Carvedilol

Class
Adrenergic receptor blockers
Subclass
Non-cardioselective β-blockers
Substance name
Carvedilol
Brand names
Coreg®, Carvil®, Carloc®
Common formulations
Film-coated tablet
See also
Carvedilol ER (Coreg CR®)
Dosage and administration
Adults patients
Treatment
HF
Weight ≤ 85 kg
•
Start at: 3.125 mg PO BID for 2 weeks
•
Maintenance: 6.25-25 mg PO BID
•
Maximum: 50 mg per day
Consider doubling the dose every 2 weeks based on response and tolerance. Taken with meals.
Weight > 85 kg
•
Start at: 3.125 mg PO BID for 2 weeks
•
Maintenance: 6.25-25 mg PO BID
•
Maximum: 100 mg per day
Consider doubling the dose every 2 weeks based on response and tolerance. Taken with meals.
Hypertension
•
Start at: 6.25 mg PO BID for 1-2 weeks
•
Maintenance: 6.25-25 mg PO BID
•
Maximum: 50 mg per day
Consider doubling the dose every 1-2 weeks based on response and tolerance. Taken with meals.
LV dysfunction in patients with myocardial infarction • Ejection fraction ≤ 40%
•
Start at: 6.25 mg PO BID for 3-10 days
•
Maintenance: 25 mg PO BID
•
Maximum: 50 mg per day
Consider doubling the dose every 3-10 days based on response and tolerance. Consider starting at 3.125 BID and titrating slowly if clinically required. Taken with meals.
Alternative
•
Start at: 3.125 mg PO BID, started within 24 hours after myocardial infarction
•
Maintenance: 25-50 mg PO BID
Avoid β-blockers in patients with decompensated HF, cardiogenic shock, acute RV infarction, or bradyarrhythmias. Taken with meals.
AF • Rate control • Off-label
•
3.125-25 mg PO BID
Taken with meals.
Dilated cardiomyopathy • Off-label
•
3.125-25 mg PO BID
Taken with meals.
Liver cirrhosis • Compensated • Off-label
•
12.5-25 mg PO daily
Taken with meals.
Rosacea • Off-label
•
6.25 mg PO BID
Taken with meals.
Stable angina • Off-label
•
25-50 mg PO BID
Taken with meals.
Prevention
Prevention of variceal hemorrhage in patients with gastroesophageal varices • Off-label
•
Start at: 6.25 mg PO daily for 1 week
•
Maintenance: 12.5 mg PO daily
•
Maximum: 12.5 mg per day
Taken with meals.
Secondary prevention
Secondary prevention of variceal hemorrhage • Off-label
•
Start at: 6.25 mg PO daily for 1 week
•
Maintenance: 12.5 mg PO daily
Taken with meals.
Other off-label uses
•
Treatment of NSTEMI
Indications for use
Labeled indications
Adults
•
Treatment of HF
•
Treatment of hypertension
•
Treatment of LV dysfunction in patients with myocardial infarction (ejection fraction ≤ 40%)
Off-label indications
Adults
•
Treatment of AF (rate control)
•
Treatment of dilated cardiomyopathy
•
Treatment of liver cirrhosis (compensated)
•
Treatment of NSTEMI
•
Treatment of rosacea
•
Treatment of stable angina
•
Prevention of variceal hemorrhage in patients with gastroesophageal varices
•
Secondary prevention of variceal hemorrhage
Safety risks
Contraindications
Hypersensitivity to carvedilol or its components
Bronchospastic airway disease
Cardiogenic shock or decompensated HF
Severe bradycardia, second- or third-degree AV block, or sick sinus syndrome
Warnings and precautions
Angina pectoris
•
Use caution in patients with suspected vasospastic angina.
Angina pectoris, myocardial infarction, ventricular arrhythmia
•
Do not discontinue abruptly in patients taking the drug for a prolonged period.
Bradycardia, hypotension, renal failure
•
Maintain a high level of suspicion, as carvedilol has been associated with an increased risk for these adverse events. Reduce dose in case of bradycardia or renal function deterioration.
Exacerbation of arterial insufficiency
•
Use caution in patients with PAD.
Exacerbation of HF
•
Use caution when up-titrating carvedilol in patients with HF. Increase diuretic dose if HF worsens or fluid retention occurs. Do not advance carvedilol dose until clinical stability resumes.
Hypertensive crisis
•
Use caution in patients with untreated pheochromocytoma.
Increased blood glucose
•
Use caution in patients with diabetes.
Intraoperative floppy iris syndrome
•
Use caution in patients undergoing cataract surgery.
Mask symptoms of hyperthyroidism
•
Use caution in patients with thyroid disease.
Mask symptoms of hypoglycemia
•
Use caution in patients with diabetes.
Thyroid storm
•
Do not discontinue abruptly in patients with thyroid disease suspected of developing thyrotoxicosis.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required. Monitor renal function.
Renal replacement therapy
Any modality
•
Use acceptable. No dose adjustment required. Monitor renal function.
Hepatic impairment
Child-Pugh A (mild)
•
Use acceptable. No dose adjustment required.
Child-Pugh B (moderate)
•
Use acceptable. No dose adjustment required.
Child-Pugh C (severe)
•
Do not use.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in animals. Monitor neonates for hypotension, bradycardia, hypoglycemia and respiratory depression.
Breastfeeding
Use only if benefits outweigh potential risks.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
No overt adverse effects on lactation reported.
Adverse reactions
Very common > 10%
•
Bradycardia, hypotension, ↑ blood glucose, orthostatic hypotension, diarrhea, dizziness, dyspnea, fatigue, weight gain
Common 1-10%
•
AV block, anemia, ↓ WBC count, ↓ blood glucose, ↓ platelet count, ↓ prothrombin, ↓ serum potassium, ↓ serum sodium, erythema multiforme, gout, hypertension, hypotonia, ↑ liver enzymes, ↑ serum TBIL, ↑ serum cholesterol, ↑ serum potassium, ↑ serum triglycerides, ↑ serum uric acid, ↑ urine glucose, ↑ urine protein, peripheral edema, pharyngitis, pulmonary edema, purpura, abdominal pain, angina pectoris, arthralgia, asthenia, blurred vision, confusion, cough, depression, erectile dysfunction, fever, headache, hematuria, hypoesthesia, insomnia, malaise, melena, memory impairment, muscle cramps, nasal congestion, nausea, palpitations, paresthesia, somnolence, syncope, vertigo, visual disturbances, vomiting, weight loss, stroke, tachycardia, tardive dyskinesia
Uncommon < 1%
•
Bronchospasm, exfoliative dermatitis, gastrointestinal bleeding, gastroparesis, hyperhidrosis, maculopapular rash, myocardial infarction, neuropathic pain, pancytopenia, photosensitivity of skin, ↓ libido, dry mouth, emotional lability, hair loss, nightmares, pruritus, skin rash, tinnitus, urinary frequency, urinary frequency, tremor
Unknown frequency
•
Angioedema, aplastic anemia, heart failure, intraoperative floppy iris syndrome, jaundice, pancytopenia, pneumonitis, anxiety, urinary incontinence, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria, wheezing
Interactions
Drug(s)
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