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Heart Failure Pregnancy: Contraindicated — reproductive toxicity in animal studies; effective contraception required; discontinue if pregnancy occurs

Vericiguat

Brand names: Verquvo

Adult dose

Dose: 2.5 mg once daily starting dose; titrate to 5 mg, then 10 mg once daily at 2-week intervals as tolerated
Route: Oral
Frequency: Once daily with food
Max: 10 mg once daily
Take with food — increases absorption. Target dose is 10 mg daily if tolerated. Titrate up slowly. Available as 2.5 mg, 5 mg, and 10 mg tablets.

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: N/A
Max: N/A
Not established in paediatrics; seek specialist paediatric cardiology opinion

Dose adjustments

Renal

No dose adjustment for eGFR above 15; not studied below eGFR 15 — use with caution

Hepatic

No dose adjustment in mild-moderate impairment; avoid in severe hepatic impairment (Child-Pugh C) — no data

Paediatric weight-based calculator

Not established in paediatrics; seek specialist paediatric cardiology opinion

Clinical pearls

  • Mechanism: soluble guanylate cyclase (sGC) stimulator — stimulates sGC both directly (independent of NO) and by sensitising sGC to endogenous NO; increases cGMP production → vasodilation + anti-fibrotic + positive lusitropy; fills therapeutic gap in HF patients with low NO bioavailability
  • VICTORIA trial (NEJM 2020): vericiguat + standard HF therapy vs placebo in HFrEF (EF below 45%) post-worsening HF event — significant 10% relative risk reduction in composite of CV death or HHF (hospitalisation for HF); NNT approximately 24 over 10 months
  • Distinct from sacubitril/valsartan and SGLT2 inhibitors — vericiguat is 4th pillar of HFrEF quadruple therapy for high-risk patients (recent hospitalisation for HF); fills a different mechanistic niche
  • MHRA 2022: licensed for symptomatic chronic HFrEF (LVEF below 45%) in adults stabilised after recent decompensation requiring IV therapy; NOT for de novo acute HF
  • NICE TA940 (2023): recommended as option for HFrEF in adults who have had a recent decompensation event requiring IV diuretics, when added to optimal standard therapy
  • BP monitoring critical: systolic under 90 mmHg contraindication — may need to reduce diuretic dose or ACE/ARB before initiating in borderline hypotensive patients

Contraindications

  • Concomitant use with other sGC stimulators (riociguat) or PDE5 inhibitors (sildenafil, tadalafil) — SEVERE HYPOTENSION risk
  • Severe hypotension (systolic below 90 mmHg) at initiation
  • Symptomatic hypotension
  • Pregnancy (reproductive toxicity)

Side effects

  • Hypotension (most common — dose-dependent)
  • Anaemia
  • Nausea
  • Dizziness
  • Headache

Interactions

  • PDE5 inhibitors (sildenafil, tadalafil, vardenafil) — ABSOLUTE CONTRAINDICATION — severe hypotension; same NO-cGMP pathway downstream from different points
  • Other sGC stimulators (riociguat) — contraindicated
  • Antihypertensives (additive hypotension — monitor BP)
  • Nitrates (additive hypotension — caution; short-acting nitrates for breakthrough angina acceptable with BP monitoring)

Monitoring

  • Blood pressure at initiation and after each dose titration
  • Haemoglobin (anaemia reported in trials)
  • Symptoms of hypotension (dizziness, presyncope)
  • Renal function and electrolytes

Reference: BNFc; BNF 90; VICTORIA trial NEJM 2020;382(20):1883-1893; NICE TA940; MHRA 2022; ESC HF Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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