What is the initial dose and titration schedule for Cardivas (Carvedilol) in patients with heart failure or hypertension?

Cardivas (Carvedilol) Initial Dosing and Titration

Heart Failure with Reduced Ejection Fraction

For heart failure, start Carvedilol at 3.125 mg twice daily with food, double the dose every 2 weeks as tolerated, and aim for a target dose of 25 mg twice daily (or 50 mg twice daily if body weight >75 kg). 1, 2

Starting Dose and Titration Schedule

• Initial dose: 3.125 mg twice daily, taken with food to reduce orthostatic effects 1, 2
• Titration interval: Double the dose at intervals of not less than 2 weeks 1
• Titration sequence: 3.125 mg → 6.25 mg → 12.5 mg → 25 mg twice daily 1
• Target dose: 25 mg twice daily for patients <75 kg, or 50 mg twice daily for patients >75 kg 1, 2

Monitoring During Titration

• Monitor heart rate, blood pressure, clinical status (especially signs of congestion), and body weight at each visit 1
• Check blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 1
• Patients should weigh themselves daily and increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days 1

Problem-Solving During Titration

Worsening congestion (dyspnea, edema, weight gain):

• First: Double the diuretic dose 1
• Second: If increasing diuretic fails, halve the Carvedilol dose 1
• Review patient in 1-2 weeks; seek specialist advice if no improvement 1

Symptomatic bradycardia (heart rate <50 bpm with symptoms):

• Halve the Carvedilol dose 1
• Review other heart rate-slowing drugs (digoxin, amiodarone, diltiazem) 1
• Arrange ECG to exclude heart block 1

Symptomatic hypotension (dizziness, lightheadedness):

• First: Reconsider need for nitrates, calcium channel blockers, and other vasodilators 1
• Second: If no signs of congestion, reduce diuretic dose 1
• Third: Only if above measures fail, temporarily reduce Carvedilol dose 1
• Asymptomatic low blood pressure requires no change in therapy 1

Post-Myocardial Infarction with Left Ventricular Dysfunction

Start Carvedilol at 6.25 mg twice daily after the patient is hemodynamically stable and fluid retention minimized, increase to 12.5 mg twice daily after 3-10 days, then to target dose of 25 mg twice daily. 2

• Initial dose: 6.25 mg twice daily (or 3.125 mg twice daily if lower blood pressure, heart rate, or fluid retention present) 2
• First increase: After 3-10 days based on tolerability, increase to 12.5 mg twice daily 2
• Target dose: 25 mg twice daily 2
• A slower rate of up-titration may be used if clinically indicated 2
• Maintain on lower doses if higher doses are not tolerated 2

Hypertension

For hypertension, start Carvedilol at 6.25 mg twice daily, maintain for 7-14 days, then increase to 12.5 mg twice daily if needed, and finally to 25 mg twice daily if tolerated, with maximum daily dose of 50 mg. 2

• Initial dose: 6.25 mg twice daily 2
• First increase: After 7-14 days if tolerated (using standing systolic pressure 1 hour after dosing as guide), increase to 12.5 mg twice daily 2
• Second increase: After another 7-14 days if tolerated and needed, increase to 25 mg twice daily 2
• Maximum dose: 50 mg total daily dose 2
• Full antihypertensive effect is seen within 7-14 days 2
• Concomitant diuretic use produces additive effects and exaggerates orthostatic hypotension 2

Critical Contraindications Before Starting

Do not initiate Carvedilol in patients with:

• Severe (NYHA class IV) heart failure without specialist supervision 1
• Current or recent (within 4 weeks) heart failure exacerbation requiring hospitalization 1
• Heart block or heart rate <60 bpm 1
• Persisting signs of congestion (raised jugular venous pressure, ascites, marked peripheral edema) 1
• Severe hepatic impairment 2

Key Clinical Pearls

• Carvedilol is one of only three beta-blockers proven to reduce mortality in heart failure (along with bisoprolol and metoprolol succinate) 1
• Some beta-blocker is better than no beta-blocker—aim for highest tolerated dose even if target cannot be reached 1
• Temporary symptomatic deterioration occurs in 20-30% of patients during initiation/up-titration but can usually be managed by adjusting other medications 1
• Never abruptly discontinue Carvedilol due to risk of rebound ischemia, myocardial infarction, and arrhythmias 1
• Always take with food to reduce orthostatic effects 2