What is the recommended perioperative management for patients taking Entresto (sacubitril/valsartan)?

From the Guidelines

For patients taking Entresto (sacubitril/valsartan), it is generally recommended to continue the medication perioperatively, as the benefits of continuation likely outweigh the risks, especially in patients with heart failure, as suggested by the principle of continuing ACE inhibitors or ARBs perioperatively 1. The medication's effects on blood pressure and renal function should be closely monitored, particularly in patients with pre-existing kidney disease or those undergoing procedures with significant fluid shifts.

• The main perioperative concern is hypotension during anesthesia, which can be managed with careful fluid administration and vasopressors if needed.
• Patients should be instructed to inform their anesthesiologist about their Entresto use, and the surgical team should coordinate with the patient's cardiologist regarding the timing of medication discontinuation and resumption, particularly for patients with severe heart failure where the risk-benefit of holding the medication requires careful consideration.
• The decision to hold or continue Entresto should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgery being performed, with consideration of the recommendations for perioperative management of patients with heart failure and the use of ACE inhibitors or ARBs 1.
• It is essential to monitor renal function closely and adjust the medication as needed to minimize the risk of adverse effects, as the combination of an angiotensin receptor blocker (valsartan) and a neprilysin inhibitor (sacubitril) in Entresto may affect blood pressure and renal function.
• The principle of continuing medications that are essential for the patient's chronic condition, such as heart failure, should guide the decision-making process, as suggested by the recommendations for perioperative beta-blocker therapy and statin therapy 1.

From the FDA Drug Label

1. 1 General Considerations Sacubitril and valsartan tablet is contraindicated with concomitant use of an angiotensin-converting enzyme (ACE) inhibitor. If switching from an ACE inhibitor to sacubitril and valsartan tablet allow a washout period of 36 hours between administration of the two drugs

The FDA drug label does not provide specific recommendations for the perioperative management of patients taking Entresto (sacubitril/valsartan). However, it does mention that sacubitril and valsartan tablet is contraindicated with concomitant use of an ACE inhibitor and recommends a washout period of 36 hours between administration of the two drugs. Key considerations for perioperative management may include:

• Withholding ACE inhibitors: allowing a washout period of 36 hours before surgery
• Monitoring renal function and potassium levels: as kidney problems and hyperkalemia are common side effects of sacubitril and valsartan tablets
• Managing blood pressure: as low blood pressure is common during treatment with sacubitril and valsartan tablets 2 2

From the Research

Perioperative Management of Entresto

The recommended perioperative management for patients taking Entresto (sacubitril/valsartan) is not directly addressed in the provided studies. However, some general considerations can be inferred:

• When switching patients from an angiotensin-converting enzyme inhibitor to sacubitril/valsartan, a 36-hour washout period is recommended 3.
• Sacubitril/valsartan is contraindicated in patients receiving concomitant angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and those with a history of angioedema 3.
• Initiating the lower dosage form of sacubitril/valsartan is warranted in patients with severe renal impairment, moderate hepatic impairment, and low blood pressure, and close monitoring is warranted in such patients 3.

Potential Interactions and Considerations

Some potential interactions and considerations to keep in mind:

• Co-administration of atorvastatin and sacubitril/valsartan should be monitored closely with laboratory investigations of CK and liver and renal function due to the increased risk of muscle-related toxicity 4.
• Rosuvastatin could be an alternative to atorvastatin, as it has less drug-drug interaction with sacubitril, thereby reducing the adverse effect 4.
• Entresto may have a protective effect on kidney function and filtration barrier injury in certain situations, such as partial nephrectomy 5.

Key Points to Consider

Key points to consider when managing patients taking Entresto perioperatively:

• Carefully review the patient's medication list and medical history to identify potential interactions and contraindications.
• Monitor laboratory values, such as CK and liver and renal function, in patients taking Entresto and other medications that may interact with it.
• Consider alternative medications, such as rosuvastatin, if necessary.
• Follow recommended guidelines for switching patients from other medications to Entresto, including the recommended washout period.