The lowest available dose of Entresto is 24/26 mg, meaning each tablet contains 24 mg of sacubitril and 26 mg of valsartan. This tablet is taken twice daily and serves as the starting point for specific patient groups before gradually increasing to a higher maintenance dose.
What the 24/26 mg Tablet Contains
Entresto is a combination medication with two active ingredients. Sacubitril helps the body retain beneficial hormones that relax blood vessels and reduce fluid buildup. Valsartan blocks a hormone that constricts blood vessels and raises blood pressure. The 24/26 mg tablet is the smallest of three available strengths. The middle strength is 49/51 mg and the target dose for most adults is 97/103 mg, both taken twice daily.
Who Starts on the Lowest Dose
Not everyone begins at 24/26 mg. Many patients start on the middle dose (49/51 mg) and work up from there. The lowest dose is specifically recommended for a few groups:
- Patients not currently on a blood pressure medication in the ACE inhibitor or ARB class. Because their bodies haven’t adjusted to this type of drug, starting low reduces the risk of a sharp drop in blood pressure.
- Patients with moderate liver impairment (classified as Child-Pugh B). The FDA labeling specifies starting at 24/26 mg twice daily, which is half the usual starting dose, because the liver processes these medications more slowly.
- Patients with severe kidney impairment (an eGFR below 30). Reduced kidney function affects how the drug is cleared from the body, so the lowest dose provides a safer entry point.
If you fall into more than one of these categories, your prescriber will almost certainly begin at 24/26 mg and monitor you closely before considering any increase.
How Titration Works From the Lowest Dose
Starting at 24/26 mg is not the end goal. The purpose of the low dose is to let your body adjust before moving toward the target dose where the medication provides its full benefit for heart failure. The typical schedule looks like this:
- Step 1: 24/26 mg twice daily for about four weeks
- Step 2: 49/51 mg twice daily for about four weeks
- Step 3: 97/103 mg twice daily, continued long term
Each step up happens only if your blood pressure and kidney function remain stable. Some people never reach the target dose, and that’s common. Staying on 24/26 mg or 49/51 mg long term still provides benefit, though the clinical trials that established Entresto’s effectiveness tested the full 97/103 mg dose.
Switching From an ACE Inhibitor
If you’re currently taking an ACE inhibitor (medications like lisinopril, enalapril, or ramipril), you cannot start Entresto immediately. There is a mandatory 36-hour washout period between your last ACE inhibitor dose and your first Entresto dose. Taking both too close together raises the risk of a serious reaction called angioedema, which involves rapid swelling of the face, throat, or tongue. Switching from an ARB (like losartan or candesartan) does not require this waiting period.
Pediatric Dosing Differs
For children with heart failure, Entresto dosing is weight-based rather than fixed-tablet. In clinical trials, pediatric target doses ranged from about 2.3 to 3.1 mg per kilogram of body weight, taken twice daily, depending on the child’s age group. A liquid formulation is available for younger children who cannot swallow tablets. The specific dose a child receives will be much lower in absolute milligrams than the adult 24/26 mg tablet, particularly for infants and toddlers.
What to Expect at the Lowest Dose
The most common side effect when starting Entresto, especially at any dose, is low blood pressure. You may feel lightheaded when standing up, particularly in the first few days. This is more likely if you’re also taking a diuretic (water pill). Elevated potassium levels are another concern your prescriber will watch for through blood tests, especially if you have kidney problems. These checks are typically done within a week or two of starting and again after each dose increase.
Some people notice a mild cough, which is generally less frequent than with ACE inhibitors alone. Kidney function can also shift early on, so lab work in the first few weeks helps catch any changes before they become a problem.