARNI) | 24/26 to 49/51 mg twice daily* | 97/103 mg twice daily | Double dose after 1 to 2 weeks or as tolerated¶ |
Alternatives | Lisinopril | 2.5 to 5 mg once daily | 20 to 40 mg once daily | ||
Ramipril | 1.25 to 2.5 mg once daily | 10 mg once daily | |||
Enalapril | 2.5 mg twice daily | 10 to 20 mg twice daily | |||
Captopril | 6.25 mg three times daily | 50 mg three times daily | |||
Trandolapril | 1 mg once daily | 4 mg once daily | |||
Losartan | 25 to 50 mg once daily | 150 mg once daily | |||
Candesartan | 4 to 8 mg once daily | 32 mg once daily | |||
Valsartan | 20 to 40 mg twice daily | 160 mg twice daily | |||
Beta blockers | Preferred | Carvedilol | 3.125 mg twice daily | ≤85 kg: 25 mg twice daily | Double every 2 weeks¶ |
>85 kg: 50 mg twice daily | |||||
Carvedilol CR | 10 mg once daily | 80 mg once daily | |||
Metoprolol succinate CR | 12.5 to 25 mg once daily | 200 mg once daily | |||
Bisoprolol | 1.25 mg once dailyΔ | 10 mg once daily | |||
Mineralocorticoid receptor antagonists | Preferred | Spironolactone | 12.5 to 25 mg once daily | 25 to 50 mg once daily or in two divided doses | Double every 4 weeks¶ |
Eplerenone | 25 mg once daily | 50 mg once daily | |||
SGLT2 inhibitors | Preferred | Dapagliflozin | 10 mg once daily | Fixed dose | |
Empagliflozin | 10 mg once daily | ||||
Alternative | Canagliflozin | 100 mg once daily |
ACE: angiotensin converting enzyme; ARB: angiotensin II receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; CR: controlled release; HFrEF: heart failure with reduced ejection fraction; SGLT2: sodium-glucose co-transporter 2.
* Selection of initial dose of ARNI is dependent upon whether patient has been treated previously with a moderate to high dose of an ACE inhibitor or ARB; to reduce risk of toxicity, a 36-hour washout period is required if switching from ACE inhibitor to ARNI. Refer to drug monograph included within UpToDate.
¶ Dose increases may be performed more rapidly in a management program or with other forms of monitoring for complications. The requirements for monitoring are described in UpToDate content on pharmacologic therapy for HFrEF.
Δ In the United States, the lowest available bisoprolol tablet strength is 5 mg. A 1.25 mg dose requires splitting a round tablet into quarters, which may be difficult and inaccurate.Do you want to add Medilib to your home screen?