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Sacubitril with valsartan oral


Oral formulations of sacubitril with valsartan.

Drugs List

  • ENTRESTO 24mg+26mg film coated tablets
  • ENTRESTO 49mg+51mg film coated tablets
  • ENTRESTO 97mg+103mg film coated tablets
  • sacubitril 24mg and valsartan 26mg tablets
  • sacubitril 49mg and valsartan 51mg tablets
  • sacubitril 97mg and valsartan 103mg tablets
  • Therapeutic Indications


    Symptomatic chronic cardiac failure with reduced ejection fraction



    Starting dose is one 49mg/51mg tablet twice a day.
    The dose should be doubled at 2 to 4 weeks to the target dose of one 97mg/103mg tablet twice a day, as tolerated by the patient.

    If patients experience tolerability issues (systolic blood pressure (SBP) less than or equal to 95mmHg, symptomatic hypotension, hyperkalaemia and renal dysfunction), adjustment of concomitant medicinal products, temporary down titration or discontinuation of sacubitril with valsartan is recommended.

    Patients not currently taking an angiotensin converting enzyme inhibitor (ACE inhibitor) or an angiotensin II receptor blocker (ARB) or taking low doses of these medicinal products should have a starting dose of 24mg/26mg twice a day, doubling every 3 to 4 weeks.

    Treatment should not be initiated in patients with serum potassium level greater than 5.4mmol/l or with SBP less than 100mmHg. A starting dose of 24mg/26mg twice a day should be considered for patients with SBP greater or equal to 100mmHg to 110mmHg.

    Patients with Renal Impairment

    Moderate renal impairment (eGFR 30 to 60 ml/minute/1.73 metre squared)
    Starting dose of 24mg/26mg twice a day.

    Severe renal impairment (eGFR less than 30 ml/minute/1.73 metre squared)
    Starting dose of 24mg/26mg twice a day.

    Patients with Hepatic Impairment

    Moderate hepatic impairment or AST/ALT values more than twice the upper limit of the normal range
    Starting dose is 24mg/26mg twice a day.

    Additional Dosage Information

    If a dose is missed, the patient should take the next dose at the scheduled time.

    The valsartan contained within sacubitril with valsartan is more bioavailable than the valsartan in other marketed tablet formulations.


    Children under 18 years
    Hyperkalaemia where serum potassium over 5.4 mmol/l
    Systolic blood pressure below 100mmHg
    Within 36 hours of discontinuing an ACE inhibitor containing product
    Biliary cirrhosis
    End stage renal disease
    Hereditary angioneurotic oedema
    History of angioedema
    Idiopathic angioneurotic oedema
    Severe hepatic impairment

    Precautions and Warnings

    Aortic stenosis
    Bilateral renal artery stenosis
    Diabetes mellitus
    Elevated serum transaminases - greater than twice the upper limit of normal
    Hypertrophic obstructive cardiomyopathy
    Mitral stenosis
    Moderate hepatic impairment
    New York Heart Association class IV failure
    Renal impairment
    Unilateral stenosis of solitary functioning kidney

    Patients with primary aldosteronism may not benefit from this treatment
    Switch to more suitable alternative before planned pregnancy
    Advise ability to drive/operate machinery may be affected by side effects
    Correct volume and/or salt depletion before initiating therapy
    Evaluate renal function before and during treatment
    Monitor blood pressure
    Monitor serum potassium regularly
    Reduce dose or discontinue if excessive hypotension occurs
    Discontinue if psychiatric disturbances develop
    Higher incidence of angioedema in black patients
    Hypotension may occur during or after therapy
    Increased risk of hyperkalaemia with K+ suppl. and K+ sparing diuretic
    May affect results of some laboratory tests
    Discontinue if angioedema occurs
    Discontinue if hyperkalaemia occurs
    Pregnancy confirmed: Advise patient to discontinue and consult doctor
    Advise patient not to take NSAIDs unless advised by clinician
    Advise on problems of salt substitutes/high intake of potassium-rich food

    The combination of sacubitril with valsartan with direct renin inhibitors such as aliskiren is not recommended. The combination of sacubitril with valsartan with aliskiren containing products is contraindicated in patients with diabetes mellitus or in patients with renal impairment (eGFR less than 60 ml/minute/1.73 metre squared).

    Monitoring of angioedema should be provided until all signs and symptoms are resolved. Angioedema associated with laryngeal oedema may be fatal. Where there is involvement of the tongue, glottis or larynx likely to cause airway obstruction, appropriate therapy, e.g. adrenaline solution 1mg/1ml (0.3ml to 0.5ml), and/or measures necessary to ensure a patent airway, should be promptly administered.

    Down-titration should be considered in patients who develop a clinically significant decrease in renal function.

    Pregnancy and Lactation


    Sacubitril with valsartan is contraindicated during pregnancy.

    The manufacturer does not recommend using sacubitril with valsartan during pregnancy during the first trimester and is contraindicated during the second and third trimesters of pregnancy. At the time of writing there is limited published information regarding the use of sacubitril with valsartan during the first trimester of pregnancy, however a small risk cannot be excluded. Exposure during the second and third trimesters of pregnancy have shown teratogenic effects including human foetotoxicity and neonatal toxicity.

    Should exposure to sacubitril with valsartan occur from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended.


    Sacubitril with valsartan is contraindicated during breastfeeding.

    The manufacturer advises that the patient either discontinues sacubitril with valsartan or discontinues breastfeeding. Animal data reports sacubitril with valsartan is excreted into the breast milk, however presence in human breast milk is unknown.

    Side Effects

    Hypersensitivity reactions
    Orthostatic hypotension
    Renal failure
    Renal impairment
    Sleep disorders

    Effects on Laboratory Tests

    B-type natriuretic peptide (BNP)
    BNP is not a suitable biomarker of heart failure in patients treated with sacubitril and valsartan because it is a neprilysin substrate.


    It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

    The following number will direct the caller to the relevant local centre (0844) 892 0111

    Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( ) or if this is unavailable at the backup site ( ).

    Further Information

    Last Full Review Date: October 2019

    Reference Sources

    Summary of Product Characteristics: Entresto Film-coated tablets. Novartis Pharmaceuticals UK Ltd. Revised January 2021.

    NICE Evidence Services Available at: Last accessed: 10 October 2019

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