How to manage diarrhea in a patient taking Entresto (sacubitril/valsartan)?

Management of Diarrhea in Patients Taking Entresto (Sacubitril/Valsartan)

For patients experiencing diarrhea while taking Entresto (sacubitril/valsartan), loperamide should be initiated at 4 mg followed by 2 mg after every loose stool (maximum 16 mg/day) along with oral hydration and dietary modifications as first-line management.

Initial Assessment

When a patient on Entresto presents with diarrhea, assess:

• Severity of diarrhea (frequency, volume, consistency)
• Presence of complicating factors:
  • Fever
  • Orthostatic symptoms (dizziness)
  • Moderate to severe abdominal cramping
  • Nausea/vomiting
  • Decreased performance status
  • Dehydration signs
  • Blood in stool

Management Algorithm

For Uncomplicated Diarrhea (Mild to Moderate without Risk Factors)

1. Oral Hydration

   • Ensure adequate fluid intake (8-10 large glasses of clear liquids daily)
   • Include electrolyte-containing fluids, not just water 1

2. Dietary Modifications

   • Implement BRAT diet (bread, rice, applesauce, toast) 2
   • Eliminate lactose-containing products 2
   • Avoid high-osmolar dietary supplements 2
   • Avoid spices, coffee, and alcohol 2

3. Pharmacological Management

   • Loperamide: Start with 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) 2
   • Continue until 12 hours after the last unformed stool 1

4. Skin Care

   • Use skin barriers to prevent irritation from fecal material 2

For Complicated Diarrhea (Severe or with Risk Factors)

If diarrhea is severe (grade 3-4) or accompanied by risk factors such as fever, dehydration, or significant cramping:

1. Consider Hospitalization for:

   • IV fluid replacement
   • Close monitoring
   • More aggressive management 2

2. Advanced Pharmacological Management

   • Continue loperamide as above
   • Consider adding octreotide:
     • Starting dose: 100-150 μg SC three times daily
     • Can escalate up to 500 μg SC three times daily until diarrhea is controlled 2
   • Consider antibiotics (e.g., fluoroquinolones) if infection is suspected 2

3. Diagnostic Evaluation

   • Complete blood count
   • Electrolyte profile
   • Stool evaluation for:
     • Blood
     • C. difficile
     • Other infectious pathogens (Salmonella, E. coli, Campylobacter) 2

Special Considerations for Entresto

While diarrhea is not specifically listed as a common side effect of Entresto in the available evidence, management should follow standard protocols for medication-induced diarrhea.

If diarrhea persists despite appropriate management:

• Consider temporary dose reduction of Entresto
• Evaluate for other potential causes of diarrhea
• Monitor for electrolyte abnormalities, particularly hyponatremia, which has been reported with Entresto 3

Follow-up and Monitoring

• Monitor hydration status and electrolyte balance
• Assess response to therapy within 24-48 hours
• If no improvement after 24-48 hours on loperamide, escalate to more aggressive management 2
• Continue intervention until the patient has been diarrhea-free for 24 hours

Common Pitfalls to Avoid

1. Inadequate hydration assessment - Dehydration can worsen quickly in patients with heart failure
2. Overlooking electrolyte imbalances - Monitor for hyponatremia, which can occur with Entresto 3
3. Failure to escalate therapy - If diarrhea persists after 24-48 hours on loperamide, more aggressive management is needed
4. Not considering infectious causes - Always evaluate for potential infectious etiologies, especially in patients with fever or bloody diarrhea

By following this structured approach, diarrhea in patients taking Entresto can be effectively managed while minimizing complications and maintaining the benefits of heart failure therapy.