Carvedilol Dosage

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Usual Adult Dose for:

Additional dosage information:

Usual Adult Dose for Angina Pectoris

Immediate-release tablets:
Initial dose: 6.25 mg orally twice a day with food
Maintenance dose: 6.25 mg to 25 mg orally twice a day with food
Maximum dose: 50 mg per day

Usual Adult Dose for Congestive Heart Failure

Immediate-release tablets:
Initial dose: 3.125 mg orally twice a day for 2 weeks. If tolerated, increase dosage to 6.25 mg orally twice a day.

Dosage should then be doubled every 2 weeks to the highest level tolerated by the patient.

Maximum dose: 50 mg orally twice a day in patients weighing 85 kg or greater and 25 mg orally twice a day in patients weighing 85 kg or less

Extended-release capsules:
Initial dose: 10 mg orally once a day for 2 weeks. If tolerated, increase dosage to 20 mg, 40 mg, and 80 mg over successive intervals of at least 2 weeks.

Usual Adult Dose for Hypertension

Immediate-release tablets:
Initial dose: 6.25 mg orally twice a day with food
Maintenance dose: 6.25 mg to 25 mg orally twice a day with food
Maximum dose: 50 mg per day

Extended-release capsules:
Initial dose: 20 mg orally once a day for 7 to 14 days. If tolerated, may increase dosage to 40 mg orally once a day, then again to 80 mg orally once a day after 7 to 14 days.

Maximum dose: 80 mg per day

Usual Adult Dose for Left Ventricular Dysfunction

Immediate-release tablets:
Initial dose: 6.25 mg orally twice a day (an initial dosage of 3.25 mg twice daily can be given to patients unable to tolerate the initial dosage).

Maintenance dose: If tolerated, the initial dosage may be titrated to 12.5 mg twice a day after 3 to 10 days to a target dose of 25 mg twice a day.

Extended-release capsules:
Initial dose: 20 mg orally once a day (an initial dosage of 10 mg once daily can be given to patients unable to tolerate the initial dosage). If tolerated, may increase dosage to 40 mg after 3 to 10 days, then again to 80 mg orally once a day.

Renal Dose Adjustments

Data not available

Liver Dose Adjustments

Carvedilol is not recommended in patients with liver failure or cirrhosis since the drug is primarily eliminated by the liver.

Dose Adjustments

For the treatment of hypertension, increase dose every 7 to 14 days as needed based on trough blood pressure.

The dosage of carvedilol should be reduced if pulse rate drops below 55 beats per minute.

In patients with renal insufficiency, renal function should be monitored during up-titration of carvedilol and the drug discontinued or dosage reduced if worsening of renal function occurs.

If fluid retention or worsening heart failure occurs during up-titration of carvedilol, the dose of carvedilol should not be advanced and the dose of diuretic should be increased until patient is stable. In some cases, it may be necessary to discontinue or lower the dose of carvedilol.

Precautions

Patients with coronary artery disease receiving carvedilol should be advised to avoid abrupt discontinuation of the drug, as severe exacerbation of angina and occurrence of myocardial infarction and ventricular arrhythmias have occurred. When discontinuing carvedilol, particularly in patients with ischemic heart disease, the dosage should be reduced gradually over a 1 to 2 week period and the patient should be closely monitored. If angina noticeably worsens or acute coronary insufficiency develops, carvedilol should be reinstated quickly, at least temporarily, and other appropriate measures for the management of unstable angina should be taken.

When switching elderly patients (65 years of age or older) who are taking the highest dose of immediate-release carvedilol (25 mg twice daily) to carvedilol extended-release, a lower starting dose (40 mg) of carvedilol extended-release is recommended to minimize the potential for dizziness, syncope, or hypotension. Patients who have switched and who tolerate carvedilol extended-release 40 mg should, if needed, have their dose increased to 80 mg after an interval of at least 2 weeks.

Carvedilol is contraindicated in patients with bronchial asthma or related bronchospastic conditions, second- or third-degree AV heart block, sick sinus syndrome or severe bradycardia (in the absence of a functioning pacemaker), or in patients with cardiogenic shock who have decompensating heart failure requiring the use of intravenous inotropic therapy. Such patients should be weaned from intravenous therapy before initiating carvedilol. Hepatic injury has been observed in patients receiving carvedilol. It is generally reversible and has occurred after short- and/or long-term therapy without clinical symptoms. Carvedilol use is not recommended in patients with liver failure or cirrhosis.

As with other beta-blockers, carvedilol should be used with caution, if at all, in patients with reactive airways disease (bronchial asthma or a history of bronchial asthma or obstructive pulmonary disease with bronchospasm), severe obstructive pulmonary disease, peripheral vascular disease, or diabetes mellitus.

Withdrawal of beta-blocker therapy prior to major surgery is controversial, as the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures.

Diabetic patients receiving insulin or oral hypoglycemic agents or patients subject to spontaneous hypoglycemia should be cautioned that beta-blockers, in general, may mask some of the symptoms of hypoglycemia, particularly tachycardia. Non-selective beta-blockers may potentiate insulin-induced hypoglycemia and delay recovery of serum glucose levels. There is a risk of worsening hyperglycemia in patients with congestive heart failure and diabetes.

In patients with pheochromocytoma, an alpha-blocker should be initiated prior to the use of any beta-blocking agent. Although carvedilol has both alpha and beta-blocking pharmacological activities, there has been no experience with its use in this condition. Therefore, caution should be taken in the administration of carvedilol to patients suspected of having pheochromocytoma.

Carvedilol may induce chest pain in patients with Prinzmetal's variant angina. Although the alpha-blocking activity may prevent such symptoms, there has been no clinical experience with carvedilol in these patients. However, carvedilol should be administered with caution in patients suspected of having Prinzmetal's variant angina.

Dialysis

Since carvedilol is not removed by hemodialysis, supplemental dosing after dialysis is not necessary. Because of the increased risk of hypotension, if doses are given too soon after dialysis sessions, it is recommended that carvedilol be given at some time after hemodialysis when this patient is hemodynamically stable.

Other Comments

Extended-release capsules should be taken once daily in the morning with food and should not be crushed, chewed, or taken in divided doses.

The extended-release formulation of carvedilol contains enteric-coated microparticles that are pH sensitive. Under conditions of increased gastric pH, the enteric coating may disintegrate faster and may alter the absorption of carvedilol. However, one small study reported that concomitant administration with a proton pump inhibitor did not significantly affect the pharmacokinetic profile of the extended-release formulation.

Compared with Caucasian patients, Black patients have a reduced blood pressure response to monotherapy with beta-blockers; however, the reduced response is largely eliminated if combination therapy that includes an adequate dose of a diuretic is instituted.

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