Royal Hospital for Children Glasgow – Carvedilol initiation and dose increase
Carvedilol is indicated for patients with Congestive heart failure (CHF), with systemic ventricular dysfunction secondary to cardiomyopathy or congenital heart disease.
In general it is commenced after establishment of therapy with diuretics, ACE inhibitors +/- digoxin (unless contraindicated or intolerant).
Carvedilol is a non-selective beta blocker with alpha blocking action. The beta blocker action reduces heart rate and cardiac contractility by blocking the action of catecholamines on the heart muscle, while the alpha blocking action causes peripheral dilatation by blocking the action of the catecholamines on the peripheral arteries and arterioles.
Asthma
Cardiogenic shock
Metabolic acidosis
Severe congestive heart failure unresponsive to diuretic and ACE inhibitor
2nd or 3rd degree AV block, Sick sinus syndrome
Hypotension
Marked bradycardia
Severe peripheral arterial disease
Uncontrolled heart failure
Phaeochromocytoma (Adrenal tumour)
Clinically significant hepatic dysfunction
Diabetes
1st-degree AV block
Obstructive airways disease (introduce cautiously)
Myasthenia gravis
Portal hypertension (risk of deterioration in liver function)
Psoriasis
Thyrotoxicosis (symptoms may be masked)
Carvedilol is not licensed in <18 years of age
Carvedilol is always initiated by a consultant cardiologist and supervised by a cardiac pharmacist.
|
Initial dose |
1st dose increase |
2nd dose increase |
3rd dose increase |
Dose |
50 micrograms/kg BD |
100 micrograms/kg BD |
200 micrograms/kg BD |
350 micrograms/kg BD |
Maximum dose |
3.125mg |
6.25mg |
12.5mg |
25mg |
Doses may be increased every two weeks. This requires a day-case admission for each dose increase. However, if adverse effects occur dose increases are made at longer intervals and by smaller increments.
Titrate to maximum tolerated dose. Tolerance is defined as maintaining an acceptable systolic blood pressure 30 minutes and one hour post dose.
Dizziness, hypotension, syncope, headache, bradycardia, abdominal discomfort/nausea/vomiting/diarrhoea, tiredness, dyspnoea, oedema, rash, dry eye, sleep disorders |
Initiation and dose increase of carvedilol requires inpatient monitoring as hypotension can occur, especially in children with heart failure receiving concurrent diuretic therapy and ACE inhibitors. Dose titration and close monitoring of blood pressure are therefore required.
Complete nursing and medical admission
Baseline Echo, ECG, U&Es and LFTs (D/W consultant cardiologist re: need to check bloods before dose increase).
Ensure baseline observations are within acceptable limits. This includes:
After dose administration check BP and HR
|
Notify medical staff/ANP:
|
Discharge criteria:
|
Carvedilol 3.125mg or 6.25mg tablets (various manufacturers)
BNFC March 2021
Starship NZ. (2020) Clinical guidelines: carvedilol - observations after first dose.
Leeds Children's Hospital (2018) Guidelines on the use of Carvedilol in Children
NPPG et al (2019) Carvedilol for heart failure
Shaddy R et al (2007) Carvedilol for children and adolescents with heart failure JAMA 298(10) 1171-1179
Last reviewed: 22 February 2022
Next review: 31 May 2023
Author(s): Donna Nelson
Version: 2
Approved By: Paediatric Cardiology