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Heart Failure Medication Titration – Adult – Ambulatory [82]

Heart Failure Medication Titration – Adult – Ambulatory [82] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 82

Delegation Protocol Title:
Heart Failure Medication Titration – Adult - Ambulatory

Delegation Protocol Applies To:
UW Health Complex Case Management Program
UWHC Heart Failure Program
UW Health Heart & Vascular Clinics

Target Patient Population:
Adult patients with heart failure

Delegation Protocol Champion:
Peter Rahko, MD – Department of Medicine - Cardiology

Delegation Protocol Reviewers:
Bethany Westerfeldt, NP – Department of Medicine - Cardiology
Orly Vardeny, MD – Department of Pharmacy

Responsible Department:
Department of Medicine – Cardiology

Purpose Statement:
To delegate authority from the Primary Care Provider (PCP) or Cardiology Provider managing the
patient’s heart failure to registered nurses (RNs) and pharmacists (RPHs) to titrate specific medications
identified in this protocol to the goal dose and to place orders for the lab tests needed for monitoring
therapy.

Who May Carry Out This Delegation Protocol:
RNs or clinic-based RPHs experienced in managing patients with heart failure and who have successfully
completed training on heart failure medication monitoring and dose adjustments.

Guidelines for Implementation:
1. This protocol is activated when a provider enters an order for “Heart Failure Medication
Management by Registered Nurse or Pharmacist per protocol” and orders the covered medications.
The RN/RPh will titrate the patient’s heart failure medications following the steps in this protocol.
The provider must renew the order annually.
2. Only medications listed in this protocol are authorized for delegated action. See table 1 for the
included medications.
3. Before initiating this protocol, the RN/RPh will verify the patient is on low doses of both a heart
failure specific beta blocker and an ACE-I/ARB. If not, the prescribing provider will be contacted.
4. The prescribing provider will be consulted when patient experiences an adverse reaction, reaches
the dosing maximum without expected therapeutic response, or as needed for other issues.
5. Titration Steps
5.1. Therapeutic goal
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

5.1.1. The medications will be titrated to the maximum goal dose or the maximum tolerated
dose.
5.2. Dose Adjustment
5.2.1. The patient will return to clinic one to two weeks ( for BP and HR check) after every other
dose adjustment (and may also have)— follow-up lab tests. (Clinic follow up to alternate
with protocol adjustments in 2-3 week increments.)
5.2.2. The dose of the beta blocker will be adjusted first until the patient is at the goal or
maximum tolerated dose. Once the beta blocker dose has been maximized the ACE-I/ARB
will be adjusted to goal or maximum tolerated dose.
• For beta blockers not at goal full dose, increase as follows:
 Increase the dose in increments of ¼ dose up to full dose of previous dose,
based on patient BP and symptoms.
 May adjust dose in smaller increments if patient experiences transient side
effects from previous dose increase. In these cases, the adjustment will be
based on the last well tolerated dose adjustment and can increase (for
carvedilol) in stepwise approach of pm dose increase for 1 week followed by
AM dose the following week.
• For ACE-I/ARB, the dose is increased as follows:
 For SBP 90-99 mmHg, the dose is increased by 50% of the current dose
 For SBP >/=100 mmHg, the current dose will be doubled or increased to target
dose.
• RN/RPh will check blood pressure and review results of lab tests and assess for adverse
reactions/side effects 7-14 days following each dose change. If needed, the RN/RPh will
enter orders for the needed labs. The RNs and RPHs will mark the orders as “Cosign
required” for routing to the provider, but the tests may be obtained prior to
cosignature.
• A repeat echocardiogram will be ordered 2-4 months after the patient has reached the
goal or maximum tolerated dose. If the ejection fraction is still less than 35, the RN will
refer the patient to the provider for initiation of an aldosterone antagonist and refer the
patient to EP Cardiology for further evaluation.
5.3. Discontinuation of protocol-based management
The RN/RPh will contact the provider for further direction if:
5.3.1. Systolic blood pressure >120 mmHg or < 90 mmHg, diastolic blood pressure >110 mmHg or
< 50 mmHg, or heart rate consistently < 50 beats per minute or > 120 beats per minute.
5.3.2. Goal dose of current agents reached and patient continues to experience heart failure
symptoms
5.3.3. Decrease in renal function (i.e. >30% decrease from baseline eGFR), hyperkalemia (i.e.,
potassium >5 mmol/L) or other pertinent labs outside of normal limits.
5.3.4. Patient experiences significant side effects/adverse reactions or heart failure symptoms
worsen.
5.3.5. Patient is non-adherent with taking the medications as directed per this protocol
5.3.6. Other questions/issues as needed.


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Table 1. Allowed Beta Blockers with Titration Parameters
Medication Available
Strengths
Initial
Dose
Dose
Adjustment
Schedule
Goal Max Dose Monitoring Significant Adverse
Effects/Contraindications
Carvedilol
3.125,
6.25,
12.5, 25
mg
3.125 mg
2x/day
Increase dose
every 2 weeks
as tolerated
until reaching
goal dose or
maximum
tolerated dose
If weight dose = 25 mg 2x/day
If weight > 85 kg, goal
dose = 50mg 2x/day
Max dose =
goal dose
●BP and HR every 1-2
weeks while titrating then
every 6 months once dose
is stable
Dizziness,
lightheadedness
(increased SOB, and
extreme fatigue, require
checking blood pressure
and heart rate and
possible dose reduction)
Metoprolol
ERT
25, 50,
100, 200
mg
25 mg
1x/day
200 mg 1x/day

Table 2. Allowed ACE/ARBs with Titration Parameters
Medication Available
Strengths
Initial
Dose
Dose
Adjustment
Schedule
Goal Max Dose Monitoring Significant Adverse
Effects/Contraindications
Enalapril
2.5, 5,
10, 20
mg
2.5 mg
2x/day
Increase dose
every 2 weeks
as tolerated
until reaching
goal dose or
maximum
tolerated dose
10 mg 2x/day 20 mg 2x/day
●K, BUN, Cr 1-2 weeks
after dose change, then
every 6 months when
dose is stable
●BP and HR every 1-2
weeks while titrating
then every 6 months
once dose is stable
Declining renal function
(>30% decrease from
baseline eGFR),
hyperkalemia (K >5 mmol/L)

Angioedema, bilateral renal
artery stenosis, pregnancy
Lisinopril
2.5, 5,
10, 20,
30, 40
mg
2.5 mg
1x/day
20 mg 1x/day 40 mg 1x/day
Candesartan
4, 8, 16,
32 mg
4 mg
1x/day
Increase dose
every 2 weeks
as tolerated
until reaching
goal dose or
maximum
tolerated dose
32 mg 1x/day
Max dose =
goal dose
●K, BUN, Cr 1-2 weeks
after dose change, then
every 6 months when
dose is stable
●BP and HR every 1-2
weeks while titrating
then every 6 months
once dose is stable
Declining renal function
(>30% decrease from
baseline eGFR),
hyperkalemia (K >5 mmol/L)

Angioedema, bilateral renal
artery stenosis, pregnancy
Valsartan
40, 80,
160, 320
mg
40 mg
2x/day
160 mg 2x/day

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

>/= 2 weeks
since last BB
dose
increase?
Is BB dose at
goal?
Did patient
tolerate last
increase?
Average
heart rate >/=
50 bpm?
Average SBP
>/= 90
mmHg?
Patient on beta blocker (BB) and
ACE-I/ARB for Heart Failure (EF
< 40)
Refer to provider
No
No
Yes
No
Yes
No
Yes
NoNo
Heart Failure Medication Titration Algorithm
April 17, 2013
Yes
Restart algorithm
once last BB dose
increase > 2 weeks
Restart algorithm
once average SBP
>/= 90 mmHg
Restart algorithm
after 2 weeks
Increase BB
dose as
appropriate per
patient age or
as per previous
dose changes
that have been
well tolerated
Yes
Refer to provider
Increase current
ACE-I/ARB
dose by 50%
eDCR ≥ 30 mL/
min, not
lightheaded?
>/= 2 weeks since
last ACE-I/ARB
dose increase?
Is ACE-I/ARB
dose at goal?
Refer to provider
No
Yes
Yes
No No
Yes
No
No
Restart algorithm
once last ACE-I/ARB
dose increase > 2
weeks
SBP ≥ 90
mmHg?
Yes
Order repeat Echo
in 2-4 months
Refer to provider
SBP ≥ 100
mmHg?
Yes
Double current
ACE-I/ARB
dose
Restart algorithm
after 2 weeks
EF > 35? Yes
A1
A1
Is SBP <120
mmHg?
Yes
No No
Refer to provider
Continue to monitor
labs
Refer to provider




Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

References:
1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, And Blood Institute Joint National
Committee On Prevention, Detection, Evaluation, And Treatment Of High Blood Pressure, National
High Blood Pressure Education Program Coordinating Committee. The Seventh Report Of The Joint
National Committee On Prevention, Detection, Evaluation, And Treatment Of High Blood Pressure:
The JNC 7 Report. JAMA. 2003;289(19):2560.
2. UW Health. Hypertension – Adult – Clinical Practice Guideline (CPG).
2012. https://uconnect.wisc.edu/servlet/Satellite?cid=1126647069710&pagename=B_EXTRANET_U
WH_HOME%2FFlexMemberFile%2FLoad_File&c=FlexMemberFile. Accessed April 2016.
3. UW Health. UW Health Chronic Left Ventricular Systolic Heart Failure – Adult - Clinical Practice
Guideline. 2012.
https://uconnect.wisc.edu/clinical/cckm-tools/cpg/guidelines/cardiovascular/resources/name-
28523-en.file. Accessed April 2016.

Order Mode: Protocol/Policy without cosign

Collateral Documents/Tools:
UW Health Chronic Left Ventricular Systolic Heart Failure – Adult - Clinical Practice Guideline

Approved By:
UW Health Ambulatory Protocol Committee: February 2013, September 2015 (expedited review), June
2016 (expedited review)
UW Health Laboratory Practice Committee: May 2013, September 2015 (expedited review), June 2016
(expedited review)
UWHC Pharmacy & Therapeutics Committee: May 2013, September 2015 (expedited review), June 2016
(expedited review)
UWHC Medical Board: June 2013, September 2015 (expedited review), June 2016 (expedited review)
UW Health Chief Medical Officer: September 2015 (expedited review), June 2016 (expedited review)

Effective Date: June 2016

Scheduled for Review: June 2019
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org