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Beta-Blocker / HFrEF Pregnancy: Use with caution — neonatal bradycardia, hypoglycaemia; use only when essential

Carvedilol

Brand names: Eucardic

Adult dose

Dose: HFrEF: 3.125 mg BD; double every 2 weeks to target 25 mg BD (>85 kg: 50 mg BD). Hypertension: 12.5 mg OD initially, then 25 mg OD.
Route: Oral
Frequency: Twice daily (with food to reduce postural hypotension)
Max: 50 mg BD (HFrEF >85 kg); 50 mg/day (hypertension)
Non-selective beta-1/beta-2 blocker + alpha-1 blocker. COPERNICUS (severe HFrEF) and CAPRICORN (post-MI LV dysfunction) trials. Take with food — reduces absorption rate and first-dose postural hypotension.

Paediatric dose

Dose: 0.05 mg/kg
Route: Oral
Frequency: Twice daily — double every 2 weeks as tolerated
Max: 0.75 mg/kg/day
Specialist paediatric cardiology only (dilated cardiomyopathy). BNFc for guidance.

Dose adjustments

Renal

No dose adjustment required — completely hepatically metabolised; safe in CKD including haemodialysis

Hepatic

Contraindicated in severe hepatic impairment

Paediatric weight-based calculator

Specialist paediatric cardiology only (dilated cardiomyopathy). BNFc for guidance.

Clinical pearls

  • COPERNICUS trial (Packer et al. NEJM 2001): carvedilol vs placebo in severe HFrEF (EF <25%) — 35% reduction in all-cause mortality. Established benefit even in most severe HFrEF when started carefully.
  • CAPRICORN trial: carvedilol post-MI with LV dysfunction (EF <40%) — 23% reduction in all-cause mortality. Beneficial post-MI regardless of symptomatic HF.
  • Alpha-1 blockade advantage: carvedilol reduces afterload via vasodilation — particularly beneficial in hypertensive HFrEF. Postural hypotension is the trade-off (mitigated by taking with food).
  • Hepatic metabolism advantage in CKD: carvedilol is completely hepatically metabolised — no dose adjustment needed in any CKD stage or in dialysis patients. Preferred over bisoprolol in severe CKD.
  • Initiation protocol: start only when euvolaemic. Begin 3.125 mg BD, double every 2 weeks. If fluid retention develops — increase diuretic, do not stop carvedilol.

Contraindications

  • Decompensated heart failure requiring IV inotropes
  • Severe bradycardia
  • 2nd/3rd degree AV block (without pacemaker)
  • Severe bronchospasm
  • Cardiogenic shock

Side effects

  • Dizziness/postural hypotension (alpha-1 blockade — especially first dose; take with food)
  • Bradycardia
  • Fatigue
  • Fluid retention/peripheral oedema
  • Bronchospasm
  • Hyperglycaemia

Interactions

  • Non-dihydropyridine CCBs — additive AV block; avoid IV combination
  • CYP2D6 inhibitors (fluoxetine, quinidine) — increase carvedilol levels
  • Rifampicin — reduces carvedilol AUC 70%

Monitoring

  • Heart rate (target 50-60 bpm in HFrEF)
  • Blood pressure (lying and standing)
  • Signs of decompensation
  • Weight (fluid retention)

Reference: BNFc; BNF 90; COPERNICUS Trial (Packer et al. NEJM 2001); CAPRICORN Trial (Lancet 2001); ESC HF Guidelines 2021; SPC Eucardic. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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