Sacubitril/valsartan (ARNI) is getting more attention in the guidelines with regards to its use in heart failure (specifically HFrEF). Many patients are already on an ACE and making the transition from an ACE inhibitor to an ARNI is likely something you will come across. In clinical practice, there is a significant risk for angioedema when overlapping the dose of sacubitril/valsartan with an ACE Inhibitor. In this blog post, we will discuss the appropriate transition from an ACE Inhibitor to an ARNI as well as what dosing we need to target when using sacubitril/valsartan.
Transition from an ACE Inhibitor to ARNI – Washout Period
A highly testable pearl on many different board exams stems from the knowledge of the washout period when making this transition. You must not give the ACE inhibitor and ARNI within 36 hours of one another. There is a significantly greater risk for angioedema in patients who haven’t abided by this rule. Be sure patients are appropriately educated as to when to stop the ACE and start the ARNI if you are making this transition. With the ARNI being dosed twice daily, this shouldn’t be that difficult to coordinate.
What about the dose of the ACE inhibitor?
When making the transition from an ACE inhibitor to an ARNI, does it matter what the dose of the ACE inhibitor is? Yes, it does. If the patient is on a low dose of an ACE inhibitor (or no ACE/ARB), you should begin the medication at the usual starting dose of 24 mg/26 mg BID.
In patients who are taking moderate to high doses of an ACE inhibitor, you can consider starting the middle dose (49/51 mg BID) of sacubitril/valsartan. Some clinical common sense should be employed. If your patient has a history of falls or orthostasis, more conservative initial dosing could be considered. A moderate to high dose of lisinopril would be considered in the 20-40 mg/day range and a low dose would be considered 10 mg or less.
Using Cautious Initial Dosing With Sacubitril/Valsartan
In addition to a patient who may be at risk for adverse effects like hypotension, another situation where sacubitril/valsartan dosing should be reduced is in patients with poor renal function. In patients with an eGFR less than 30 mls/min, the conservative initial dosing should be utilized.
Hopefully these common sense pearls help you make a successful and smooth transition from an ACE inhibitor to an ARNI.
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