What is the starting dose of Ranexa (ranolazine) for angina?

Starting Dose of Ranolazine for Angina

The recommended starting dose of ranolazine for angina is 500 mg orally twice daily, which can be increased to 1000 mg twice daily based on clinical response. 1, 2

Dosing Guidelines and Titration

• Initial dose: 500 mg twice daily
• Maximum dose: 1000 mg twice daily
• Titration should be based on:
  • Clinical symptoms
  • Patient tolerance
  • Side effect profile

Clinical Context

Ranolazine is indicated for the treatment of chronic angina as:

• Add-on therapy when symptoms persist despite standard treatment with beta-blockers, calcium channel blockers, or nitrates
• Monotherapy in selected patients 1, 2

Unlike traditional antianginal medications, ranolazine:

• Does not significantly reduce heart rate
• Does not significantly affect blood pressure
• Works through a different mechanism (likely membrane ion-channel effects) 3

Special Populations and Dose Adjustments

• Hepatic impairment: Contraindicated in patients with liver cirrhosis 1, 2
• Medication interactions:
  • Limit dose to 500 mg twice daily when used with moderate CYP3A inhibitors (e.g., diltiazem, verapamil, erythromycin) 2
  • Contraindicated with strong CYP3A inhibitors (e.g., ketoconazole, clarithromycin) 2
  • Contraindicated with CYP3A inducers (e.g., rifampin, phenobarbital) 2
  • Titrate based on clinical response when used with P-gp inhibitors (e.g., cyclosporine) 2

Monitoring Recommendations

• Baseline ECG to evaluate QTc interval
• Renal function assessment
• Hepatic function assessment
• Medication review for potential interactions 1
• Follow-up ECG after dose adjustments
• Periodic renal function tests in at-risk patients 1

Common Side Effects

• Dizziness
• Headache
• Constipation
• Nausea
• QT interval prolongation 1, 2

Important Precautions

• QT interval prolongation can occur, increasing risk of cardiac arrhythmias 2
• Use with caution in patients taking:
  • Digoxin (increases digoxin concentration)
  • Simvastatin (limit to 20 mg daily)
  • Metformin (limit to 1700 mg daily when used with ranolazine 1000 mg twice daily) 1, 2

Ranolazine provides modest but significant improvements in exercise duration and reduction in angina frequency, with data showing it can reduce angina episodes by approximately one attack per week 4, 5.