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.
	Epaned	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 1^st dose, if possible; observe patient for ≥2hrs after 1^st 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	—	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 1^st 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	—	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	—	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.
carvedilol	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.
metoprolol succinate	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
	Lanoxin	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.
bumetanide	—	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.
	Furoscix	80mg/10mL	soln for SC infusion	Adults: Using On-body Infusor to deliver 30mg over first hour followed by 12.5mg/hr for the subsequent 4hrs. Replace with oral diuretics as soon as practical. Children: Not established.
	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.
torsemide	Soaanz	20mg, 40mg, 60mg	tabs	Adults: Initially 20mg orally once daily. If inadequate, titrate upwards by doubling dose until desired response; max: 200mg/day. 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.
spironolactone	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– thiazide⁴	—	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	—	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	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.
ivabradine	Corlanor	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): may continue on 10mg once daily. <18yrs: Not established.
empagliflozin	Jardiance	10mg, 25mg	tabs	≥18yrs: 10mg once daily in the AM. Insufficient data for dosing: in those who have T2DM and established CV disease (with eGFR <30mL/min/1.73m²), or those who have HF (with eGFR <20mL/min/1.73m²). <18yrs: Not established.
sotagliflozin	Inpefa	200mg, 400mg	tabs	≥18yrs: Initially 200mg once daily (at ≤1hr before the first meal of the day). After ≥2wks, titrate up to 400mg once daily as tolerated; may down-titrate to 200mg as needed. <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. (Rev. 9/2023)

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