Congestive Heart Failure Treatments
CONGESTIVE HEART FAILURE TREATMENTS
Generic Brand Strength Form Dose
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
captopril1 12.5mg, 25mg, 50mg, 100mg scored tabs Adults: Initially 25mg 3 times daily 1hr before meals (generally with diuretic and digitalis regimen); increase to 50mg 3 times daily if needed. After 2wks, may increase; max 450mg/day. Salt/volume depleted, or SBP <100mmHg: initially 6.25mg or 12.5mg 3 times daily. Titrate to usual dose after several days.
Children: Not established.
enalapril1 Epaned 150mg/150mL pwd for oral soln Adults: Initially 2.5mg twice daily; may titrate up to max 20mg twice daily. Hyponatremia or serum creatinine >1.6mg/dL: initially 2.5mg once daily.
Children: Not established.
1mg/mL oral soln
Vasotec 2.5mg, 5mg, 10mg, 20mg scored tabs Adults: Initially 2.5mg 1–2 times daily. May increase to 5–20mg daily in 1–2 divided doses; max 40mg/day. Reduce diuretic dose before 1st dose, if possible; observe patient for ≥2hrs after 1st dose, until BP has stabilized for ≥1hr.
Children: Not established.
fosinopril1 10mg+, 20mg, 40mg tabs Adults: Initially 10mg once daily. Maintenance: 20–40mg once daily. Moderate to severe renal failure or volume depleted: initially 5mg once daily.
Children: Not established.
lisinopril1 Prinivil 5mg, 10mg, 20mg scored tabs Adults: Initially 5mg once daily; max 40mg/day as tolerated. Hyponatremia, CrCl ≤30mL/min, hemodialysis: initially 2.5mg once daily; monitor closely. Reduce diuretic dose before 1st dose, if possible, and observe until BP is stabilized.
Children: Not established.
Qbrelis 1mg/mL oral soln
Zestril 2.5mg, 5mg+, 10mg, 20mg, 30mg, 40mg tabs
quinapril1 Accupril 5mg+, 10mg, 20mg, 40mg tabs Adults: Initially 5mg twice daily; increase weekly to 20–40mg daily in 2 equally divided doses if tolerated. Hyponatremia, renal impairment: initially 2.5–5mg once daily based on CrCl (see full labeling), if needed titrate dose under supervision.
Children: Not established.
ramipril2 Altace 1.25mg, 2.5mg, 5mg, 10mg hard gel caps Adults: Initially 2.5mg twice daily; if hypotension occurs may reduce to 1.25mg twice daily. Adjust at 3wk intervals. Usual maintenance: 5mg twice daily. CrCl <40mL/min: initially 1.25mg once daily; may increase up to max 2.5mg twice daily. Volume depletion, renal artery stenosis: initially 1.25mg once daily; adjust according to BP response.
Children: Not established.
trandolapril2 Mavik 1mg+, 2mg, 4mg tabs Adults: Initially 1mg once daily; titrate to 4mg once daily as tolerated. CrCl <30mL/min, hepatic cirrhosis: initially 0.5mg once daily.
Children: Not established.
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
candesartan Atacand 4mg, 8mg, 16mg, 32mg scored tabs ≥18yrs: Initially 4mg once daily; double daily dose at 2wk intervals as tolerated to target 32mg once daily. Salt/volume depleted, moderate hepatic impairment: consider lower initial dose.
<18yrs: Not recommended.
valsartan Diovan 40mg+, 80mg, 160mg, 320mg tabs Adults: Initially 40mg twice daily, increase to 80mg twice daily, then to 160mg twice daily as tolerated.
Children: Not recommended.
BETA-BLOCKERS
carvedilol Coreg 3.125mg, 6.25mg, 12.5mg, 25mg tabs ≥18yrs: Initially 3.125mg twice daily with food for 2wks; may double dose every 2wks if tolerated; mild to moderate heart failure (>85kg): usual max 50mg twice daily. Reduce dose if pulse <55.
<18yrs: Not recommended.
Coreg CR 10mg, 20mg, 40mg, 80mg ext-rel caps ≥18yrs: Initially 10mg once daily with food in the AM for 2wks; may double dose every 2wks if tolerated; max 80mg once daily. Reduce dose if pulse <55. Switching from IR carvedilol: see full labeling. ≥65yrs: switching from highest dose of IR carvedilol (25mg twice daily) to Coreg CR: initially Coreg CR 40mg; if tolerated for ≥2wks, may increase to 80mg.
<18yrs: Not recommended.
metoprolol succinate Toprol XL 25mg, 50mg, 100mg, 200mg scored ext-rel tabs Adults: Initially 25mg once daily. Toprol XL (more severe HF): initially 12.5mg once daily. May double dose as tolerated every 2wks; max 200mg/day. Reduce dose if symptomatic bradycardia occurs.
Children: Not established.
Kapspargo Sprinkle 25mg, 50mg, 100mg, 200mg ext-rel caps
CARDIAC GLYCOSIDE
digoxin 0.05mg/mL oral soln Adults and Children: Individualize (see full labeling). Reduce dose in premature and immature infants. Children usually need proportionally larger doses (based on body weight or surface area) than adults. Use divided doses for children <10yrs. Re-titrate when changing formulation (especially oral tabs to or from other dose forms).
Lanoxin 0.0625mg, 0.125mg+, 0.25mg+ tabs
0.1mg/mL, 0.25mg/mL soln for inj
DIURETICS
Loop
bumetanide 0.5mg, 1mg, 2mg scored tabs ≥18yrs: 0.5–2mg daily; max 10mg/day. Intermittent dosing optimal.
<18yrs: Not established.
0.25mg/mL soln for inj ≥18yrs: Initially 0.5–1mg IM or IV. May give 1–2 more doses at 2–3hr intervals; max 10mg/day.
<18yrs: Not established.
ethacrynic acid Edecrin 25mg scored tabs Adults: Initially 50–100mg daily; adjust in 25–50mg increments. Usual maintenance: 50–200mg daily or intermittently.
Children: Initially 25mg; adjust gradually in 25mg increments (see full labeling). Infants: Contraindicated.
furosemide 10mg/mL, 40mg/5mL oral soln Adults: Initially 20–80mg daily. May repeat or increase after 6–8hrs; max 600mg/day. Maintenance: intermittent dosing optimal.
Children: Initially 2mg/kg; increase if needed by 1–2mg/kg after 6–8hrs; max 6mg/kg/day. Maintenance: lowest effective dose.
10 mg/mL soln for inj Adults: Initially 20–40mg IM or IV 1–2 times daily. May repeat or increase by 20mg after 2hrs until desired response.
Children: Initially 1mg/kg IM or IV; may increase by 1mg/kg after 2hrs until desired response; max 6mg/kg. Premature infants: max 1mg/kg/day.
Lasix 20mg, 40mg+, 80mg+ tabs Adults: Initially 20–80mg daily. May repeat or increase after 6–8hrs; max 600mg/day. Maintenance: intermittent dosing optimal.
Children: Initially 2mg/kg; increase if needed by 1–2mg/kg after 6–8hrs; max 6mg/kg/day. Maintenance: lowest effective dose.
torsemide 5mg, 10mg, 20mg, 100mg scored tabs Adults: 10–20mg once daily, if needed titrate upwards by doubling dose until desired response; max 200mg daily.
Children: Not established.
Potassium-sparing
amiloride 5mg tabs Adults: Initially 5mg/day with kaliuretic and food; 5–10mg usually adequate. If hypokalemia persists; may increase to 15mg/day and then 20mg/day with careful electrolyte monitoring. After initial diuresis; reassess therapy; may be given intermittently for maintenance.
Children: Not established.
eplerenone Inspra 25mg, 50mg tabs Adults: Initially 25mg once daily, titrate within 4wks to 50mg once daily. Adjust based on serum K+ (see full labeling). Concomitant moderate CYP3A inhibitors3: max 25mg daily.
Children: Not established.
spironolactone Aldactone 25mg, 50mg+, 100mg+ tabs Adults: Serum K+ ≤5mEq/L and eGFR >50mL/min/1.73m2: initially 25mg once daily; may increase to 50mg once daily as tolerated, or decrease to 25mg every other day if hyperkalemia develops. eGFR 30–50mL/min/1.73m2: consider initiating at 25mg every other day.
Children: Not established.
Carospir 25mg/5mL oral susp Adults: Serum K+ ≤5mEq/L and eGFR >50 mL/min/1.73m2: initially 20mg (4mL) once daily; may increase to 37.5mg (7.5mL) once daily as tolerated. May decrease to 20mg (4mL) every other day if hyperkalemia develops. If eGFR 30–50 mL/min/1.73m2: consider initiating at 10mg (2mL). If dose >100mg required, use another formulation.
Children: Not established.
triamterene Dyrenium 50mg, 100mg caps Adults: Initially 100mg twice daily after meals; max 300mg/day.
Children: Not recommended.
Potassium-sparing + Thiazide
amiloride/ hydrochloro
thiazide
4
5mg/50mg scored tabs Adults: Initially 1 tab daily with food. May increase to 2 tabs daily in single or divided doses. After initial diuresis, reassess therapy; may be given intermittently for maintenance.
Children: Not established.
spironolactone/ hydrochloro
thiazide4
Aldactazide 25mg/25mg, 50mg/50mg+ tabs Adults: Usual maintenance: 100mg each of spironolactone and HCTZ daily in single or divided doses. Range: 25–200mg of each component daily based on response to initial titration.
Children: Not established.
triamterene/ hydrochloro
thiazide4
Dyazide 37.5mg/25mg caps Adults: 1–2 caps once daily.
Children: Not established.
Maxzide-25mg 37.5mg/25mg scored tabs Adults: Initially one Maxzide-25mg tab daily. Usual dosage: 1–2 Maxzide-25mg tabs or one Maxzide tab once daily. As a substitute for triamterene 50-100mg/day and hydrochlorothiazide 25–50mg/day in less bioavailable form, give one Maxzide-25mg tab/day.
Children: Not established.
Maxzide 75mg/50mg scored tabs
Thiazide
chlorothiazide 250mg, 500mg scored tabs Adults: Initially 0.5–1g once or twice daily; may give on intermittent schedule (every other day or 3–5 days/wk).
Children: <6mos: up to 30mg/kg/day in 2 divided doses. ≥6mos: 10–20mg/kg/day in 1–2 divided doses. Max (<2yrs): 375mg/day; (2–12yrs): 1g/day.
Diuril 500mg/vial pwd for IV inj Adults: 0.5–1g IV once or twice daily.
Children: Not recommended.
chlorthalidone 25mg, 50mg tabs Adults: Initially 50–100mg daily or 100mg on alternate days. Some may require 150–200mg at these intervals or up to 200mg daily. Maintenance: doses often lower than initial doses; individualize.
Children: Not established.
hydrochloro
thiazide
12.5mg, 25mg+, 50mg+ tabs Adults: 25–100mg daily in single or divided doses; may give on intermittent schedule (every other day or 3–5 days/wk).
Children: <6mos: up to 3mg/kg/day in 2 divided doses. ≥6mos: 1–2mg/kg/day in 1–2 divided doses. Max (<2yrs): 37.5mg/day; (2–12yrs): 100mg/day.
indapamide 1.25mg, 2.5mg tabs Adults: Initially 2.5mg once daily in the AM. After 1wk, may increase to 5mg daily.
Children: Not established.
metolazone 2.5mg, 5mg, 10mg tabs Adults: Individualize. 5–20mg once daily.
Children: Not established.
HYPERPOLARIZATION-ACTIVATED CYCLIC NUCLEOTIDE-GATED (HCN) CHANNEL BLOCKER
ivabradine Corlanor 5mg+, 7.5mg tabs ≥18yrs: Initially 5mg twice daily with food. Adjust dose after 2wks to achieve resting heart rate 50–60bpm (see full labeling); then adjust dose as needed based on resting heart rate and tolerability. Max 7.5mg twice daily. History of conduction defects or if bradycardia can lead to hemodynamic compromise: initially 2.5mg twice day.
Children: <6mos: not established. Take with food. ≥6mos: <40kg (use oral soln): initially 0.05mg/kg twice daily. Adjust dose at 2wk intervals by 0.05mg/kg to achieve target heart rate reduction of ≥20%, based on tolerability. Max: 6mos–<1yr: 0.2mg/kg twice daily; ≥1yr: 0.3mg/kg twice daily, up to total of 7.5mg twice daily. ≥40kg (use tabs or oral soln): initially 2.5mg twice daily. Adjust dose at 2wk intervals by 2.5mg to achieve target heart rate reduction of ≥20%, based on tolerability. Max: 7.5mg twice daily. If bradycardia develops, reduce dose to the previous titration step. If bradycardia develops at the initial dose, consider reducing to 0.02mg/kg twice daily.
1mg/mL oral soln
NEPRILYSIN INHIBITOR + ANGIOTENSIN II RECEPTOR BLOCKER
sacubitril/ valsartan Entresto 24mg/26mg, 49mg/51mg, 97mg/103mg tabs Adults: Initially 49mg/51mg twice daily; double dose after 2-4wks to target maintenance dose of 97mg/103mg twice daily as tolerated. Not currently on ACEI/ARB, previously on low doses of ACEI/ARB, severe renal impairment (eGFR <30mL/min/1.73m2) or moderate hepatic impairment (Child-Pugh B): initially 24mg/26mg twice daily; double dose every 2-4wks to target maintenance dose of 97mg/103mg twice daily as tolerated. If switching from or to an ACEI: allow 36hr wash-out period between taking the two drugs.
Children: <1yr: not established. ≥1yr: administer twice daily; adjust dose every 2wks as tolerated. <40kg (use oral susp): initially 1.6mg/kg, titrate to 2.3mg/kg, then to target dose of 3.1mg/kg; ≥40–<50kg: initially 24mg/26mg, titrate to 49mg/51mg, then to target dose of 72mg/78mg; ≥50kg: initially 49mg/51mg, titrate to 72mg/78mg, then to target dose of 97mg/103mg. Not currently on ACEI/ARB, previously on low doses of ACEI/ARB, severe renal impairment (eGFR <30mL/min/1.73m2), or moderate hepatic impairment (Child-Pugh B): initiate at half the usual dose (for 40–50kg: initially 0.8mg/kg with oral susp); follow recommended dose escalation every 2wks. If switching from or to an ACEI: allow 36hrs wash-out period between taking the two drugs. Preparation of oral suspension: see full labeling.
SOLUBLE GUANYLATE CYCLASE (sGC) STIMULATOR
vericiguat Verquvo 2.5mg, 5mg, 10mg tabs Adults: Initially 2.5mg once daily with food, then double the dose approx. every 2wks. Target dose: 10mg once daily as tolerated.
Children: Not established.
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR
dapagliflozin Farxiga 5mg, 10mg tabs ≥18yrs: (eGFR ≥45mL/min/1.73m2): initially 10mg once daily; (eGFR 25–<45mL/min/1.73m2): 10mg once daily; (eGFR <25mL/min/1.73m2): not recommended.
<18yrs: Not established.
VASODILATOR
isosorbide dinitrate/ hydralazine BiDil5 20mg/37.5mg scored tabs Adults: Initially 1 tab 3 times daily, may reduce to ½ tab 3 times daily if not tolerated; titrate as tolerated after 3–5 days. Max 2 tabs 3 times daily. NYHA Class IV: not established.
Children: Not established.
NOTES

Key:+ = scored; IR = immediate-release; HCTZ = hydrochlorothiazide; SBP = systolic blood pressure

 

1 Treatment of heart failure concomitant with diuretic +/- digitalis.

2 Treatment of CHF in stabilized patients after MI.

3 Moderate CYP3A inhibitors include erythromycin, verapamil, saquinavir, fluconazole.

4 Fixed combination is not indicated for initial therapy of edema except in patients in whom the development of hypokalemia cannot be risked.

5 As adjunct to standard therapy for heart failure in black patients.

 

Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

(Created 7/2021)