What parameters should be monitored when initiating Entresto (sacubitril and valsartan) therapy?

Monitoring Parameters for Entresto (Sacubitril/Valsartan) Therapy

When initiating Entresto therapy, blood pressure, renal function, and potassium levels should be monitored within 1-2 weeks after starting or increasing the dose, with more frequent monitoring needed in patients with renal impairment, elderly patients, or those on medications affecting renal function. 1

Initial Assessment Before Starting Entresto

• Blood pressure: Ensure systolic BP is >100 mmHg before initiation 2, 1
• Renal function: Check baseline eGFR and serum creatinine 1, 3
  • For severe renal impairment (eGFR <30 mL/min/1.73m²): Start at half the usual dose 3
• Potassium levels: Obtain baseline serum potassium 1, 3
• Volume status: Ensure patient is not volume-depleted to avoid hypotension 2
• Medication history: Check for:
  • ACE inhibitor use (requires 36-hour washout period) 1, 3
  • Current ARB dose (to determine appropriate starting dose) 1
  • Concomitant medications that affect renal function 1

Ongoing Monitoring Parameters

Blood Pressure

• Monitor within 1-2 weeks after initiation or dose increase 1
• Assess for symptomatic hypotension (dizziness, lightheadedness) 2, 3
• Consider temporary dose reduction or discontinuation if systolic BP <100 mmHg 3

Renal Function

• Check serum creatinine and eGFR within 1-2 weeks after initiation or dose changes 1
• More frequent monitoring in:
  • Elderly patients (≥75 years) 1
  • Patients with baseline renal impairment 1
  • Patients on other medications affecting kidney function 1
• Consider dose reduction if clinically significant decrease in renal function occurs 3

Electrolytes

• Monitor serum potassium within 1-2 weeks of starting or increasing dose 1, 3
• Continue periodic monitoring, especially in patients with:
  • Severe renal impairment 3
  • Diabetes 2
  • Hypoaldosteronism 3
  • High potassium diet 3
  • Concomitant use of medications that can increase potassium 2, 3

Signs of Angioedema

• Monitor for facial swelling, lip swelling, tongue swelling, or laryngeal edema 3
• Discontinue immediately if angioedema occurs 3

Special Populations Requiring Additional Monitoring

Severe Renal Impairment

• Start at half the usual dose (24/26 mg twice daily) 3
• Monitor renal function more frequently 1
• Recent evidence suggests Entresto may still be beneficial even when eGFR declines below 30 mL/min/1.73m² during treatment 4

Moderate Hepatic Impairment

• Start at half the usual dose (24/26 mg twice daily) 3
• Monitor liver function tests periodically 1

Elderly Patients (≥75 years)

• Consider starting at lower dose 1
• Monitor blood pressure and renal function more frequently 1

Patients with Borderline Blood Pressure

• Monitor more closely for hypotension 2
• Consider reducing diuretic dose in non-congested patients to mitigate hypotensive effects 2

Dose Titration Monitoring

• Reassess blood pressure, renal function, and potassium before each dose increase 1
• Standard titration schedule: Increase dose every 2-4 weeks as tolerated 1, 3
• Target dose: 97/103 mg twice daily 1
• If patient develops intolerance during titration, consider temporary dose reduction rather than discontinuation 1

Common Pitfalls and How to Avoid Them

1. Failing to observe ACE inhibitor washout period

   • Always ensure 36-hour washout when switching from ACE inhibitor to Entresto 1, 3
   • No washout needed when switching from ARB to Entresto 1

2. Inadequate monitoring in high-risk patients

   • Increase monitoring frequency in elderly, those with renal impairment, and patients on multiple medications 1

3. Premature discontinuation due to mild hypotension

   • Consider reducing diuretic dose first in non-congested patients 2
   • Temporary dose reduction may be preferable to discontinuation 1

4. Overlooking volume status

   • Ensure patients are not volume-depleted before initiation 2
   • Up to 25% of patients may develop hypotension when treated with Entresto 2

5. Failing to monitor for hyperkalemia

   • Regularly check potassium levels, especially in patients with risk factors 3
   • Consider dose adjustment if hyperkalemia occurs 3

By carefully monitoring these parameters, clinicians can optimize the safety and efficacy of Entresto therapy while minimizing adverse effects.