What is the recommended dosage and usage of Vigliance is not needed, Valsartan (Angiotensin II receptor antagonist) for a patient with hypertension (high blood pressure) or heart failure, particularly those who cannot tolerate Angiotensin-Converting Enzyme (ACE) inhibitors due to side effects?

Valsartan Dosing for Hypertension and Heart Failure

For hypertension, start valsartan at 80-160 mg once daily and titrate up to a maximum of 320 mg daily; for heart failure, start at 40 mg twice daily and uptitrate to the target dose of 160 mg twice daily (320 mg total daily). 1

Hypertension Dosing

Starting dose:

• Begin with 80 mg or 160 mg once daily in patients who are not volume-depleted 1
• Higher starting dose (160 mg) may be used when greater blood pressure reduction is needed 1

Titration and maintenance:

• Dose range: 80-320 mg once daily 1
• Antihypertensive effect appears within 2 weeks, with maximal reduction at 4 weeks 1
• If additional blood pressure lowering is needed beyond 80 mg, adding a diuretic is more effective than increasing valsartan dose 1
• Maximum dose: 320 mg once daily 1

Pediatric dosing (ages 1-16 years):

• Starting dose: 1 mg/kg once daily (up to 40 mg total) 1
• Higher starting dose of 2 mg/kg may be considered when greater blood pressure reduction is needed 1
• Maximum dose: 4 mg/kg once daily (not to exceed 160 mg daily) 1
• Not recommended in children under 1 year of age 1

Heart Failure Dosing

Starting and target doses:

• Start at 40 mg twice daily and uptitrate to 80 mg twice daily, then to the target dose of 160 mg twice daily 2, 1
• Maximum studied dose: 320 mg daily in divided doses 1
• Consider reducing concomitant diuretic doses when initiating valsartan 1

Titration strategy:

• The American College of Cardiology recommends adjusting doses no more frequently than every 2 weeks 3
• At minimum, achieve 50% of target dose (160 mg total daily) for clinical benefit 3, 4
• Many physicians underdose valsartan in heart failure—less than 25% of patients are titrated to target doses in clinical practice 3

Clinical evidence:

• Valsartan 160 mg twice daily demonstrated non-inferiority to captopril in reducing mortality in the VALIANT trial 2, 5
• In Val-HeFT, valsartan reduced heart failure hospitalizations by 13.2% compared to placebo 5
• Higher doses provide greater AT1-receptor blockade over 24 hours and superior clinical benefits 3

Post-Myocardial Infarction Dosing

Initiation and titration:

• May start as early as 12 hours post-MI 1
• Starting dose: 20 mg twice daily 1
• Uptitrate within 7 days to 40 mg twice daily 1
• Target maintenance dose: 160 mg twice daily 1
• If symptomatic hypotension or renal dysfunction occurs, reduce dose 1

Use as Alternative to ACE Inhibitors

Indications for valsartan instead of ACE inhibitors:

• Valsartan is recommended for patients intolerant to ACE inhibitors due to cough or angioedema 2
• Cough occurs in up to 20% of ACE inhibitor users but is significantly less common with valsartan 2, 5
• Angioedema occurs in <1% of ACE inhibitor users (more frequent in blacks and women) but is rare with valsartan 2

Important caveat on angioedema:

• Exercise extreme caution when substituting valsartan in patients who developed angioedema with ACE inhibitors—some patients also develop angioedema with ARBs 2
• Never initiate valsartan in patients with a history of angioedema 2

Comparative efficacy:

• In VALIANT, valsartan 160 mg twice daily was non-inferior to captopril 50 mg three times daily for mortality reduction post-MI 2
• In CHARM-Alternative, candesartan reduced cardiovascular or heart failure hospitalization by 23% in ACE inhibitor-intolerant patients 2
• Valsartan and candesartan have demonstrated mortality and morbidity benefits comparable to ACE inhibitors 2

Monitoring and Safety

Required monitoring:

• Check renal function and potassium within 1-2 weeks after initiation or dose increases, then every 3-6 months 3
• Monitor blood pressure, especially in patients with baseline systolic BP <90 mmHg 3

Contraindications and cautions:

• Use caution when creatinine >221 μmol/L (>2.5 mg/dL) or eGFR <30 mL/min/1.73 m² 3
• Avoid in pregnancy 2
• Exercise caution with potassium >5.0 mEq/L 2, 3

Drug interactions to avoid:

• Do not combine valsartan with ACE inhibitors—this increases risk of hyperkalemia and renal dysfunction without mortality benefit 2, 3
• Avoid triple combination of ACE inhibitor + ARB + mineralocorticoid receptor antagonist 3
• Avoid NSAIDs unless essential, as they may cause renal impairment and attenuate diuretic effects 3
• Avoid potassium supplements and potassium-sparing diuretics 3

Managing adverse effects:

• For symptomatic hypotension: reconsider need for nitrates, calcium-channel blockers, and other vasodilators; reduce or stop if possible 3
• Temporary dose reductions may be necessary, but attempt to return to target doses when tolerated 3
• Discontinuation rates due to adverse effects are lower with valsartan than with ACE inhibitors 2

Common Pitfalls

• Underdosing is the most common error—many clinicians use doses that are too low to provide optimal benefits 3
• Failing to uptitrate to target doses or at least 50% of target dose 3, 4
• Not monitoring renal function and potassium appropriately during titration 3
• Combining valsartan with ACE inhibitors, which increases adverse effects without mortality benefit 2, 3
• Assuming all patients with ACE inhibitor-related angioedema can safely take valsartan—some will also develop angioedema with ARBs 2