Carvedilol initiation and dose increase

GGC Paediatric Guidelines
NHS GGC

Objectives

Royal Hospital for Children Glasgow – Carvedilol initiation and dose increase

Indications

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.

Contra-indications

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

Cautions

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)

Dosing information

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.

Side effects

Dizziness, hypotension, syncope, headache, bradycardia, abdominal discomfort/nausea/vomiting/diarrhoea, tiredness, dyspnoea, oedema, rash, dry eye, sleep disorders

Monitoring

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:

  • Heart rate (HR)
  • Respiratory rate (RR)
  • Blood pressure (BP)
  • Oxygen saturations
  • Temperature

After dose administration check BP and HR

  • Every 30 minutes for at least 4 hours
  • Continue until stable

  Notify medical staff/ANP: 

  • if significant drop in systolic and mean BP (usually >20mmhg from base line)
  • if child is symptomatic  (e.g dizziness, pale, altered level of consciousness, profoundly hypotensive/bradycardic, tachycardic, capillary refill >3 seconds, cool peripheries)

Discharge criteria:

  • Observations within acceptable parameters for child
  • Child reviewed by Dr/ANP
  • Information given to family/carer re: medicine administration and clear instructions for the adjusted dose.
  • Family / Caregiver has demonstrated competence in drawing up appropriate (adjusted) dose of Carvedilol 
  • Family/carer aware of common side effects and know to contact cardiac nurse specialists if child experiencing these side effects.( Give family PDF of medicines information leaflet)
  • Discharge summary completed and given to family/carer with a follow up plan

Preparations

Carvedilol 3.125mg or 6.25mg tablets (various manufacturers)

Editorial Information

Last reviewed: 22/02/2022

Next review date: 31/05/2023

Author(s): Donna Nelson.

Version: 2

Approved By: Paediatric Cardiology