ARB / HFrEF Pregnancy: Not recommended in the first trimester; contraindicated in the second and third trimesters (fetotoxicity: decreased renal function, oligohydramnios, skull ossification retardation; neonatal renal failure, hypotension, hyperkalaemia). Not recommended during breastfeeding.

Candesartan (HFrEF / ACEi Intolerance)

Brand names: Amias

Used in: Hypertension

Candesartan is an angiotensin-II receptor blocker (ARB) used for hypertension and for heart failure with reduced ejection fraction, including where an ACE inhibitor is not tolerated (e.g. because of cough).

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 4 mg once daily initially, up-titrated to target 32 mg once daily (or highest tolerated dose)

Route: Oral

Frequency: once daily

Max: 32 mg once daily

Heart failure: usual recommended initial dose 4 mg once daily; up-titration to target 32 mg once daily (maximum) or highest tolerated dose by doubling the dose at intervals of at least 2 weeks. Evaluation should always include assessment of renal function with monitoring of serum creatinine and potassium. Can be given with other heart failure treatment (ACE inhibitors, beta-blockers, diuretics, digitalis). May be co-administered with an ACE inhibitor in symptomatic heart failure despite optimal standard therapy when mineralocorticoid receptor antagonists are not tolerated; triple combination of ACE inhibitor + MRA + candesartan is not recommended. (Hypertension indication: initial and usual maintenance 8 mg once daily, up to a maximum of 32 mg once daily.)

Dose adjustments

Renal

In heart failure no initial dose adjustment is necessary for renal impairment, but renal function, serum creatinine and potassium must be monitored, especially in the elderly (≥75 years). Trials excluded serum creatinine >265 micromol/L (>3 mg/dl).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

Starting Dose Target Dose Adult Hypertension (2.1) 16 mg tablet once daily 8 to 32 mg tablet total daily dose Pediatric Hypertension (1 to ˂6 years) (2.2) 0.2 mg/kg oral suspension once daily 0.05 to 0.4 mg/kg oral suspension once daily or consider divided dose Pediatric Hypertension (6 to ˂17 years) (2.2) <50 kg 4 to 8 mg tablet once daily >50 kg 8 to 16 mg tablet once daily <50 kg 4 to 16 mg tablet once daily or consider divided dose >50 kg 4 to 32 mg tablet once daily or consider divided dose Adult Heart Failure (2.3) 4 mg tablet once daily 1 The target dose is 32 mg once daily, which is achieved by doubling the dose at approximately 2-week intervals, as tolerated by patient 2.1 Adult …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2021-10-04. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Second and third trimester of pregnancy
Severe hepatic impairment and/or cholestasis
Children aged below 1 year
Concomitant use with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR <60 ml/min/1.73 m2)

Side effects

Respiratory infection (common)
Dizziness / vertigo (common)
Headache (common)
Hyperkalaemia and hyponatraemia (very rare)
Renal impairment including renal failure in susceptible patients (very rare); angioedema (very rare)

Interactions

Aliskiren-containing products — contraindicated in diabetes mellitus or renal impairment (GFR <60)
ACE inhibitors — combination increases risk of hypotension, hyperkalaemia and decreased renal function; specialist supervision and close monitoring required; not to be used concomitantly in diabetic nephropathy
Triple combination with a mineralocorticoid receptor antagonist plus an ACE inhibitor — not recommended

Clinical monograph

How it works

Candesartan selectively blocks the angiotensin-II type-1 receptor, producing vasodilatation and reduced aldosterone effect without the rise in bradykinin that causes ACE-inhibitor cough.

Prescribing in practice

Start low and titrate; check renal function and potassium before starting and after initiation or dose increase.
Avoid in pregnancy and in bilateral renal artery stenosis; use caution with potassium-raising drugs and NSAIDs.
Do not routinely combine an ARB with an ACE inhibitor because of renal and hyperkalaemia risk.

Monitoring

Monitor U&E (renal function and potassium) at baseline, after initiation and titration, and periodically; monitor blood pressure and heart-failure status.

Counselling the patient

Report dizziness, especially after the first doses or dose increases.
Avoid potassium-based salt substitutes, and tell your prescriber if you become pregnant or unwell with vomiting or diarrhoea.

Evidence & guidelines

ARBs are an alternative to ACE inhibitors for hypertension and HFrEF (e.g. CHARM programme for candesartan in heart failure); first-line where ACE-inhibitor cough is limiting, per NICE NG136/NG106.

Reference: CHARM-Alternative Trial (Granger et al. Lancet 2003); ESC HF Guidelines 2021; NICE NG106; SPC Amias; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways