Switching from Telmisartan to Sacubitril/Valsartan

Introduction to Sacubitril/Valsartan Switching Protocol

• The American College of Cardiology recommends that patients already on telmisartan can be directly switched to sacubitril/valsartan without a washout period, as there is no increased risk of angioedema when switching from an ARB to an ARNI 1, 2

Protokol Penggantian yang Aman

• The American College of Cardiology suggests that telmisartan can be stopped and sacubitril/valsartan started on the same day or the next day, unlike switching from an ACE inhibitor which requires a 36-hour washout to avoid angioedema 1, 3
• The risk of angioedema does not increase when combining neprilysin inhibition with ARB therapy, allowing for a safe and rapid transition 2

Dosis Awal Berdasarkan Dosis Telmisartan Sebelumnya

• For patients with high-dose ARB (equivalent to valsartan ≥160 mg daily): start sacubitril/valsartan 49/51 mg twice daily 1, 4
• Telmisartan 80 mg once daily is equivalent to valsartan 160 mg daily 1
• For patients with low or medium-dose ARB (equivalent to valsartan <160 mg daily): start sacubitril/valsartan 24/26 mg twice daily 1, 4

Protokol Titrasi

• Double the dose every 2-4 weeks towards the target dose of 97/103 mg twice daily, as tolerated 1, 3, 5
• Titrasi dapat dilakukan setiap 1-2 minggu tergantung pada gejala, tanda vital, dan temuan laboratorium 5

Monitoring Penting

• Evaluasi dalam 1-2 minggu setelah inisiasi atau peningkatan dosis: tekanan darah, kreatinin serum, dan eGFR 5, 6

Pertimbangan Klinis Penting

• Sacubitril/valsartan has a more significant effect on blood pressure compared to ARB 6, 7
• In patients with borderline blood pressure (systolic ≤100 mmHg), careful administration and close follow-up are required 6, 7

Kesalahan Umum yang Harus Dihindari

• Do not delay initiation due to waiting for a washout period - this is only required for ACE inhibitors, not ARB 1, 2
• Do not permanently stop or reduce the dose for asymptomatic hypotension, mild transient creatinine increase, or mild hyperkalemia 8

Manfaat Klinis

• The AHA/ACC/HFSA 2022 guidelines provide a Class 1, Level B-R recommendation for replacing ARB with ARNI in patients with symptomatic chronic HFrEF NYHA class II or III to further reduce morbidity and mortality 2
• The PARADIGM-HF study showed a 20% relative reduction in cardiovascular death or heart failure hospitalization compared to enalapril 2