Entresto dosing is easiest to understand when you match the starting dose to the patient’s previous ACE inhibitor or ARB use, then titrate upward every 2 to 4 weeks as tolerated. The chart below gives you a practical dosing guide for adults and children, based on the current prescribing information and HCP dosing guidance.
Entresto dosing chart
| Patient group | Starting dose | Titration | Target / final dose |
|---|---|---|---|
| Adults, no prior ACE inhibitor or ARB, or previously on low doses | 24/26 mg twice daily | Double every 2 to 4 weeks as tolerated | 97/103 mg twice daily |
| Adults previously on a high-dose ACE inhibitor or ARB | 49/51 mg twice daily | Double every 2 to 4 weeks as tolerated | 97/103 mg twice daily |
| Adults with severe renal impairment | 24/26 mg twice daily | Double every 2 to 4 weeks as tolerated | 97/103 mg twice daily if tolerated |
| Adults with moderate hepatic impairment | 24/26 mg twice daily | Double every 2 to 4 weeks as tolerated | 97/103 mg twice daily if tolerated |
| Pediatric patients less than 40 kg | 1.6 mg/kg twice daily | Increase every 2 weeks as tolerated | 3.1 mg/kg twice daily |
| Pediatric patients at least 40 kg to less than 50 kg | 24/26 mg twice daily | Increase every 2 weeks as tolerated | 72/78 mg twice daily |
| Pediatric patients at least 50 kg | 49/51 mg twice daily | Increase every 2 weeks as tolerated | 97/103 mg twice daily |
The adult label also says to allow a 36-hour washout when switching from an ACE inhibitor to Entresto, and not to give Entresto together with an ACE inhibitor. The tablet strengths available are 24/26 mg, 49/51 mg, and 97/103 mg, which makes the titration ladder simple to follow.
How to choose the starting dose
You usually start lower if the patient is new to renin-angiotensin system therapy, has only been on low-dose ACE inhibitor or ARB treatment, or has severe renal impairment or moderate hepatic impairment. You can start higher, at 49/51 mg twice daily, when the patient was already tolerating a high dose of an ACE inhibitor or ARB before the switch. If the patient is switching from an ACE inhibitor, you wait 36 hours before the first Entresto dose. If the patient is switching from an ARB, the HCP guidance notes that a washout is not required, but you should not combine the two drugs.
Adult titration plan
For most adults, you begin with 24/26 mg or 49/51 mg twice daily depending on prior therapy, then increase to the next strength after 2 to 4 weeks if blood pressure, kidney function, and potassium allow it. The usual goal is 97/103 mg twice daily, which is the target maintenance dose used in the adult heart failure evidence base. If the patient develops hypotension, worsening renal function, or hyperkalemia, the label advises dose reduction or temporary interruption rather than forcing titration.
Pediatric dosing
For children age 1 year and older, dosing is weight-based if they weigh less than 40 kg, while fixed tablet strengths are used for heavier children. Children weighing 40 kg to less than 50 kg start at 24/26 mg twice daily and may titrate to 72/78 mg twice daily, while those weighing at least 50 kg can titrate up to the adult target of 97/103 mg twice daily. The label says pediatric doses are adjusted every 2 weeks as tolerated.
Safety points
You should not use Entresto together with an ACE inhibitor because the combination raises the risk of angioedema. The drug also carries important pregnancy warnings, and the prescribing information advises discontinuation if pregnancy is detected because of fetal harm risk. Common adverse reactions include hypotension, hyperkalemia, dizziness, cough, and renal failure/acute renal failure, so monitoring blood pressure, kidney function, and potassium matters during titration.
Practical use
A simple way to remember the adult chart is: low prior RAAS exposure means 24/26 mg twice daily, higher prior exposure means 49/51 mg twice daily, and the usual finish line is 97/103 mg twice daily. For a patient who just stopped lisinopril, you wait 36 hours before starting; for a patient already stable on a high-dose ARB, you can usually choose the higher starting dose without the ACE inhibitor washout issue. This dosing logic helps you move from initiation to target while minimizing avoidable adverse effects.