Suspected Acute Heart Failure Clinical Pathway – Emergency Department, ICU and Inpatient – Transition to Chronic HF Enteral Medications

Suspected Acute Heart Failure Clinical Pathway – Emergency Department, ICU and Inpatient

Transition to Chronic HF Enteral Medications

Angiotensin Converting Enzyme Inhibitors (ACEI) Consider angiotensin receptor blocker (ARB) in children unable to tolerate an ACEI (e.g., cough) Captopril
  • Consider single test dose at 50% of the recommendation below if hyponatremic, hypovolemic, severe congestive HF, impaired renal function, on afterload reducing agents, or receiving diuretics.
  • Neonates, may not be appropriate for premature infants; use caution
    • Initial 0.01–0.05 mg/kg/dose TID
    • Increase to a goal of 0.5 mg/kg/dose TID
  • Infants < 6 mos
    • Initial 0.15–0.3 mg/kg/dose TID
    • Increase to goal of 0.5–1 mg/kg/dose TID
    • Max 2 mg/kg/dose TID
  • Adjust dose for renal impairment
  • Monitor kidney function, BP, potassium levels
Enalapril
  • Consider single test dose at 50% of the recommendation below if hyponatremic, hypovolemic, severe congestive HF, impaired renal function, on afterload reducing agents, or receiving diuretics.
  • Infants > 6 mos and children, may not be appropriate for premature infants; use caution
    • Initial 0.05 mg/kg/dose BID
    • Increase to a goal of 0.25 mg/kg/dose BID
  • Adjust dose for renal impairment
  • Monitor kidney function, BP, and potassium levels
Lisinopril
  • Consider single test dose at 50% of the recommendation below if hyponatremic, hypovolemic, severe congestive HF, impaired renal function, on afterload reducing agents, or receiving diuretics.
  • Adolescents and adults, not appropriate for children < 6 yrs
    • Initial 0.07 mg/kg/dose daily
    • Max initial dose 5 mg once daily
    • Max 0.6 mg/kg/day or 40 mg/day
    • Increase to goal of 40 mg
  • Adjust dose for renal impairment
  • Monitor kidney function, BP, potassium levels
Angiotensin II Receptor Blocker/Neprilysin Inhibitor Sacubitril/Valsartan (Entresto)

Oral suspension includes combined mg dosing of sacubitril and valsartan

Tablet includes individual mg for each component

If switching between oral suspension and tablets, consider available strengths, adjust dose as needed

Concomitant use of an ACEI is contraindicated

Allow a 36 hr washout period when switching from or to an ACEI

Monitor kidney function, BP, potassium levels

Previously on Moderate to High Dose ACE Inhibitor
≥ 0.2 mg/kg/day or 10 mg/day of enalapril or equivalent or angiotensin II receptor blocker
Oral Suspension
  • Children ≥ 1 yr and adolescents < 40 kg
    • Initial 1.6 mg/kg/dose BID
    • 2 wks: Increase to 2.3 mg/kg/dose BID
    • 4 wks: Increase to 3.1 mg/kg/dose BID
    • Alternative titration schedules may be considered as tolerated
Tablets
  • Children and adolescents 40 to < 50 kg
    • Initial sacubitril 24 mg/valsartan 26 mg BID
    • 2 wks: Increase to sacubitril 49 mg/valsartan 51 mg BID
    • 4 wks: Increase to sacubitril 72 mg/valsartan 78 mg BID
    • Alternative titration schedules may be considered as tolerated
  • Children and adolescents ≥ 50 kg
    • Initial sacubitril 49 mg/valsartan 51 mg BID
    • 2 wks: Increase to sacubitril 72 mg/valsartan 78 mg BID
    • 4 wks: Increase to sacubitril 97 mg/valsartan 103 mg BID
    • Alternative titration schedules may be considered as tolerated
Not currently taking ACE inhibitor or ARB or
previously taking low doses of an ACE inhibitor
0.1 mg/kg/day or 5 mg/day of enalapril or equivalent or ARB
Oral Suspension
  • Children ≥ 1 yr and adolescents ≤ 50 kg
    • Initial 0.8 mg/kg/dose BID
    • 2 wks: Increase dose to 1.6 mg/kg/dose BID
    • 4 wks: Increase dose to 2.3 mg/kg/dose BID
    • 6 wks: Increase dose to 3.1 mg/kg/dose BID 2
    • Alternative titration schedules may be considered as tolerated
Tablets
  • Children and adolescents > 50 kg
    • Initial sacubitril 24 mg/valsartan 26 mg BID
    • 2 wks: Increase dose to sacubitril 49 mg/valsartan 51 mg BID
    • 4 wks: Increase dose to sacubitril 72 mg/valsartan 78 mg BID
    • 6 wks: Increase dose to sacubitril 97 mg/valsartan 103 mg BID
    • Alternative titration schedules may be considered as tolerated
Beta Blockers Carvedilol
  • Infants > 1 mo and children
    • Initial 0.05 mg/kg/dose PO BID
    • Increase to a goal of 0.4–0.8 mg/kg/dose BID
    • Max 50 mg/day
    • For children < 3.5 yrs old, TID dosing can be considered
  • Adults
    • Initial 3.125 mg BID
    • Max dose of 25 mg BID if ≥ 85 kg
    • Max dose of 50 mg BID
    • Monitor HR, BP, kidney, and liver function
Aldosterone Antagonist Spironolactone
  • Neonates
    • 1–3 mg/kg/day in 1–2 divided doses
  • Children
    • 1.5–3.3 mg/kg/day in 1–4 divided doses
    • Max 200 mg/day
  • Adults
    • 12.5–50 mg/day in 1–2 divided doses
    • Use caution with other potassium supplements, ACEIs/ARBs, and NSAIDs
  • Consider non-formulary eplerenone to avoid gynecomastia in adolescent males
  • Monitor kidney function, BP, potassium levels
Diuretics Furosemide
  • PO 1–2 mg/kg/dose 1–4x/day
  • Note: conversion from IV to PO furosemide is 1:2
  • Consider continuous infusion of furosemide or other diuretic to avoid large fluid shifts
  • Consider bumetanide or chlorothiazide if poor response to furosemide
SGLT2 inhibitors Dapagliflozin
  • Children > 1 year and Adolescents
    • 0.1-0.2 mg/kg/dose once daily
    • Max 10 mg/dose
    • May need to dose in partial tablets
  • Adults
    • 10 mg once daily
    • Not recommended
      • eGFR ≤ 25 mL/min/1.73 m2
      • If major surgery/procedure within next 3 days
Antiarrhythmic Digoxin
  • Loading dose not recommended
  • See CHOP Formulary for dosing information
  • Reduce dose for renal impairment
  • ECG at initiation and at steady-state, 3–5 days
  • Use ½ the maintenance dose of digoxin if concomitant use of amiodarone or carvedilol
  • Avoid hypokalemia which potentiates digoxin toxicity
  • If concerned for digoxin toxicity, check trough level: goal < 1 ng/mL
Ivabradine
  • Infants 6–12 mons
    • Initial 0.02 mg/kg/dose BID
    • Increase by 0.02 mg/kg/dose BID every 2 wks as clinically indicated
  • Children < 40 kg
    • Initial 0.05 mg/kg/dose BID
    • Increase by 0.05 mg/kg/dose BID every 2 wks as clinically indicated
    • Max 7.5 mg/dose BID
  • Children, adolescents and adults ≥ 40 kg
    • Initial 2.5 mg BID
    • Increase by 2.5 mg BID every 2 wks as clinically indicated
    • Max 7.5 mg/dose BID
  • Reduce dose in patients with severe renal or hepatic dysfunction
  • Liquid preparation available only from specialty pharmacy—contact case management, if indicated, to facilitate before discharge
  • Monitor blood pressure, heart rate, EKG, and liver function