When to stop Entresto (sacubitril/valsartan)?

From the Guidelines

When stopping Entresto, it is crucial to consult a healthcare provider to avoid worsening heart failure symptoms, as this medication is a key component of heart failure management, particularly for patients with reduced ejection fraction, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Stopping Entresto abruptly can lead to severe consequences, including increased risk of hospitalization and death due to heart failure. The decision to stop Entresto should be made under the guidance of a healthcare provider, who can assess the patient's condition and determine the best course of action. Some key points to consider when stopping Entresto include:

• Severe side effects such as significant hypotension, angioedema, or worsening kidney function may necessitate stopping the medication, but this should be done under medical supervision 1.
• The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend sacubitril/valsartan as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.
• The healthcare provider may need to adjust the dosage rather than completely stopping the medication if the patient is experiencing concerning symptoms such as dizziness or lightheadedness.
• Entresto works by enhancing beneficial neurohormonal systems while inhibiting harmful ones, improving heart function and reducing hospitalizations in heart failure patients, as supported by the 2022 AHA/ACC/HFSA guideline 1. It is essential to prioritize the patient's safety and well-being when stopping Entresto, and this should only be done under the guidance of a healthcare provider.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Stoop Entresto

• The term "stoop entresto" is not clearly defined in the provided studies, but it can be inferred that it might be related to the timing of when to start or stop Entresto (sacubitril/valsartan) treatment.
• According to the study 2, Entresto was recommended as the frontline therapy for heart failure with reduced ejection fraction, but the pattern of Entresto-related hypotension has not been fully reported.
• The study 3 reviews the benefits of sacubitril/valsartan in the treatment of patients with heart failure with reduced ejection fraction, including reduction of mortality and disease progression, but does not provide information on when to start or stop the treatment.
• The systematic review and meta-analysis 4 compares the efficacy and safety of sacubitril/valsartan with renin-angiotensin-aldosterone system inhibitors, but does not address the specific question of when to start or stop Entresto treatment.
• The review 5 discusses the role of sacubitril/valsartan in providing additional renal benefit in patients with heart failure with reduced ejection fraction, but does not provide guidance on the timing of treatment.
• The study 6 summarizes the importance of sacubitril/valsartan in heart failure in terms of efficacy and safety in clinical trials and daily clinical practice, but does not address the specific question of when to start or stop Entresto treatment.

Potential Side Effects

• The study 2 reports a case of delayed onset and prolonged first-dose hypotension with Entresto, which occurred 8 to 18 hours after the first dose and lasted for 3 to 6 days.
• The systematic review and meta-analysis 4 found that sacubitril/valsartan increased the risk of hypotension compared to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
• The review 5 notes that sacubitril/valsartan has a complementary activity that counteracts the potential unwanted long-term effects of over-activation of the renin-angiotensin-aldosterone system, but does not discuss the potential side effects of the treatment.

Clinical Use

• The study 3 positions sacubitril/valsartan as a fundamental pillar in the treatment of patients with heart failure with reduced ejection fraction, based on its demonstrated benefits in reducing mortality and disease progression.
• The review 6 summarizes the importance of sacubitril/valsartan in heart failure in terms of efficacy and safety in clinical trials and daily clinical practice, and notes that the treatment has been increasingly used in clinical practice over time.