Dosing Adjustments for Sacubitril/Valsartan in Renal Impairment

Patient Evaluation and Dosing

The American College of Cardiology recommends that patients with moderate renal impairment (eGFR between 30-60 mL/min/1.73 m²) do not require an initial dose adjustment of sacubitril/valsartán 1
In patients with severe renal impairment (eGFR <30 mL/min/1.73 m²), the initial dose of sacubitril/valsartán should be reduced to 24/26 mg twice daily 1

The American College of Cardiology suggests that renal function and potassium levels should be evaluated within 1 to 2 weeks after initiation or dose increase of sacubitril/valsartán 1
During initiation and titration, a decrease in eGFR >30% or the development of hyperkalemia should alert the physician to the possible need for dose reduction 1
In patients with evidence of hypovolemia, the dose of diuretics should be reduced 1
The dose of sacubitril/valsartán may also need to be reduced in case of renal impairment or hypotension 1

Evaluate the patient's eGFR before initiating sacubitril/valsartán 1
Monitor renal function and potassium 1-2 weeks after initiation 1
If renal function deteriorates (decrease in eGFR >30%) or hyperkalemia occurs, consider reducing the dose 1

The American College of Cardiology recommends starting sacubitril/valsartan at 24/26 mg twice daily for patients with HFrEF and severe renal impairment (eGFR <30 mL/min/1.73 m²), then uptitrate every 2-4 weeks to the target dose of 97/103 mg twice daily as tolerated 2
For patients with normal renal function (eGFR >60 mL/min/1.73 m²), the American College of Cardiology recommends starting sacubitril/valsartan at 49/51 mg twice daily 3, 4, 5

The American College of Cardiology recommends a 36-hour washout period when switching from an ACE inhibitor to ARNI to avoid angioedema risk 2, 6

The American College of Cardiology and the American Heart Association recommend doubling the dose every 2-4 weeks toward the target of 97/103 mg twice daily, unless not tolerated 3, 4, 5
The 2022 AHA/ACC/HFSA guidelines suggest that titration as frequently as every 1-2 weeks can be useful depending on symptoms, vital signs, and laboratory findings 3, 5