Soluble guanylate cyclase stimulator (vericiguat)
AMT in HFrEF · Class IIbRemoval by dialysis
What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.
- VericiguatNot removed (or not meaningfully removed)
“VERQUVO is unlikely to be removed by hemodialysis because of high protein binding.”
“VERQUVO has not been studied in patients with eGFR <15 mL/min/1.73m2 at treatment initiation or on dialysis”
Drugs and doses
| Drug | Brands | Start | Target | Kidney dosing |
|---|---|---|---|---|
| Vericiguat | Verquvo | 2.5 mg o.d. with food per ESC 2026/VICTORIA; FDA (01/2026) and EMA labels now start at 5 mg o.d., 2.5 mg o.d. if at risk of symptomatic hypotension | 10 mg o.d. (double approximately every 2 weeks as tolerated) | No dose adjustment for eGFR ≥15 not on dialysis; not studied (FDA) / not recommended (EMA) at eGFR <15 at initiation or on dialysis. |
Status by kidney stage
| Stage | Initiate | Continue |
|---|---|---|
| G1 | Allowed ESC 2026 Class IIb (LVEF <45% despite optimal FMT); FDA-labelled after a worsening-HF event; no kidney restriction. | Allowed Continue at highest tolerated dose; no kidney-related adjustment. |
| G2 | Allowed As G1; no dose adjustment. | Allowed As G1. |
| G3a | Allowed ESC CVD–CKD Class IIb for eGFR ≥30; label: no adjustment. | Allowed Continue; no adjustment. |
| G3b | Allowed ESC CVD–CKD Class IIb for eGFR ≥30; label: no adjustment. | Allowed Continue; no adjustment. |
| G4 | Use with caution Label permits without dose change (eGFR ≥15), but ESC CVD–CKD makes no recommendation below 30 and the pooled VICTOR/VICTORIA HR for eGFR 15–30 was >1.0. | Use with caution May be continued (label), but benefit below eGFR 30 is uncertain; reassess. |
| G5 | Not recommended Not studied at eGFR <15 (FDA); EMA: not recommended. | No data Labels address eGFR <15 at treatment initiation; no statement on continuing when eGFR falls below 15 (not on dialysis). |
| dialysis | Not recommended EMA: not recommended on dialysis; FDA: not studied; unlikely to be dialysed (98% protein bound). | Not recommended EMA wording covers patients on dialysis; no data. |
| aki | No data No AKI-specific statement. Labels require stabilisation/volume optimisation and SBP ≥100 before starting. | No data No AKI-specific statement; VICTORIA showed benefit irrespective of worsening renal function (creatinine rise ≥0.3 mg/dL); reduce/hold if SBP <90 or symptomatic hypotension. |
| transplant | No data No kidney-transplant-specific statement found. | No data No kidney-transplant-specific statement found. |
Cutoffs recorded from the sources
- sbp < 100 mmHg → not-recommended (initiate; vericiguat)“Treatment should not be initiated in patients with SBP <100 mmHg (see section 4.4).” — ema-vericiguat, SmPC 4.2 Posology, p. 3
- sbp < 90 mmHg → temporary down-titration or discontinuation (dose_reduce; vericiguat)“If patients experience tolerability issues (symptomatic hypotension or systolic blood pressure [SBP] less than 90 mmHg), temporary down-titration or discontinuation of vericiguat is recommended” — ema-vericiguat, SmPC 4.2 Posology, p. 3
- egfr < 15 mL/min/1.73m2 → not-recommended (initiate; vericiguat)“Patients with eGFR <15 mL/min/1.73 m2 at treatment initiation or on dialysis have not been studied, therefore treatment with vericiguat is not recommended in these patients” — ema-vericiguat, SmPC 4.4 Renal impairment, p. 4
- egfr < 30 mL/min/1.73m2 → caution (initiate; vericiguat)“Vericiguat may be considered in patients with eGFR ≥30 mL/min/1.73 m2 to reduce the risk of cardiovascular death and HF hospitalization,347,349,350 but there is insufficient certainty about effects of vericiguat in patients with eGFR <30 mL/min/1.73 m2 to make a formal recommendation.” — esc2026-ckd, p. 37
- other >= 45 % → not indicated (initiate; vericiguat)“The oral soluble guanylate cyclase stimulator vericiguat may be considered in patients with symptomatic HFrEF and LVEF <45% despite optimal FMT.” — esc2026, p. 34
Trial evidence (informational)
- VICTORIA · HFrEF LVEF <45% after worsening HF event, eGFR ≥15, SBP ≥100CV death or HF hospitalisation: HR 0.90 (95% CI 0.82–0.98)“In VICTORIA, VERQUVO was superior to placebo in reducing the risk of CV death or heart failure hospitalization based on a time-to-event analysis (hazard ratio [HR]: 0.90, 95% confidence interval [CI], 0.82-0.98; p=0.019).” — fda-vericiguat, Section 14 Clinical Studies
- VICTORIA (NT-proBNP highest quartile) · highest baseline NT-proBNP quartileCV death; HF hospitalisation: HR 1.16 and 1.19 (unfavourable)“However, among patients in the highest baseline NT-proBNP quartile, the estimated HRs for both CV death (HR: 1.16; 95% CI: [0.95, 1.43]) and first HF hospitalization (HR:1.19; 95%CI: [0.9,1.44]) were unfavorable, in contrast to the estimated HRs for patients in the three quartiles with lower NT-proBNP levels.” — fda-vericiguat, Section 14 Clinical Studies
- VICTOR · ambulatory HFrEF LVEF ≤40% without recent WHFCV death; HF hospitalisation: CV death HR 0.83 (0.71–0.97); HFH HR 0.95 (0.82–1.10); primary composite neutral HR 0.93“Over a median follow-up of ∼18.5 months, CV death was numerically lower with vericiguat (9.6% vs 11.3%; HR 0.83; 95% CI 0.71–0.97), whereas HFH was similar between groups (11.4% vs 11.9%; HR 0.95; 95% CI 0.82–1.10).” — esc2026, p. 34
- VICTOR + VICTORIA IPD meta-analysis · pooled HFrEFCV death or HF hospitalisation: HR 0.91 (95% CI 0.85–0.98)“In an individual patient data meta-analysis of VICTOR and VICTORIA, vericiguat reduced the composite of cardiovascular death or HF hospitalization (HR 0.91, 95% CI 0.85–0.98), with consistent effects on both components and all-cause mortality.” — esc2026-ckd, p. 37
Acute kidney injury
No source addresses vericiguat in AKI. In VICTORIA, eGFR trajectories matched placebo and benefit was consistent irrespective of worsening renal function; hypotension (SBP <90) should prompt down-titration.
“Renal function trajectories were similar between vericiguat‐ and placebo‐treated patients and the beneficial effects of vericiguat on the primary outcome were consistent across the full range of eGFR and irrespective of WRF.”
Voors AA, et al. Renal function and the effects of vericiguat in patients with worsening heart failure with reduced ejection fraction: insights from VICTORIA. Eur J Heart Fail 2021 (PMC8453520) (2021)· Abstract, Conclusion Source“In patients with CKD stage 4 included in VICTORIA, vericiguat showed no excess of adverse events compared with placebo.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 15 Source
Dialysis
Not studied; EMA says not recommended on dialysis; high protein binding means it is unlikely to be removed by haemodialysis.
“Patients with eGFR <15 mL/min/1.73 m2 at treatment initiation or on dialysis have not been studied, therefore treatment with vericiguat is not recommended in these patients”
Verquvo (vericiguat) EPAR product information (SmPC), Bayer AG (2026)· SmPC 4.4 Renal impairment, p. 4 Source“VERQUVO is unlikely to be removed by hemodialysis because of high protein binding.”
“Patients with eGFR <15 mL/min/1.73 m2 at treatment initiation or on dialysis have not been studied, therefore treatment with vericiguat is not recommended in these patients”
“VERQUVO has not been studied in patients with eGFR <15 mL/min/1.73m2 at treatment initiation or on dialysis”
“but there is insufficient certainty about effects of vericiguat in patients with eGFR <30 mL/min/1.73 m2 to make a formal recommendation.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 37, Section 6.2.2.1.6 Source
Kidney transplant
No kidney-transplant-specific statement found.
No verbatim statement found for this cell.
Albuminuria
No source differentiates vericiguat use by albuminuria category.
No verbatim statement found for this cell.
Monitoring
Check pregnancy status before start; monitor BP/symptomatic hypotension at each titration (2-weekly); anaemia is a common adverse reaction; avoid PDE-5 inhibitors; contraindicated with other sGC stimulators.
“Obtain a pregnancy test in females of reproductive potential prior to initiating treatment with VERQUVO”
“Most common adverse reactions reported in ≥5% are hypotension and anemia.”
“Concomitant use of VERQUVO with PDE-5 inhibitors is not recommended because of the potential for hypotension”
In-hospital initiation
Labelled population is post-worsening-HF; EMA requires stabilisation and volume optimisation after the decompensation before starting. Reasonable to start at/after discharge once SBP ≥100.
“Verquvo is indicated for the treatment of symptomatic chronic heart failure in adult patients with reduced ejection fraction who are stabilised after a recent decompensation event requiring IV therapy”
“Before starting vericiguat, care should be taken to optimise volume status and diuretic therapy to stabilise patients after the decompensation event, particularly in patients with very high NT-proBNP levels”
Verquvo (vericiguat) EPAR product information (SmPC), Bayer AG (2026)· SmPC 4.2 Posology, p. 3 Source
Outpatient
ESC 2026 broadened the population to stable ambulatory HFrEF (LVEF <45%) despite optimal FMT, although VICTOR (no recent WHF) was neutral on its primary endpoint.
“The VICTOR study evaluated vericiguat in ambulatory patients with HFrEF (LVEF ≤40%) who did not have a recent WHF event and who were on contemporary FMT.”
“VICTOR was neutral for the primary composite endpoint of time to CV death or HFH (HR 0.93; 95% CI 0.83–1.04; P = .22).”
Where sources disagree
Starting dose (2.5 mg vs 5 mg)
“The recommended starting dose of VERQUVO is 5 mg orally once daily with food.”
“For patients at risk of symptomatic hypotension, the recommended starting dose is 2.5 mg orally once daily with food”
“For patients with symptomatic hypotension within the past 4 weeks, the recommended starting dose is 2.5 mg vericiguat once daily.”
Verquvo (vericiguat) EPAR product information (SmPC), Bayer AG (2026)· SmPC 4.2 Posology, p. 3 Source“Vericiguat 2.5 mg o.d. 10 mg o.d.”
“Vericiguat 2.5 mg daily 10 mg daily”
Tool uses fda-vericiguat: Label > guideline; the 01/2026 FDA label (VELOCITY) and EMA SmPC start at 5 mg, 2.5 mg if hypotension risk. ESC/ACC tables reflect the VICTORIA 2.5 mg start.
Lower eGFR limit (label ≥15 vs ESC CVD–CKD ≥30)
“No dosage adjustment of VERQUVO is recommended in patients with estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73m2 who are not on dialysis.”
“There were consistent effects on the outcome of cardiovascular death or hospitalization for HF down to a eGFR 30 mL/min/1.73 m2, but the HR for the eGFR 15–30 mL/min/1.73 m2 subgroup was >1.0.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 37 Source“Vericiguat, when adopted in international guidelines, can be used in patients with HFrEF with severe CKD stage 4, because VICTORIA included patients with eGFR 15 mL/min/1.73 m2 or greater.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 15 Source
Tool uses fda-vericiguat: Label permits use at eGFR 15–29, but the newer pooled data and ESC CVD–CKD justify 'caution' rather than 'allowed' in G4 (conservative rule).
Eligible population (worsening-HF event required?)
“The oral soluble guanylate cyclase stimulator vericiguat may be considered in patients with symptomatic HFrEF and LVEF <45% despite optimal FMT.”
“VERQUVO is a soluble guanylate cyclase (sGC) stimulator, indicated to reduce the risk of cardiovascular death and heart failure (HF) hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics, in adults with symptomatic chronic HF and ejection fraction less than 45%.”
“In selected high-risk patients with HFrEF and recent worsening of HF already on GDMT, an oral soluble guanylate cyclase stimulator (vericiguat) may be considered to reduce HF hospitalization and cardiovascular death”
Tool uses esc2026: ESC-centric eligibility per brief; show that the FDA/EMA indication and AHA 2022 require a recent worsening-HF event (label indication is narrower).
Open questions
- Map ESC Class IIb to 'allowed' (current choice) or treat FDA-indicated post-WHF use as 'recommended'?
- Default starting dose: FDA/EMA 5 mg (2.5 mg if hypotension risk) vs ESC Table 11 2.5 mg.
- G4 (eGFR 15–29): label allows, ESC CVD–CKD gives no recommendation and pooled HR >1; we chose 'caution'.