Sacubitril/Valsartan

How it works

Sacubitril is metabolised to an active neprilysin inhibitor that increases natriuretic peptide levels, while valsartan blocks the angiotensin II type-1 receptor.

Prescribing in practice

• It must not be combined with an ACE inhibitor and must not be started until an adequate washout has elapsed after stopping one, owing to the risk of angioedema; it is also contraindicated in pregnancy and in those with prior ACE-inhibitor or ARB-related angioedema.
• It can cause hypotension, hyperkalaemia and renal impairment, so blood pressure, renal function and potassium need checking; avoid concomitant aliskiren in relevant patients.
• It can falsely lower measured BNP, so NT-proBNP is preferred for monitoring during treatment.

Monitoring

Monitor blood pressure, renal function and serum potassium, particularly after initiation and dose changes.

Counselling the patient

• Stop the medicine and seek urgent help if you develop swelling of the face, lips, tongue or throat.
• Rise slowly from sitting or lying as it can cause dizziness.
• Do not take this with another blood pressure tablet of the ACE inhibitor type, and tell clinicians you take it if you may be pregnant.

Evidence & guidelines

A large randomised outcome trial in heart failure with reduced ejection fraction showed reductions in cardiovascular death and hospitalisation versus enalapril, and it is recommended by NICE.