Parameters to Hold Carvedilol
Carvedilol should be held when patients present with symptomatic hypotension, bradycardia (heart rate <50 beats per minute), or decompensated heart failure requiring intravenous inotropic support. 1
Specific Parameters for Holding Carvedilol
Cardiovascular Parameters
- Heart rate <50 beats per minute (symptomatic bradycardia) 1
- Systolic blood pressure <90 mmHg (symptomatic hypotension) 1
- Second or third-degree heart block (in absence of permanent pacemaker) 1
- Sick sinus syndrome (without permanent pacemaker) 1
- Acute decompensated heart failure requiring IV inotropic support 1
- Cardiogenic shock 2
Respiratory Parameters
- Severe bronchospasm or status asthmaticus (asthma is a contraindication) 1
- Acute exacerbation of reactive airway disease 1
Metabolic/Renal Parameters
- Severe hepatic impairment (cirrhosis) - carvedilol is contraindicated due to 4-7 fold increase in drug levels 2
- Acute kidney injury with hemodynamic compromise 1
- In patients with end-stage liver disease and refractory ascites - consider holding or using reduced doses 1
Special Considerations
Heart Failure Patients
- In patients admitted for worsening heart failure, a temporary reduction in carvedilol dose may be necessary 1
- In severe situations, temporary discontinuation can be considered 1
- Low-dose therapy should be re-instituted as soon as the patient's clinical condition permits, preferably prior to discharge 1
Cirrhotic Patients
- In patients with cirrhosis and refractory ascites, carvedilol may need to be held or dose-reduced if systolic blood pressure falls below 90 mmHg 1
- Consider holding in patients with spontaneous bacterial peritonitis who develop acute kidney injury 1
Important Cautions
- Avoid abrupt cessation of carvedilol whenever possible, as this can lead to rebound hypertension, tachycardia, or worsening angina 1
- When discontinuation is necessary, taper gradually if possible 1
- If carvedilol must be discontinued in a patient with heart failure, consider switching to another beta-blocker as soon as clinically feasible 1
- Monitor patients closely for 24-48 hours after any significant dose reduction 3
Resuming Carvedilol
- After temporary discontinuation, restart at a lower dose (e.g., 3.125-6.25 mg twice daily) 1
- Titrate slowly based on heart rate and blood pressure response 1
- For heart failure patients, aim to resume beta-blockade before discharge if possible 1