Switching from Valsartan to ARNI (Sacubitril/Valsartan)
Key Considerations for Switching
- The American College of Cardiology recommends switching from valsartan to sacubitril/valsartan without a washout period, as the risk of angioedema is not elevated when combining neprilysin inhibition with ARB therapy, unlike with ACE inhibition 1, 2, 3, 4
- The American Heart Association and American College of Cardiology suggest that patients can stop valsartan and start sacubitril/valsartan the same day or next day 2
Initial Dosing and Titration
- For patients on high-dose ARB (valsartan ≥160 mg total daily), the American College of Cardiology recommends starting sacubitril/valsartan at 49/51 mg twice daily 5, 2
- For patients on low- or medium-dose ARB (valsartan <160 mg total daily), the American College of Cardiology suggests starting sacubitril/valsartan at 24/26 mg twice daily 5, 2
- The dose can be doubled every 2-4 weeks as tolerated by the patient, with a target maintenance dose of 97/103 mg twice daily 1, 5, 2
Special Populations and Monitoring
- Patients with severe renal impairment (eGFR <30 mL/min/1.73 m²), moderate hepatic impairment (Child-Pugh Class B), or systolic blood pressure <100 mmHg should start at a lower dose of 24/26 mg twice daily 7, 5, 8, 9
- Blood pressure, serum creatinine, and serum potassium should be monitored within 1-2 weeks after initiation or dose increase 6, 10
Clinical Benefits
- The 2022 AHA/ACC/HFSA guidelines give a Class 1, Level B-R recommendation for replacing an ARB with ARNI in patients with chronic symptomatic HFrEF NYHA class II or III to further reduce morbidity and mortality 1
- The PARADIGM-HF trial demonstrated a 20% relative reduction in cardiovascular death or HF hospitalization compared to enalapril 1