Entresto alternatives: What can I take instead of Entresto?

Compare Entresto alternatives | Enalapril | Valsartan | Carvedilol | BiDil | Spironolactone | Natural alternatives | How to switch meds

Entresto (sacubitril/valsartan) is a first-of-its-kind prescription medication made by Novartis Pharmaceuticals. It’s used to lower the risk of cardiovascular death and hospitalization related to heart failure in people with chronic heart failure. Approved by the FDA in 2015, Entresto is a combination tablet of two different medications: an angiotensin II receptor blocker (valsartan) and a neprilysin inhibitor (sacubitril). These two medications work together as an angiotensin receptor-neprilysin inhibitor (ARNI) to widen blood vessels leading to increased blood flow and reduced blood pressure. High blood pressure and reduced blood flow both contribute to the degenerative process of congestive heart failure. Additionally, these two medications can decrease the amount of sodium and fluid in the body. Increased amounts of sodium and fluid in those with heart failure often leads to symptoms of swelling, weight gain, and shortness of breath.

Who shouldn’t take Entresto?

While an effective treatment for some people, Entresto may not be the best option for everyone with chronic heart failure. People who should avoid or switch their Entresto medication to a different heart failure medication include:

• People who are pregnant or breastfeeding
• Those who experienced an allergic reaction to Entresto
• Anyone with a history of angioedema related to previous ACE inhibitor or ARB therapy
• Anyone also taking ACE inhibitor or ARB medications
• A person with diabetes also taking the medication aliskiren
• People taking lithium, non-steroidal anti-inflammatory drugs (NSAIDs), and potassium-sparing diuretics (such as spironolactone, triamterene, and amiloride) are at risk for dangerous drug interactions with Entresto

Entresto is currently only available as a brand-name medication and is often an expensive treatment option even with insurance or Medicare. Some people may consider alternative medications due to cost. Free coupons for Entresto are available from SingleCare.

RELATED: Entresto side effects

What can I take in place of Entresto?

There are many types of medications used in people with heart failure including medications that help improve survival and medications that help with symptoms. People will often take more than one medication to help treat heart failure. Medications used to help manage symptoms include diuretics (such as furosemide or torsemide) and digoxin (digitalis).

Entresto helps improve survival in people with heart failure. Since Entresto is the only medication in the angiotensin receptor-neprilysin inhibitor (ARNI) class, there are no available alternatives within the same drug class. However, alternative medications that have shown improved survival in heart failure include some of the ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists, isosorbide dinitrate/hydralazine, ivabradine, and SGLT2 inhibitors.

Other alternatives to Entresto

The following are included in the American College of Cardiology clinical guidelines for the management of heart failure:

• ACE inhibitors:
  • Captopril
  • Fosinopril
  • Lisinopril
  • Perindopril
  • Quinapril
  • Ramipril
  • Trandolapril
• ARBs:
  • Candesartan
  • Losartan
• Beta blockers:
  • Bisoprolol
  • Metoprolol succinate
• Aldosterone antagonists:
  • Eplerenone
• Ivabradine
• SGLT2 inhibitors:
  • Jardiance

Top 5 Entresto alternatives

1. Enalapril

Enalapril is used for the treatment of symptomatic congestive heart failure. It improves symptoms, increases survival, and decreases the frequency of hospitalization. Enalapril is an ACE inhibitor (angiotensin-converting enzyme inhibitor) and is usually dosed as a 97/103 mg tablet taken by mouth twice daily. According to the manufacturer, enalapril showed effectiveness when used with other heart failure medications, digitalis, and diuretics. Clinical trials showed patients had decreased systemic vascular resistance, blood pressure, pulmonary capillary wedge pressure and heart size, and increased cardiac output and exercise tolerance. In the PARADIGM-HF study, Entresto was found superior to enalapril in reducing the risk of the combined endpoint of cardiovascular death or hospitalization for heart failure.

2. Valsartan

Valsartan, generic for Diovan, is used to reduce the risk of hospitalization for heart failure in adult patients with heart failure (NYHA class II-IV). NYHA class II-IV is identified as mild to severe heart failure. Valsartan is an ARB (angiotensin receptor blocker) and usually has a starting dose of a 160 mg tablet taken by mouth twice daily. Valsartan is one of two medications in Entresto and is available individually as a tablet. According to the manufacturer controlled clinical trial, Valsartan significantly reduced hospitalizations for heart failure.

RELATED: Valsartan side effects

3. Carvedilol

Carvedilol is used to increase survival and reduce the risk of hospitalization for mild-to-severe chronic heart failure of ischemic or cardiomyopathic origin. For heart failure, carvedilol is often used in combination with diuretics, ACE inhibitors, and digitalis. Carvedilol is a beta blocker and is usually dosed as a 6.25 to 25 mg tablet taken by mouth twice daily. According to the COMET trial, treatment with carvedilol was associated with a significantly lower rate of the primary endpoint of all-cause mortality and morbidity compared to metoprolol. In this study, the majority of participants were also taking digitalis, diuretics, and an ACE inhibitor.

RELATED: What’s the best beta blocker for heart failure?

4. BiDil (isosorbide dinitrate/hydralazine)

Isosorbide dinitrate/hydralazine (BiDil) is used for the treatment of heart failure as an add-on to standard therapy in self-identified Black patients to improve survival, prolong time to hospitalization for heart failure, and improve patient-reported functional status. BiDil is a combination tablet of a nitrate vasodilator (isosorbide dinitrate) and an arteriolar vasodilator (hydralazine) and is usually dosed as a 20/37.5 mg tablet taken by mouth three times daily. In the A-HeFT trial, Black patients were studied because they may have less nitric oxide in the body than other patients, suggesting better results with BiDil. The study determined that BiDil treated participants had a statistically significant 43% reduction in all-cause mortality compared to placebo. BiDil can be used in non-Black people as well, especially if they are intolerant to other heart failure medications.

RELATED: Heart disease statistics

5. Spironolactone

Spironolactone is used for the treatment of heart failure (NYHA Class III-IV) and reduced ejection fraction to increase survival, manage edema (swelling caused by trapped fluid in tissues), and reduce the need for hospitalization for heart failure. NYHA class III-IV is identified as moderate to severe heart failure and reduced ejection fraction indicates that the left side of the heart doesn’t pump blood out to the body as well as normal. Spironolactone is an aldosterone antagonist and is usually dosed as a 12.5 to 50 mg tablet taken by mouth one to two times daily. In the RALES study focusing on NYHA class III-IV, spironolactone reduced the risk of death by 30% and reduced the risk of hospitalization for cardiac causes by 30% compared to placebo. In this study, most participants were also taking a diuretic and an ACE inhibitor.

RELATED: Spironolactone side effects

Natural alternatives to Entresto

According to the Journal of the American College of Cardiology, natural alternatives are not included in the standard treatment for heart failure. However, there are natural remedies that can be used along with standard treatment for heart failure. It’s important that people with heart failure consult with their healthcare provider or cardiologist before starting any natural remedies. This is especially important because some natural remedies may interact with prescription heart failure medications or may not be appropriate for certain medical conditions.

Carnitine

Also called L-carnitine, this nutrient is naturally made in the body and is involved in fatty acid metabolism for the body to make energy. There is evidence that L-carnitine given as a supplement helps with relief of heart failure including improvement of energy metabolism in cardiomyocytes (heart muscle cells), which may contribute to the improvement of clinical symptoms and cardiac function.

Magnesium

Magnesium is an important mineral that people get from their diets, however, some people may benefit from additional magnesium supplementation. Due to the nature of the condition, many people with congestive heart failure are deficient in magnesium. There is evidence that magnesium likely improves outcomes in people with congestive heart failure by preventing ventricular arrhythmias (a type of abnormal heart rhythm).

Coenzyme Q10

Coenzyme Q10, also called CoQ10, is an antioxidant naturally made in the body and is available as a supplement. In the Q-SYMBIO study, treatment with CoQ10 in addition to standard therapy for people with moderate to severe heart failure was studied. It was concluded that CoQ10 supplementation is safe and well tolerated and is associated with a reduction in symptoms and major adverse cardiovascular events.

Vitamin B1

Also called thiamine, vitamin B1 is a water-soluble vitamin found in foods and is available as a supplement. Vitamin B1 helps the body make food into energy. Studies have shown people with congestive heart failure who receive thiamine supplementation have improved cardiac function as thiamine acts as a vasodilator (opens blood vessels) and reduces the afterload on the heart (force against which the heart has to contract to eject the blood). Vitamin B1 has also shown to increase urination and excretion of sodium in urine in people receiving diuretics, which is a great benefit in heart failure patients.

How to switch to an Entresto alternative

1. Talk with a healthcare provider to discuss medical conditions

Before switching from Entresto to a substitute, it’s important that the prescribing doctor is aware of all medical conditions. Some alternatives should be used with caution or avoided with certain medical conditions. For example, SGLT2 inhibitors, Farxiga and Jardiance, are contraindicated in people on dialysis. Another example is aldosterone antagonist spironolactone, which must be avoided in people with hyperkalemia (elevated levels of potassium) and Addison’s disease.

2. Discuss all prescription and over-the-counter medications with a healthcare provider

Before switching from Entresto to an alternative, it’s important that the prescribing doctor has reviewed a medication list including prescription drugs and over-the-counter medications. Some alternatives have dangerous drug interactions that must be avoided. For example, BiDil must not be used in combination with medications like Viagra (sildenafil) or Cialis (tadalafil).

3. Wait 36 hours when switching from Entresto to an ACE inhibitor

When switching from Entresto to an ACE inhibitor (such as captopril, lisinopril, or ramipril), there should be a 36-hour washout period. This means that there should be 36 hours between the last Entresto dose and the first ACE inhibitor dose. This washout period helps to minimize the chance of angioedema (swelling under the skin usually in the lips, tongue, face, or throat), which can be life-threatening.

RELATED: Entresto dosage, forms, and strengths

4. Stop Entresto safely with instructions from a healthcare professional

Only stop taking Entresto if the prescribing doctor has been consulted and decided stopping the medication is safe. If Entresto is stopped suddenly, the condition of heart failure may worsen. It’s important for a therapy plan to be established prior to stopping Entresto suddenly. Once Entresto is safely stopped and a new medication has been prescribed, always review the prescribing information for the new medication.