Suspected Acute Heart Failure — Transition to PO Medications: Dosing — Clinical Pathway: Emergency, ICU and Inpatient

Suspected Acute Heart Failure Clinical Pathway — Emergency Department, ICU and Inpatient

Transition to PO Medications: Dosing

Angiotensin Converting Enzyme
(ACE) Inhibitors
Consider angiotensin receptor blocker (ARB) in children unable to tolerate an ACEI
(e.g., cough)		 Captopril
  • Consider a test dose at 50% of the recommendation below x 1 for patients with hyponatremia, hypovolemia, severe congestive heart failure, impaired renal function, patients on afterload reducing agents, or in those receiving diuretics.
  • Neonates
    • Initial 0.01-0.05 mg/kg/dose TID
    • Increase to a goal of 0.5 mg/kg/dose TID
  • Infants (< 6 months)
    • Initial 0.15-0.3 mg/kg/dose TID
    • Increase to goal of 0.5-1 mg/kg/dose TID
      • Maximum 2 mg/kg/dose TID
  • Adjust dose for renal impairment
  • Monitor kidney function, blood pressure, and potassium levels
  • May not be appropriate for premature infants; use caution
Enalapril
  • Consider a test dose at 50% of the recommendation below x 1 for patients with hyponatremia, hypovolemia, severe congestive heart failure, impaired renal function, patients on afterload reducing agents, or in those receiving diuretics.
  • Infants (> 6 months) and Children:
    • Initial 0.05 mg/kg/dose BID
    • Increase to a goal of 0.25 mg/kg/dose BID
  • Adjust dose for renal impairment
  • Monitor kidney function, blood pressure, and potassium levels
  • May not be appropriate for premature infants; use caution
Lisinopril
  • Consider a test dose at 50% of the recommendation below x 1 for patients with hyponatremia, hypovolemia, severe congestive heart failure, impaired renal function, patients on afterload reducing agents, or in those receiving diuretics.
  • Adolescents and Adults:
    • Initial 0.07 mg/kg/dose daily (maximum initial dose 5 mg once daily)
    • Increase to goal of 40 mg
      • Maximum 0.6 mg/kg/day or 40 mg/day
  • Adjust dose for renal impairment
  • Monitor kidney function, blood pressure, and potassium levels
  • May not be appropriate for children < 6 years of age
Angiotensin II Receptor blocker (ARB) / Neprilysin inhibitor Sacubitril/valsartan (Entresto™)
  • Note:
    • Entresto is a combination of sacubitril and valsartan. Dosing for the oral suspension is presented as the combined mg dose of sacubitril and valsartan. Dosing for the oral tablet is presented as the individual mg for each component.
    • If switching between oral suspension and tablets, consider available strengths and adjust dose as needed.
  • Patients previously taking a moderate to high dose ACE inhibitor [i.e., ≥ 0.2 mg/kg/day or 10 mg/day of enalapril or equivalent) or angiotensin II receptor blocker (ARB)]:
  • Oral suspension
    Children (≥ 1 year) and Adolescents (< 40 kg):
    • Initial 1.6 mg/kg/dose BID
    • Increase dose in 2 weeks to 2.3 mg/kg/dose BID, then to 3.1 mg/kg/dose BID two weeks later
      • (Alternative titration schedules may be considered as tolerated)
  • Tablets
    Children and Adolescents (40 to < 50 kg):
    • Initial sacubitril 24 mg/valsartan 26 mg BID
    • Increase dose in 2 weeks to sacubitril 49 mg/valsartan 51 mg BID, then to sacubitril 72 mg/valsartan 78 mg BID two weeks later
      • (Alternative titration schedules may be considered as tolerated)
  • Children and Adolescents (≥ 50 kg):
    • Initial sacubitril 49 mg/valsartan 51 mg BID
    • Increase dose in 2 weeks to sacubitril 72 mg/valsartan 78 mg BID, then to sacubitril 97 mg/valsartan 103 mg BID two weeks later
      • (Alternative titration schedules may be considered as tolerated)

  • Patients not currently taking an ACE inhibitor or an ARB or previously taking low doses of an ACE inhibitor (i.e., 0.1 mg/kg/day or 5 mg/day of enalapril or equivalent) or ARB:
  • Oral suspension
    Children (≥ 1 year) and Adolescents (≤ 50 kg):
    • Initial 0.8 mg/kg/dose BID
    • Increase dose in 2 weeks to 1.6 mg/kg/dose BID, then to 2.3 mg/kg/dose BID 2 weeks later, then to 3.1 mg/kg/dose BID 2 weeks later
      • (Alternative titration schedules may be considered as tolerated)
  • Tablets
    Children and Adolescents (> 50 kg):
    • Initial sacubitril 24 mg/valsartan 26 mg BID
    • Increase dose in 2 weeks to sacubitril 49 mg/valsartan 51 mg BID, then to sacubitril 72 mg/valsartan 78 mg BID 2 weeks later then to sacubitril 97 mg/valsartan 103 mg BID 2 weeks later
      • (Alternative titration schedules may be considered as tolerated)
  • Concomitant use of an ACEI is contraindicated; allow a 36-hour washout period when switching from or to an ACEI
  • Monitor kidney function, blood pressure, and potassium levels
Beta Blockers Carvedilol
  • Infants (> 1 month) and Children:
    • Initial 0.05 mg/kg/dose PO BID
    • Increase to a goal of 0.4-0.8 mg/kg/dose BID (maximum 50 mg/day)
    • For children < 3.5 years old, TID dosing can be considered
  • Adults:
    • Initial 3.125 mg BID
    • Maximum dose of 25 mg BID (if ≥ 85 kg maximum, dose of 50 mg BID)
    • Monitor heart rate, blood pressure, kidney, and liver function
Aldosterone Antagonist Spironolactone
  • Neonates
    • 1-3 mg/kg/day in 1-2 divided doses
  • Children
    • 1.5-3.3 mg/kg/day in 1-4 divided doses (maximum 200 mg/day)
  • Adults
    • 12.5-50 mg/day in 1-2 divided doses
    • Monitor kidney function, blood pressure, and potassium levels
    • Use caution with other potassium supplements, ACEIs/ARBs, and NSAIDs
  • Note: consider non-formulary eplerenone to avoid gynecomastia in adolescent males
Antiarrhythmic Digoxin
  • Note: loading dose not recommended
  • Please refer to CHOP Formulary for dosing information
  • Reduce dose for renal impairment
    • (e.g., start with doses at lower end of dosing range recommendations)
  • Check ECG at initiation and at steady-state (3-5 days)
  • Use caution in patients also taking amiodarone or carvedilol
    • (Use 1/2 the maintenance dose of digoxin)
  • Avoid hypokalemia which potentiates digoxin toxicity
  • If concerned for digoxin toxicity, check trough level: goal < 1 ng/mL
Ivabradine
  • Infants (6 - 12 months)
    • Initial 0.02 mg/kg/dose BID
    • Increase by 0.02 mg/kg/dose BID every 2 weeks as clinically indicated
  • Children (< 40 kg)
    • Initial 0.05 mg/kg/dose BID
    • Increase by 0.05 mg/kg/dose BID every 2 weeks as clinically indicated
  • Children, Adolescents, and Adults (≥ 40 kg)
    • Initial 2.5 mg BID
    • Increase by 2.5 mg BID every 2 weeks as clinically indicated
  • Reduce dose in patients with severe renal or hepatic dysfunction
  • Liquid preparation available only from specialty pharmacy – contact case management, if indicated, to facilitate before discharge
  • Monitor blood pressure, heart rate, EKG, and liver function
Diuretics Furosemide
  • PO 1-2 mg/kg/dose 1-4 times/day
  • Note: conversion from IV to PO furosemide is 1:2
  • Consider continuous infusion of furosemide or other diuretic to avoid large fluid shifts
  • Consider bumetanide or chlorothiazide if poor response to furosemide