ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
ARB / HFrEF Pregnancy: Contraindicated in 2nd/3rd trimester — same fetopathy risk as ACEi. Stop immediately if pregnancy discovered.

Candesartan (HFrEF / ACEi Intolerance)

Brand names: Amias

Adult dose

Dose: HFrEF: 4 mg OD initially; titrate to 32 mg OD. Hypertension: 8 mg OD initially, target 16-32 mg OD.
Route: Oral
Frequency: Once daily
Max: 32 mg/day
Angiotensin receptor blocker (ARB). First-line alternative when ACEi not tolerated (cough or angioedema). CHARM-Alternative trial. Do not use ACEi + ARB + MRA triple combination (hyperkalaemia/renal failure).

Paediatric dose

Route: Oral
Seek specialist opinion — not licensed for HF in children

Dose adjustments

Renal

Start 4 mg OD in CKD; monitor renal function and K+ closely. Avoid bilateral renal artery stenosis. Expect 10-20% creatinine rise.

Hepatic

Start 4 mg OD in moderate impairment; contraindicated in severe

Clinical pearls

  • CHARM-Alternative trial (Granger et al. Lancet 2003): candesartan in HFrEF intolerant of ACEi — 23% relative risk reduction in CV death or HF hospitalisation. Established ARB as the ACEi alternative.
  • CHARM-Added: candesartan added to ACEi — further event reduction but increased renal impairment/hyperkalaemia. ACEi + ARB combination is now DISCOURAGED (ESC 2021) — sacubitril/valsartan has replaced this strategy.
  • No cough: ARBs do not inhibit ACE, so no bradykinin accumulation. ~0.1% angioedema risk (vs 0.1-0.5% with ACEi). If ACEi caused angioedema, wait 3-6 months before cautious ARB trial.
  • Dual RAAS blockade guideline update: ACEi + ARB is NOT recommended. ACEi + MRA (spironolactone/eplerenone) IS recommended with potassium monitoring.
  • Val-HeFT: valsartan in HFrEF — reduced HF hospitalisation. Candesartan and valsartan both licensed for HFrEF in UK.

Contraindications

  • Bilateral renal artery stenosis
  • Hyperkalaemia (K+ >5.5 mmol/L)
  • Severe hepatic impairment
  • Concomitant aliskiren in diabetes/CKD
  • Pregnancy (2nd/3rd trimester)

Side effects

  • Hyperkalaemia
  • Hypotension
  • Renal impairment (haemodynamic)
  • Dizziness
  • Angioedema (rare — ~0.1%; less than ACEi)
  • No cough (key advantage over ACEi)

Interactions

  • Potassium-sparing diuretics/ACEi/aliskiren — hyperkalaemia
  • NSAIDs — blunted antihypertensive effect + AKI risk
  • Lithium — increased toxicity

Monitoring

  • Blood pressure
  • eGFR and potassium (1 week, 1 month)
  • Fluid status
  • Angioedema symptoms

Reference: BNFc; BNF 90; CHARM-Alternative Trial (Granger et al. Lancet 2003); ESC HF Guidelines 2021; NICE NG106; SPC Amias. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Calculators
Pathways