From the Guidelines
When stopping Entresto (sacubitril/valsartan), it is crucial to follow a gradual discontinuation process under medical supervision to minimize potential rebound effects on blood pressure and heart failure symptoms. This approach is supported by guidelines that emphasize the importance of careful management when discontinuing medications like Entresto, which is used in the treatment of heart failure 1.
Key Considerations for Discontinuation
- Gradual dose reduction: Reducing the dose by half for 1-2 weeks before complete discontinuation is a common strategy.
- Monitoring: Patients should monitor their blood pressure and weight daily during this transition period.
- Replacement with ACE inhibitor: If Entresto is being replaced with an ACE inhibitor, a 36-hour washout period is necessary to prevent angioedema risk due to the neprilysin inhibition by sacubitril, leading to bradykinin accumulation when combined with an ACE inhibitor.
- Symptom reporting: Patients should immediately report symptoms like significant weight gain, increased shortness of breath, swelling, dizziness, or chest pain during the discontinuation process.
Special Considerations
- Severe heart failure: Patients with severe heart failure may require closer monitoring or hospitalization during medication changes to ensure safety and prevent heart failure exacerbation.
- Renal impairment: Careful monitoring of blood chemistry is essential, especially in patients with renal impairment, as Entresto can affect renal function, similar to ACE inhibitors and ARBs, which may require dose adjustments or discontinuation if renal function worsens significantly 1.
- Drug interactions: Avoiding NSAIDs unless essential and being cautious with other nephrotoxic agents or drugs that can interact with Entresto or its replacement medications is crucial.
General Guidance
The decision to stop Entresto should ideally be made under specialist advice, given the potential for clinical deterioration upon withdrawal of treatment, as noted in guidelines for the management of heart failure 1. Patients should be advised on the expected benefits of treatment, the possibility of temporary adverse effects, and the importance of reporting any deterioration in symptoms 1.
From the Research
Guidelines for Stopping Entresto
When stopping Entresto (sacubitril/valsartan), the following guidelines should be considered:
- There is no specific guidance on stopping Entresto in the provided studies, but it is essential to follow the general principles of withdrawing medications that affect the renin-angiotensin-aldosterone system (RAAS) and neprilysin pathways 2.
- Patients should be closely monitored for potential adverse effects, such as changes in blood pressure, kidney function, and cardiac biomarkers 3, 4.
- The decision to stop Entresto should be made by a healthcare professional, taking into account the individual patient's condition, response to treatment, and potential risks and benefits 5, 6.
- It is crucial to consider the potential consequences of stopping Entresto on the patient's clinical symptoms, ventricular remodeling, and hospitalization rate, as well as the economic stress associated with treatment 5.
Potential Consequences of Stopping Entresto
Some potential consequences of stopping Entresto include:
- Worsening of heart failure symptoms and prognosis 5
- Decreased kidney function and increased albuminuria 3, 4
- Increased blood pressure and cardiac biomarkers 3, 4
- Potential adverse effects on the filtration barrier and kidney function 6
Monitoring and Follow-up
After stopping Entresto, patients should be closely monitored for: