Carvedilol Daily Dosage Recommendations
For heart failure with reduced ejection fraction (HFrEF), carvedilol should be initiated at 3.125 mg twice daily and uptitrated to a target dose of 25 mg twice daily (50 mg total daily dose). 1, 2
Dosing by Indication
Heart Failure with Reduced Ejection Fraction
- Start with 3.125 mg twice daily 2
- Uptitrate gradually by doubling the dose every 1-2 weeks as tolerated 2
- Follow titration scheme: 3.125 mg → 6.25 mg → 12.5 mg → 25 mg twice daily 2
- Target dose is 25 mg twice daily (50 mg total daily dose) for patients weighing over 85 kg 2
- For patients who cannot tolerate the target dose, even lower doses provide benefit 3
Post-Myocardial Infarction with Left Ventricular Dysfunction
- Start at 6.25 mg twice daily (or 3.125 mg twice daily if clinically indicated) 4
- Increase after 3-10 days to 12.5 mg twice daily based on tolerability 4
- Target dose is 25 mg twice daily 4
- Lower doses should be maintained if higher doses are not tolerated 4
Hypertension
- Start at 6.25 mg twice daily 4
- If tolerated, maintain for 7-14 days then increase to 12.5 mg twice daily if needed 4
- Can be further increased to 25 mg twice daily if needed and tolerated 4
- Total daily dose should not exceed 50 mg 4
- Full antihypertensive effect is seen within 7-14 days 4
Administration Guidelines
- Carvedilol should be taken with food to slow absorption and reduce orthostatic effects 4
- Controlled-release (CR) formulation allows once-daily dosing at equivalent total daily doses (80 mg CR once daily = 25 mg immediate-release twice daily) 5, 6
- Dosage must be individualized and monitored during up-titration 4
Monitoring During Titration
- Monitor for heart failure symptoms, fluid retention, hypotension, and symptomatic bradycardia 2
- Check heart rate and blood pressure frequently during intravenous beta-blocker therapy 1
- Target resting heart rate is 50-60 beats per minute unless a limiting side effect is reached 1
- If worsening symptoms occur, increase diuretics or ACE inhibitors first, then temporarily reduce carvedilol dose if necessary 2
Special Considerations
- For patients with both hypertension and heart failure, follow the heart failure dosing regimen 3
- Carvedilol should not be given to patients with severe hepatic impairment 4
- For patients with mild wheezing or history of chronic obstructive pulmonary disease, start with a low dose of a cardioselective agent 1
- Abrupt discontinuation should be avoided as it can precipitate rebound hypertension or worsening heart failure 2
Common Pitfalls
- Underdosing is common in clinical practice, with many patients maintained on suboptimal doses due to fear of side effects 2
- Even lower doses of beta blockers provide benefit if target doses cannot be tolerated 3
- For worsening congestion, consider doubling the dose of diuretic and/or halving the dose of beta blocker 3
- For marked fatigue or bradycardia, consider halving the dose of beta blocker 3
Carvedilol has demonstrated significant mortality reduction in heart failure patients compared to placebo, with a 34-65% reduction in clinical trials 2. Its combined alpha- and beta-blocking properties may provide additional benefits compared to other beta blockers 2.