What is the typical dosage and treatment plan for Diovan (valsartan) in patients with hypertension or heart failure?

Diovan (Valsartan) Dosing and Treatment Plan

For hypertension, start valsartan at 80-160 mg once daily with a maximum dose of 320 mg daily; for heart failure, initiate at 40 mg twice daily and uptitrate to 160 mg twice daily as tolerated. 1

Hypertension Management

Initial Dosing Strategy

• Start with 80 mg or 160 mg once daily as monotherapy in patients who are not volume-depleted 1
• The higher 160 mg starting dose should be used when greater blood pressure reduction is required initially 1
• Antihypertensive effect becomes substantially present within 2 weeks, with maximal reduction generally attained after 4 weeks 1

Dose Titration and Optimization

• The therapeutic dose range spans 80-320 mg once daily 1
• If additional blood pressure lowering is needed beyond the starting dose, increase to a maximum of 320 mg daily or add a diuretic 1
• Adding a diuretic produces greater blood pressure reduction than dose increases beyond 80 mg 1
• The 160 mg dose appears optimal for initial therapy based on efficacy/tolerability profiles 2

Combination Therapy Considerations

• Valsartan may be combined with other antihypertensive agents, particularly thiazide diuretics 1, 3
• The fixed-dose combination valsartan/hydrochlorothiazide 80/12.5 mg or 160/12.5 mg once daily controls blood pressure in approximately 70% of cases 4
• For non-Black patients, ARBs like valsartan should be combined with dihydropyridine calcium channel blockers or thiazide-like diuretics per guideline algorithms 3

Heart Failure Management

Initiation Protocol

• Begin at 40 mg twice daily as the recommended starting dose 1
• Valsartan may be initiated in patients with NYHA class II-IV heart failure who are intolerant of ACE inhibitors 5
• Consider reducing concomitant diuretic doses when starting valsartan 1

Uptitration Strategy

• Uptitrate progressively to 80 mg twice daily, then 160 mg twice daily (target dose), or to the highest dose tolerated 1
• The maximum daily dose studied in clinical trials is 320 mg in divided doses 1
• Titration should be individualized based on blood pressure tolerance and renal function 1

Evidence for Heart Failure Efficacy

• In the Val-HeFT trial, valsartan 160 mg twice daily reduced the combined endpoint of mortality and morbidity by 13.2% compared with placebo when added to conventional heart failure therapy 5
• Among patients not receiving an ACE inhibitor, valsartan reduced mortality risk by 33.1% and the combined endpoint by 44% 5
• Critical caveat: In patients already taking both an ACE inhibitor and beta-blocker, mortality was significantly higher with valsartan 5, therefore valsartan should not be combined with ACE inhibitors 3

Monitoring Requirements

• If symptomatic hypotension or renal dysfunction occurs, consider dose reduction 1
• The most common adverse events leading to discontinuation are dizziness, renal impairment, and hypotension 5

Post-Myocardial Infarction

Initiation Timing and Dosing

• Valsartan may be initiated as early as 12 hours after myocardial infarction 1
• Start with 20 mg twice daily 1
• Uptitrate within 7 days to 40 mg twice daily, then to target maintenance dose of 160 mg twice daily as tolerated 1

Concomitant Therapy

• Valsartan may be given with other standard post-MI treatments including thrombolytics, aspirin, beta-blockers, and statins 1

Pediatric Hypertension (Ages 1-16 Years)

Dosing Recommendations

• Start at 1 mg/kg once daily (maximum 40 mg total) 1
• A higher starting dose of 2 mg/kg may be considered when greater blood pressure reduction is needed 1
• Adjust dosage according to blood pressure response and tolerability, up to maximum 4 mg/kg once daily (maximum 160 mg daily) 1

Important Formulation Considerations

• Valsartan tablets and oral suspension are NOT substitutable on a milligram-per-milligram basis 1
• The oral suspension provides 60% higher systemic exposure (AUC) compared to tablets 1
• Use oral suspension for children aged 1-5 years, those unable to swallow tablets, or when calculated dose doesn't correspond to available tablet strengths 1

Contraindications in Young Children

• Use is not recommended in children less than 1 year of age 1
• No data available for pediatric patients undergoing dialysis or with GFR <30 mL/min/1.73 m² 1

Special Populations and Precautions

Renal Considerations

• Valsartan is contraindicated in patients with severe renal impairment undergoing dialysis 1
• Monitor renal function closely, particularly when initiating therapy or increasing doses 1

Pregnancy Warning

• Valsartan is contraindicated in pregnancy due to shared class-related risks with all ARBs 6

Hyperkalemia Risk

• Risk of hyperkalemia exists, especially in patients with chronic kidney disease 6
• Avoid combining with ACE inhibitors or aliskiren due to increased adverse events without additional benefit 6

Pharmacodynamic Considerations

Receptor Blockade Duration

• 80 mg and 160 mg valsartan provide similar AT₁-receptor blockade during the first 6 hours after administration 7
• Only the 160 mg dose provides sustained AT₁-receptor blockade over the full 24-hour period 7
• This pharmacodynamic profile supports once-daily dosing for hypertension and twice-daily dosing for heart failure 8