Entresto
Combination product
Pronunciation: sa-KOO-bi-tril and val-SAR-tan (en-TRES-toe)
Combination of Sacubitril and Valsartan.
Each component keeps its own pharmacology page; the combination itself adds no new mechanism.
Interesting to Sack you, bit drill
Components (2)
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Heart failure | Adults (on adequate ACEi/ARB dose) | 49/51 mg BID | 97/103 mg BID (double after 2–4 wk as tolerated) | 97/103 mg BID |
| Heart failure | Adults not on ACEi/ARB or on low doses | 24/26 mg BID (half the usual start) | escalate q2–4wk to 97/103 mg BID | 97/103 mg BID |
| Heart failure | Peds ≥1 y, <40 kg (oral suspension) | 1.6 mg/kg BID | 2.3 → 3.1 mg/kg BID (adjust q2wk) | 3.1 mg/kg BID |
| Heart failure | Peds ≥1 y, 40–<50 kg | 24/26 mg BID (0.8 mg/kg BID susp. if half-start tier applies) | 49/51 → 72/78 mg BID (adjust q2wk) | 72/78 mg BID |
| Heart failure | Peds ≥1 y, ≥50 kg | 49/51 mg BID | 72/78 → 97/103 mg BID (adjust q2wk) | 97/103 mg BID |
Titration Adults: 2–4 weeks per step before doubling. Peds: 2 weeks per step.
Renal Mild–moderate (eGFR 30–90): no adjustment. Severe (eGFR <30): half the usual starting dose, then usual escalation.
Hepatic Mild (Child-Pugh A): no adjustment. Moderate (Child-Pugh B): half the usual starting dose. Severe (Child-Pugh C): not recommended.
Do not administer within 36 hours of an ACE inhibitor (switching from or to).
Instructions
- 36-hour washout between an ACE inhibitor and this drug when switching in either direction
- Correct volume or salt depletion before starting, or start at a lower dose
- Oral suspension (4 mg/mL, prepared from 49/51 mg tablets) may substitute at the same dose for patients who cannot swallow tablets; stable 15 days, do not refrigerate, shake before use
Available strengths
- tab 24/26, 49/51, 97/103 mg
- cap 6/6, 15/16 mg
- pellet 6/6, 15/16 mg
Contraindications
- History of angioedema related to previous ACE inhibitor or ARB therapy
- Concomitant ACE inhibitors — do not administer within 36 h of switching from or to an ACEi
- Concomitant aliskiren in patients with diabetes
Cautions
- Angioedema (may be fatal with laryngeal edema; higher rate in Black patients; never re-administer after an event; avoid in hereditary angioedema)
- Symptomatic hypotension — highest risk in volume/salt-depleted patients
- Impaired renal function — monitor creatinine; caution with renal artery stenosis
- Hyperkalemia — monitor potassium, esp. with severe renal impairment, diabetes, hypoaldosteronism, high-K diet
Adverse reactions
- Hypotension (18%)
- Hyperkalemia (12%)
- Cough (9%)
- Dizziness (6%)
- Renal failure/acute renal failure (5%)
Pregnancy Fetal harm — 2nd/3rd-trimester RAS exposure reduces fetal renal function (oligohydramnios, anuria, lung/skull hypoplasia, death); discontinue when pregnancy detected.
Lactation Breastfeeding not recommended (present in rat milk; potential serious infant reactions).
Cost
| Strength | #/mo | generic $/mo | CostPlus | |
|---|---|---|---|---|
| 24/26 mg | tab | 60 BID | $29.91 | offered |
| 49/51 mg | tab | 60 BID | $32 | offered |
| 97/103 mg | tab | 60 BID | $35.53 | offered |
Other forms: Sacubitril (in ENTRESTO)
Part D rank #108.