Maximum Dosage of Carvedilol
The maximum daily dose of carvedilol immediate-release is 50 mg per day (25 mg twice daily), while the controlled-release formulation (Coreg CR) has a maximum dose of 80 mg once daily. 1, 2, 3
Standard Immediate-Release Formulation
For most adult patients, the target and maximum dose is 25 mg twice daily (50 mg total daily). 1, 3 The FDA-approved labeling explicitly states that "total daily dose should not exceed 50 mg" for the immediate-release formulation. 3
Dosing by Indication:
Heart Failure with Reduced Ejection Fraction (HFrEF): Start at 3.125 mg twice daily and uptitrate every 1-2 weeks to a target of 25 mg twice daily for patients weighing <85 kg, or up to 50 mg twice daily (25 mg twice daily) for patients >85 kg. 2, 4, 3
Post-Myocardial Infarction with LV Dysfunction: Begin at 6.25 mg twice daily (or 3.125 mg twice daily if needed for tolerability), increase after 3-10 days to 12.5 mg twice daily, then to the target dose of 25 mg twice daily. 1, 3
Hypertension: Start 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 and required, with total daily dose not exceeding 50 mg. 1, 3
Angina: The dosing regimen is 6.25 mg twice daily, uptitrated to a maximum of 25 mg twice daily. 1, 2
Controlled-Release Formulation (Coreg CR)
The maximum dose for carvedilol CR is 80 mg once daily, which is distinct from the immediate-release formulation. 2, 4 This higher maximum dose for the CR formulation provides equivalent beta-blockade to 25 mg twice daily of immediate-release carvedilol. 4, 5, 6
Dose Equivalents:
- Carvedilol IR 6.25 mg twice daily (12.5 mg total) = Coreg CR 20 mg once daily 4
- Carvedilol IR 25 mg twice daily (50 mg total) = Coreg CR 80 mg once daily 4
The controlled-release formulation delays peak concentration (Cmax) by approximately 3.5 hours compared to immediate-release but maintains equivalent beta-1 blockade over 24 hours. 5, 6
Critical Dosing Principles
Always administer carvedilol with food to slow absorption and reduce orthostatic effects. 3 This is particularly important given carvedilol's alpha-1 blocking properties that can cause postural hypotension.
Never discontinue carvedilol abruptly. 1, 2 Sudden cessation can precipitate rebound hypertension or worsening heart failure, similar to other beta-blockers. 1
Titration Strategy:
The mean dose achieved in clinical trials for HFrEF was 37 mg total daily, starting from 3.125 mg twice daily and uptitrating every 1-2 weeks as tolerated. 4 However, the target remains 25 mg twice daily (50 mg total) for most patients, with higher doses (up to 50 mg twice daily equivalent in CR form) reserved for patients >85 kg with HFrEF. 2, 4
Common Pitfalls to Avoid
Do not exceed 50 mg total daily for immediate-release formulation even in patients who appear to tolerate lower doses well, as this is the FDA-approved maximum and guideline-recommended ceiling. 1, 3
Do not confuse the two formulations: The CR formulation allows for higher once-daily dosing (up to 80 mg) because of its extended-release properties, but this does not translate to higher total daily exposure—it provides equivalent pharmacokinetics to 25 mg twice daily of IR formulation. 4, 5, 6
Avoid rapid uptitration: Carvedilol's combined alpha and beta-blocking properties require gradual dose escalation over weeks to minimize hypotension and bradycardia. 1, 3