What is the recommended dose of Coreg (carvedilol) for heart failure?

Carvedilol Dosing for Heart Failure

For heart failure, carvedilol should be initiated at 3.125 mg twice daily and titrated gradually to a target dose of 25 mg twice daily (50 mg total daily dose). 1, 2

Initial Dosing and Titration Schedule

• Start with 3.125 mg twice daily for 1-2 weeks 1, 2, 3
• If well tolerated, increase to 6.25 mg twice daily for 1-2 weeks 1, 2, 4
• Then increase to 12.5 mg twice daily for 1-2 weeks 1, 2
• Finally, increase to the target dose of 25 mg twice daily 1, 2

Administration Guidelines

• Carvedilol should be taken with food to slow absorption and reduce orthostatic effects 4
• Dose adjustments should be made no more frequently than every 1-2 weeks 1, 2
• The patient should be in relatively stable condition without need for intravenous inotropic therapy and without signs of marked fluid retention before starting carvedilol 1

Monitoring During Titration

• Monitor for heart failure symptoms, fluid retention, hypotension, and symptomatic bradycardia during the titration period 1, 2
• If worsening heart failure symptoms occur, first increase the dose of diuretics or ACE inhibitors before reducing the beta-blocker dose 1, 2
• If hypotension occurs, first reduce the dose of vasodilators; reduce the beta-blocker dose only if necessary 1
• For bradycardia, reduce or discontinue drugs that may lower heart rate; reduce beta-blocker dose if necessary, but discontinue only if clearly needed 1

Special Considerations

• For patients weighing over 85 kg, the target dose remains 25 mg twice daily 2
• For patients with severe heart failure (NYHA class III-IV), the same titration protocol should be followed, but with closer monitoring 1, 3
• Carvedilol should not be given to patients with severe hepatic impairment 4
• Lower starting doses (e.g., 3.125 mg twice daily) and slower titration may be necessary for patients with more severe heart failure 4, 3

Common Pitfalls

• Underdosing is common in clinical practice, but studies show a dose-response relationship with improved outcomes, so aim for target doses 1, 2
• Abrupt discontinuation should be avoided as it can precipitate rebound hypertension or worsening heart failure 2
• Always consider reintroduction and/or uptitration of carvedilol when the patient becomes stable, even after temporary dose reduction 1

Evidence of Benefit

• Carvedilol has been shown to improve left ventricular ejection fraction and reduce mortality in patients with heart failure 3, 5, 6
• Even in patients with severe heart failure, carvedilol improves survival and reduces hospitalizations when properly titrated 3, 5