OK (Use freely) | Renally dose | Use with caution | Case-dependent | Contraindicated | Not enough data |
Class I pillars of HFrEF GDMT
across the span of kidney disease
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
---|---|---|---|---|---|---|---|---|
ACEI | Lisinopril | Renally-dose
FDA: For eGFR < 10 or on dialysis, start with initial dose of 2.5mg daily
|
Renally-dose
FDA: For eGFR 10-30, reduce lisinopril to half the usual recommended dose
|
OK | OK | OK | OK | Contraindicated
KDIGO: Temporarily discontinue in AKI
|
ARB | Losartan | OK | OK | OK | OK | OK | OK | Contraindicated
KDIGO: Temporarily discontinue in AKI
|
ARNI | Sacubitril-valsartan | Not enough data
?
|
Renally-dose
ACC: In eGFR < 30, reduce starting dose to 24/26 mg twice daily; double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
|
Renally-dose
ACC: In eGFR < 30, reduce starting dose to 24/26 mg twice daily; double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
|
OK | OK | OK | Contraindicated
KDIGO: Temporarily discontinue in AKI
|
BBs | Metoprolol | OK | OK | OK | OK | OK | OK | OK |
Carvedilol | OK | OK | OK | OK | OK | OK | OK | |
Bisoprolol | OK | Renally-dose
FDA: If eGFR < 40, start with 2.5mg daily dose
|
Renally-dose
FDA: If eGFR < 40, start with 2.5mg daily dose
|
Renally-dose
FDA: If eGFR < 40, start with 2.5mg daily dose
|
OK | OK | OK | |
Loop diuretics | Furosemide | Case-Dependent
Diuretics should be stopped when urine output becomes negligible
|
OK | OK | OK | OK | OK | Case-Dependent
KDIGO: We recommend not using diuretics to prevent AKI. We suggest not using diuretics to treat AKI, except in the management of volume overload. |
Torsemide | Case-Dependent
Diuretics should be stopped when urine output becomes negligible
|
OK | OK | OK | OK | OK | Case-Dependent
KDIGO: We recommend not using diuretics to prevent AKI. We suggest not using diuretics to treat AKI, except in the management of volume overload. |
|
Bumetanide | Case-Dependent
Diuretics should be stopped when urine output becomes negligible
|
OK | OK | OK | OK | OK | Case-Dependent
KDIGO: We recommend not using diuretics to prevent AKI. We suggest not using diuretics to treat AKI, except in the management of volume overload. |
|
MRA | Spironolactone | Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Renally dose
AHA/ACC/HFSA: For eGFR 31 to 49, dosing should be reduced by half.
|
OK | OK | Contraindicated
?
|
Eplerenone | Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Renally dose
AHA/ACC/HFSA: For eGFR 31 to 49, dosing should be reduced by half.
|
OK | OK | Contraindicated
?
|
|
Finerenone | Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation
|
Contraindicated
AHA/ACC/HFSA: eGFR ≤ 30 or serum potassium ≥ 5.0 are contraindications to MRA initiation. FIDELIO showed eGFR down to 25 was safe. |
Renally dose
AHA/ACC/HFSA: For eGFR 25 to < 60, dosing should be reduced by half.
|
Renally dose
AHA/ACC/HFSA: For eGFR 25 to < 60, dosing should be reduced by half.
|
OK | Contraindicated
?
|
|
SGLT2i | Dapagliflozin | Contraindicated
ACC & KDIGO: SGLT2i are contraindicated in dialysis
|
Caution
KDIGO: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20, unless it is not tolerated or kidney replacement therapy is initiated.
|
Caution
KDIGO: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20, unless it is not tolerated or kidney replacement therapy is initiated.
|
OK | OK | OK | Caution
ACC: Consider temporarily discontinuing in settings of reduced oral intake or fluid losses
|
Empagliflozin | Contraindicated
ACC & KDIGO: SGLT2i are contraindicated in dialysis
|
Caution
KDIGO: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20, unless it is not tolerated or kidney replacement therapy is initiated.
|
Caution
KDIGO: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20, unless it is not tolerated or kidney replacement therapy is initiated.
|
OK | OK | OK | Caution
ACC: Consider temporarily discontinuing in settings of reduced oral intake or fluid losses
|
|
Nitrate | Isosorbide mononitrate | OK | OK | OK | OK | OK | OK | OK |
Isosorbide dinitrate | OK | OK | OK | OK | OK | OK | OK | |
Vasodilator | Hydralazine | OK | OK | OK | OK | OK | OK | OK |
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
Class II "additional therapies" for HFrEF GDMT after core GDMT has been optimized
across the span of kidney disease
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
---|---|---|---|---|---|---|---|---|
IKi | Ivabradine | Not enough data | Not enough data | OK | OK | OK | OK | Not enough data |
sGC stimulator | Vericiguat | Not enough data
VICTORIA excluded patients on dialysis
|
Not enough data
VICTORIA excluded patients with eGFR < 15
|
OK | OK | OK | OK | OK |
Chronotropes | Digoxin | Caution
No RCTs, but observational studies suggest digoxin is associated with increased mortality in ESKD
|
Caution
Careful dose adjustments may be needed with renal function
|
Caution
Careful dose adjustments may be needed with renal function
|
Caution
Careful dose adjustments may be needed with renal function
|
Caution
Careful dose adjustments may be needed with renal function
|
Caution
Careful dose adjustments may be needed with renal function
|
Contraindicated
KDIGO: Discontinue digoxin if risk of AKI
|
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
Medications that are not strictly defined as part of HFrEF GDMT but are commonly used in HFrEF
across the span of kidney disease
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
---|---|---|---|---|---|---|---|---|
Statins | Rosuvastatin | Renally dose
KDIGO: Use 10mg in CKD 3-5 and dialysis
|
Renally dose
KDIGO: Use 10mg in CKD 3-5 and dialysis
|
Renally dose
KDIGO: Use 10mg in CKD 3-5 and dialysis
|
OK | OK | OK | OK |
Atorvastatin | OK | OK | OK | OK | OK | OK | OK | |
Simvastatin | OK | OK | OK | OK | OK | OK | OK | |
Pravastatin | OK | OK | OK | OK | OK | OK | OK | |
Fluvastatin | OK | OK | OK | OK | OK | OK | OK | |
Thiazides | HCTZ | Not enough data | Not enough data | Not enough data | OK | OK | OK | Case-dependent
KDIGO: We recommend not using diuretics to prevent AKI. (1B) We suggest not using diuretics to treat AKI, except in the management of volume overload. (2C) AHA:Diuretics should be prescribed to patients who have evidence of congestion or fluid retention. In any patient with a history of congestion, maintenance diuretics should be considered to avoid recurrent symptoms. The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia. |
Chlorthalidone | Not enough data | OK | OK | OK | OK | OK | Case-dependent
KDIGO: We recommend not using diuretics to prevent AKI. (1B) We suggest not using diuretics to treat AKI, except in the management of volume overload. (2C) AHA:Diuretics should be prescribed to patients who have evidence of congestion or fluid retention. In any patient with a history of congestion, maintenance diuretics should be considered to avoid recurrent symptoms. The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia. |
|
Class | Medication | ESKD | CKD 5 | CKD 4 | CKD 3B | CKD 3A | CKD 1-2 | AKI |
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© Jiun-Ruey Hu, MD, MPH & Jiawei Tan, MD (2022)