Can Entresto be cut in half?

In this article:

• Can Entresto be cut in half?
• Understanding Entresto
• Dangers of tablet splitting
• Alternatives to pill splitting
• The bottom line

In this article

• Can Entresto be cut in half?
• Understanding Entresto
• Dangers of tablet splitting
• Alternatives to pill splitting
• The bottom line

Entresto is a prescription medication used to treat chronic heart failure in adults—a condition in which the heart can’t pump blood as efficiently as it should. Because it plays a key role in managing symptoms and reducing the risk of hospitalization, taking it correctly is essential.

Entresto comes as a film-coated oral tablet and as a capsule containing oral pellets known as Entresto Sprinkle. Unlike some medications, Entresto tablets are not designed to be split, crushed, or chewed. In fact, the manufacturer (Novartis Pharmaceuticals Corporation) and the Food and Drug Administration (FDA) recommend taking the tablet whole.

For people who are good candidates, healthcare providers may prescribe Entresto alongside other standard heart-failure treatments, such as beta blockers like carvedilol. If you have questions about dosing, side effects, cost, or whether your medication can be altered, it’s important to talk with your healthcare provider before making any changes.

Can you split Entresto tablets?

“Entresto tablets are not designed to be split, and doing so is generally not recommended unless specifically instructed by a provider or pharmacist,” says Eugene Lipov, MD, chief medical officer at Stella, a mental healthcare institute.

Dr. Lipov explains that splitting Entresto may not be ideal in many cases because: 

• The tablet does not have a score line to ensure accurate dosing.
• Splitting may lead to an uneven distribution of the two active ingredients.
• Inconsistent dosing can reduce effectiveness or increase side effects.

“With heart failure medications, dose accuracy matters. Even small variations can affect blood pressure, kidney function, and potassium levels,” he says.

Common side effects of Entresto include:

• Hypotension (low blood pressure)
• Hyperkalemia (high potassium levels)
• Dizziness
• Cough
• Changes in kidney function
• Serious side effects include:
• Angioedema (severe allergic reaction)
• Worsening kidney problems or kidney failure

Entresto also has a boxed warning for the potential to cause fetal harm and should be avoided by pregnant and breastfeeding individuals.

Entresto should be avoided by individuals taking the following medications due to potential drug interactions:

• Aliskiren
• Other ACE Inhibitors, such as lisinopril and enalapril
• Potassium-sparing diuretics, such as spironolactone
• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)
• Lithium

Understanding Entresto

Entresto belongs to a class of medications known as angiotensin receptor neprilysin inhibitors (ARNIs), which are designed to help the heart work more efficiently while reducing strain on the cardiovascular system.

The drug was initially approved to treat heart failure with reduced ejection fraction (HFrEF), sometimes called systolic heart failure, a condition in which the heart’s left ventricle becomes enlarged and can’t pump blood effectively. In 2021, the Food and Drug Administration (FDA) expanded Entresto’s approval to include cardiology patients with heart failure with preserved ejection fraction (HFpEF), a form of heart failure in which the left ventricle is stiff and unable to relax enough to fill properly, despite having normal pumping strength.

Entresto contains two active ingredients that work together:

• Sacubitril, which helps relax blood vessels and reduce fluid buildup
• Valsartan, an angiotensin II receptor blocker (ARB) that lowers blood pressure and decreases stress on the heart
  

“Together, these medications improve blood flow and reduce the workload on the heart,” says Dr. Lipov. Entresto is typically prescribed in place of an ARB or an angiotensin-converting enzyme inhibitor (ACE inhibitor) for high blood pressure, not alongside them.

Entresto tablets are available in three fixed-dose combinations:

• 24/26 mg tablets (24 mg sacubitril + 26 mg valsartan), also referred to as the 50 mg dose
• 49/51 mg tablets (49 mg sacubitril + 51 mg valsartan), also called the 100 mg dose
• 97/103 mg tablets (97 mg sacubitril + 103 mg valsartan), also known as the 200 mg dose

Your healthcare provider selects the recommended dose based on your condition, prior treatment, and how well you tolerate the medication. In case of a missed dose, take Entresto as soon as you remember, unless it’s closer to the time for your next dose.

Why pill splitting can be risky, and what to do instead

While some medications are designed to be split (often indicated by a score line), others, like Entresto, are not. Splitting tablets that aren’t intended to be cut can lead to several potential problems that affect safety and effectiveness.

• Uneven dosing: When a tablet isn’t scored, it’s difficult to divide it into equal halves. This can result in taking too much or too little medication, which may increase the risk of side effects such as low blood pressure, kidney problems, or reduced treatment effectiveness.
• Compromised stability and absorption: Cutting a tablet exposes its interior to air and moisture, which may cause the drug to degrade more quickly or absorb differently in the body. For tablets with special coatings, such as enteric coatings designed to protect the stomach or control where the drug dissolves, splitting can cause the medication to break down too early, altering how and when it works.
• Physical damage and waste: Tablets can crumble or shatter when split by hand, leading to lost medication and inconsistent dosing, especially without a proper pill splitter.

These risks stem from how tablets are designed and manufactured. During formulation, drug makers carefully combine active ingredients with inactive ones to ensure the medication remains stable, is absorbed properly, and delivers the intended dose. Some tablets are engineered to release medication slowly over time or dissolve only after reaching a specific part of the digestive tract. Altering the tablet by splitting it can disrupt these mechanisms, leading to unintended effects.

For these reasons, even tablets that appear suitable for splitting may not be safe to cut unless a healthcare provider or pharmacist confirms it’s appropriate.

If you’re taking a medication like Entresto, there are several reasons you might consider splitting a pill, such as:

Ease of swallowing

Difficulty swallowing pills is common, especially among older adults and people with certain medical conditions such as dysphagia. If swallowing tablets is challenging for you, you’re not alone, and you don’t need to split your medication to manage it.

For patients who can’t swallow tablets, the manufacturer offers Entresto Sprinkle, an alternative form of the medication. Entresto Sprinkle contains oral pellets inside a capsule that can be opened and sprinkled onto 1 to 2 teaspoonfuls of soft food, such as applesauce, and taken immediately. Because the dosing differs from the tablet form, your healthcare provider will need to adjust the dose accordingly.

In some cases, a pharmacist may also be able to prepare Entresto as a liquid oral suspension, providing another option for those who have difficulty swallowing pills.

Dosage adjustment

Some people consider splitting tablets to start on a lower dose or gradually increase their medication. However, dose titrations should never be made without seeking medical advice from a healthcare professional. Your provider can determine whether a different strength, formulation, or medication is more appropriate and ensure the dose is both safe and effective.

Reduce cost

Cost is another common reason people consider splitting their medication. Because tablets of different strengths are often priced similarly, some people attempt to stretch a higher-dose tablet by cutting it in half.

If the cost of Entresto is a concern, safer alternatives are available. You may be able to lower your out-of-pocket costs by using prescription discount cards like SingleCare, exploring manufacturer copay programs, or switching to mail-order or bulk pharmacy refills. Your healthcare provider can also help you explore more affordable treatment options that still meet your medical needs.

Alternatives to tablet splitting 

If your prescribed dose of Entresto feels too strong or difficult to tolerate, the safest option is to discuss this with your healthcare provider, rather than splitting the tablet. Your provider may adjust your dose, switch you to a different formulation, recommend a pharmacy-compounded liquid, or evaluate other heart failure treatments if side effects are a concern.

Patients should never adjust heart failure medication on their own, says Dr. Lipov. Dose changes should always be supervised.

If cost is the main reason you’re considering tablet splitting, there are other options to explore. Prescription discount programs, such as SingleCare, and manufacturer copay cards may significantly reduce monthly costs, sometimes to as little as $10 per month for eligible patients.

However, these programs typically apply only to people with commercial insurance. “Patients on Medicare are not eligible for manufacturer copay cards, and there is currently no patient assistance program for Entresto,” explains William Fryfogle, Pharm.D., a clinical pharmacy specialist at University Hospitals in Cleveland, Ohio.

For Medicare beneficiaries taking multiple high-cost medications, Dr. Fryfogle notes that enrolling in the Medicare prescription payment plan through a Part D plan may help spread out copays over the year. This option is most helpful for individuals who anticipate exceeding the annual out-of-pocket maximum, which is $2,100 in 2026.

The bottom line

Entresto is an unscored film-coated tablet that is not designed to be split. While it may be physically possible to cut the tablet, doing so can lead to dosing inaccuracies and potential safety concerns. If you’re considering splitting Entresto because of side effects, swallowing difficulties, or cost, talk with your healthcare provider first. They can help identify safer and more effective alternatives, ensuring you receive the full benefit of your treatment.