What is the maximum daily dose of Coreg (carvedilol) for a patient with heart failure or left ventricular dysfunction?

Maximum Daily Dose of Coreg (Carvedilol)

The maximum daily dose of carvedilol immediate-release (IR) is 50 mg total per day (25 mg twice daily), while the controlled-release formulation (Coreg CR) has a maximum dose of 80 mg once daily. 1, 2

Immediate-Release Carvedilol Dosing

For heart failure with reduced ejection fraction (HFrEF):

• Maximum dose: 25 mg twice daily (50 mg total daily dose) for patients weighing >85 kg 3, 2, 1
• Starting dose: 3.125 mg twice daily 3, 1
• Titration schedule: Double the dose every 1-2 weeks if tolerated (3.125 mg → 6.25 mg → 12.5 mg → 25 mg twice daily) 4, 1
• The target dose of 25 mg twice daily demonstrated 34-65% mortality reduction in clinical trials 4

For hypertension:

• Maximum dose: 25 mg twice daily (50 mg total daily dose) 2, 1
• Starting dose: 6.25 mg twice daily 1
• Titration: Increase to 12.5 mg twice daily after 7-14 days, then to 25 mg twice daily if needed and tolerated 1

For left ventricular dysfunction post-myocardial infarction:

• Maximum dose: 25 mg twice daily (50 mg total daily dose) 1
• Starting dose: 6.25 mg twice daily (or 3.125 mg twice daily if clinically indicated) 1
• Titration: Increase after 3-10 days to 12.5 mg twice daily, then to target of 25 mg twice daily 1

Controlled-Release Carvedilol (Coreg CR) Dosing

For heart failure:

• Maximum dose: 80 mg once daily 5, 2
• This is bioequivalent to immediate-release 25 mg twice daily 6, 7
• Starting dose: 10 mg once daily 5
• Titration schedule: 10 mg → 20 mg → 40 mg → 80 mg once daily 5

Critical Clinical Considerations

Absolute maximum limits:

• The FDA label explicitly states that total daily dose should not exceed 50 mg for immediate-release carvedilol 1
• The controlled-release formulation has a distinct maximum of 80 mg once daily, which is NOT interchangeable with higher doses of immediate-release 2

Common pitfall to avoid:

• Underdosing is the most frequent error in clinical practice—aim for target doses or at least 50% of target to achieve mortality benefits 5, 4
• Never abruptly discontinue carvedilol as this can precipitate rebound hypertension, worsening heart failure, myocardial ischemia, infarction, and arrhythmias 4, 2, 1

Monitoring during titration:

• Assess heart rate, blood pressure, signs of congestion, and symptoms of worsening heart failure at each dose escalation 4
• If worsening heart failure symptoms occur, first increase diuretics or ACE inhibitors; only temporarily reduce carvedilol if this fails 4

Special populations:

• Carvedilol should not be given to patients with severe hepatic impairment 1
• Contraindications include current or recent (within 4 weeks) decompensated heart failure requiring hospitalization, severe asthma with positive bronchoreactivity, second- or third-degree heart block without pacemaker, and sick sinus syndrome 4