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Initiating sacubitril/valsartan (LCZ696) in heart failure: results of TITRATION, a double?blind, randomized comparison of two uptitration regimens #MMPMID27170530
Eur J Heart Fail 2016[Sep]; 18 (9): 1193-202 PMID27170530show ga
Aims: To assess the tolerability of initiating/uptitrating sacubitril/valsartan (LCZ696) from 50 to 200 mg twice daily (target dose) over 3 and 6 weeks in heart failure (HF) patients (ejection fraction ?35%). Methods and results: A 5?day open?label run?in (sacubitril/valsartan 50 mg twice daily) preceded an 11?week, double?blind, randomization period [100 mg twice daily for 2 weeks followed by 200 mg twice daily (?condensed? regimen) vs. 50 mg twice daily for 2 weeks, 100 mg twice daily for 3 weeks, followed by 200 mg twice daily (?conservative? regimen)]. Patients were stratified by pre?study dose of angiotensin?converting enzyme inhibitor/angiotensin?receptor blocker (ACEI/ARB; low?dose stratum included ACEI/ARB?naďve patients). Of 540 patients entering run?in, 498 (92%) were randomized and 429 (86.1% of randomized) completed the study. Pre?defined tolerability criteria were hypotension, renal dysfunction and hyperkalaemia; and adjudicated angioedema, which occurred in (?condensed? vs. ?conservative?) 9.7% vs. 8.4% (P = 0.570), 7.3% vs. 7.6% (P = 0.990), 7.7% vs. 4.4% (P = 0.114), and 0.0% vs. 0.8% of patients, respectively. Corresponding proportions for pre?defined systolic blood pressure <95 mmHg, serum potassium >5.5 mmol/L, and serum creatinine >3.0 mg/dL were 8.9% vs. 5.2% (P = 0.102), 7.3% vs. 4.0% (P = 0.097), and 0.4% vs. 0%, respectively. In total, 378 (76%) patients achieved and maintained sacubitril/valsartan 200 mg twice daily without dose interruption/down?titration over 12 weeks (77.8% vs. 84.3% for ?condensed? vs. ?conservative?; P = 0.078). Rates by ACEI/ARB pre?study dose stratification were 82.6% vs. 83.8% (P = 0.783) for high?dose/?condensed? vs. high?dose/?conservative? and 84.9% vs. 73.6% (P = 0.030) for low?dose/?conservative? vs. low?dose/?condensed?. Conclusions: Initiation/uptitration of sacubitril/valsartan from 50 to 200 mg twice daily over 3 or 6 weeks had a tolerability profile in line with other HF treatments. More gradual initiation/uptitration maximized attainment of target dose in the low?dose ACEI/ARB group.