Entresto Special Precautions

Dual blockade of the Renin-Angiotensin-Aldosterone System (RAAS): Entresto must not be administered with an ACE inhibitor due to the risk of angioedema. Entresto must not be initiated until 36 hours after taking the last dose of ACE inhibitor therapy. If treatment with Entresto is stopped, ACE inhibitor therapy must not be initiated until 36 hours after the last dose of Entresto (see Contraindications, Dosage & Administration, and Interactions).
Caution is required while co-administering Entresto with direct renin inhibitors such as aliskiren (see Contraindications and Interactions). Entresto must not be administered with aliskiren-containing products in patients with diabetes mellitus or renal impairment (eGFR <60 ml/min/1.73 m²) (see Contraindications).
Entresto should not be co-administered with an ARB due to the angiotensin II receptor blocking activity of Entresto (see Dosage & Administration and Interactions).
Hypotension: Cases of symptomatic hypotension have been reported in patients treated with Entresto during clinical trials. If hypotension occurs, dose adjustment of diuretics, concomitant antihypertensive drugs, and treatment of other causes of hypotension (e.g. hypovolemia) should be considered. If hypotension persists despite such measures, the dosage of Entresto should be reduced or the product should be temporarily discontinued (see Dosage & Administration).
Permanent discontinuation of therapy is usually not required. Symptomatic hypotension is more likely to occur if the patient has been volume-depleted, e.g., by diuretic therapy, dietary salt restriction, diarrhea or vomiting. Sodium and/or volume depletion should be corrected before starting treatment with Entresto.
Renal impairment: As for any drug that acts on the renin-angiotensin-aldosterone system, use of Entresto may be associated with decreased renal function. In PARADIGM-HF, associated treatment discontinuation was observed less frequently in patients receiving Entresto (0.65%) compared to enalapril (1.28%).
In patients whose renal function depends upon the activity of the renin-angiotensin-aldosterone system (e.g., patients with severe congestive heart failure), treatment with ACE inhibitors and angiotensin receptor antagonists has been associated with oliguria, progressive azotemia and, rarely, acute renal failure and death. Closely monitor serum creatinine, and down-titrate or interrupt Entresto in patients who develop a clinically significant decrease in renal function. Caution should be exercised when administering Entresto in patients with severe renal impairment (see Dosage & Administration, Contraindications and Pharmacology under Actions).
Hyperkalaemia: As for any drug that acts on the renin-angiotensin-aldosterone system, use of Entresto may be associated with an increased risk of hyperkalemia. In PARADIGM-HF, hyperkalemia resulted in treatment discontinuation in 0.26% of Entresto treated patients compared to 0.35% of enalapril treated patients. Medications known to raise potassium levels (e.g. potassium-sparing diuretics, potassium supplements) should be used with caution when co-administered with Entresto. If clinically significant hyperkalemia occurs, measures such as reducing dietary potassium, or adjusting the dose of concomitant medications should be considered. Dosage reduction or interruption of Entresto may be required. Monitoring of serum potassium is recommended especially in patients with risk factors such as severe renal impairment, diabetes mellitus, hypoaldosteronism or receiving a high potassium diet (see Dosage & Administration).
Angioedema: Angioedema has been reported in patients treated with Entresto. If angioedema occurs, Entresto should be immediately discontinued and appropriate therapy and monitoring should be provided until complete and sustained resolution of signs and symptoms has occurred. Entresto must not be re-administered. In cases of confirmed angioedema where swelling has been confined to the face and lips, the condition has generally resolved without treatment, although antihistamines have been useful in relieving symptoms.
Angioedema associated with laryngeal edema may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, appropriate therapy, e.g., subcutaneous epinephrine/adrenaline solution 1:1000 (0.3 mL-0.5 mL), and/or measures necessary to ensure a patent airway, should be promptly administered.
Patients with a prior history of angioedema were not studied. As they may be at higher risk for angioedema, caution is recommended if Entresto is used in these patients. Entresto must not be used in patients with a known history of angioedema related to previous ACE inhibitor or ARB therapy or in patients with a history of hereditary or idiopathic angioedema (see Contraindications).
Black patients may have increased susceptibility to develop angioedema .
Patients with renal artery stenosis: Similar to other drugs that affect the renin-angiotensin-aldosterone system, Entresto may increase blood urea and serum creatinine levels in patients with bilateral or unilateral renal artery stenosis. Caution is required in patients with renal artery stenosis and monitoring of renal function is recommended.