What is the usual dose of medication for cardiomyopathy?

Usual Medication Doses for Cardiomyopathy

The usual medication doses for cardiomyopathy depend on the specific type of cardiomyopathy and the medication class being used, with dosing typically starting low and titrating to evidence-based target doses shown to reduce mortality and morbidity. 1

Medication Dosing by Drug Class for Heart Failure with Reduced Ejection Fraction (HFrEF)

ACE Inhibitors

• Starting doses:

  • Captopril: 6.25 mg three times daily
  • Enalapril: 2.5 mg twice daily
  • Lisinopril: 2.5-5 mg once daily
  • Ramipril: 1.25-2.5 mg once daily

• Target doses:

  • Captopril: 50 mg three times daily
  • Enalapril: 10-20 mg twice daily
  • Lisinopril: 20-40 mg once daily
  • Ramipril: 10 mg once daily 1

Angiotensin Receptor Blockers (ARBs)

• Starting doses:

  • Candesartan: 4-8 mg once daily
  • Losartan: 25-50 mg once daily
  • Valsartan: 20-40 mg once daily

• Target doses:

  • Candesartan: 32 mg once daily
  • Losartan: 50-150 mg once daily
  • Valsartan: 160 mg twice daily 1

Beta Blockers

• Starting doses:

  • Bisoprolol: 1.25 mg once daily
  • Carvedilol: 3.125 mg twice daily
  • Metoprolol succinate: 12.5-25 mg once daily

• Target doses:

  • Bisoprolol: 10 mg once daily
  • Carvedilol: 25-50 mg twice daily
  • Metoprolol succinate: 200 mg once daily 1

Mineralocorticoid Receptor Antagonists

• Starting doses:

  • Spironolactone: 12.5-25 mg once daily
  • Eplerenone: 25 mg once daily

• Target doses:

  • Spironolactone: 25-50 mg once daily
  • Eplerenone: 50 mg once daily 1

SGLT2 Inhibitors

• Starting and target doses:
  • Dapagliflozin: 10 mg once daily
  • Empagliflozin: 10 mg once daily 1

Angiotensin Receptor-Neprilysin Inhibitor (ARNI)

• Starting dose: Sacubitril-valsartan 49/51 mg twice daily
• Target dose: Sacubitril-valsartan 97/103 mg twice daily 1

Special Considerations for Different Types of Cardiomyopathy

Hypertrophic Cardiomyopathy

• Beta blockers: Typically used at higher doses
  • Propranolol: Up to 480 mg per day (in divided doses)
  • Metoprolol: Similar to HFrEF dosing
• Calcium channel blockers:
  • Verapamil: Up to 480 mg per day (in sustained release preparation)
• Disopyramide:
  • 150 mg four times daily 1, 2

Dilated Cardiomyopathy

• Beta blockers:
  • Metoprolol: May be tolerated at higher doses in hypertensive DCM patients (up to 189.6 ± 14.8 mg/day) compared to normotensive DCM patients (133.9 ± 12.0 mg/day)
• ACE inhibitors:
  • Captopril in children: 1.83 mg/kg body weight daily (divided in 3-4 doses) 3, 4

Important Dosing Principles

1. Start low, go slow: Begin with lower doses and titrate gradually to target doses to minimize side effects and improve tolerance.

2. Target doses matter: Clinical trials have shown that higher target doses of medications provide greater benefits in reducing mortality and hospitalizations compared to lower doses 1.

3. Dose adjustments for renal impairment:

   • For ACE inhibitors like enalapril in heart failure with renal impairment (creatinine >1.6 mg/dL), start at 2.5 mg daily and titrate cautiously 5.
   • For patients with heart failure and hyponatremia, start at lower doses and titrate more slowly 5.

4. Monitoring requirements:

   • Blood pressure and heart rate at each dose adjustment
   • Renal function and electrolytes (especially with ACE inhibitors, ARBs, and MRAs)
   • Signs/symptoms of heart failure exacerbation

5. Avoid abrupt discontinuation of beta blockers to prevent rebound tachycardia 6.

Relative Benefits of Medications

The number needed to treat (NNT) to prevent one death over 36 months varies by medication class:

• Beta blockers: NNT = 9
• Mineralocorticoid receptor antagonists: NNT = 6
• ACE inhibitors or ARBs: NNT = 26
• SGLT2 inhibitors: NNT = 22
• ARNI (incremental to ACE inhibitor): NNT = 27 1

This data highlights that beta blockers and MRAs provide the greatest mortality benefit, making them particularly important components of cardiomyopathy treatment regimens.