Formulary
Ivabradine: Indications, Dosing, Side Effects and Interactions
Ivabradine clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 3 min read
Ivabradine: Indications, Dosing, Side Effects and Interactions
Ivabradine clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Treatment of angina in patients in normal sinus rhythm**
- **Adult** (By Mouth): 75 years and over Initially 2.5 mg twice daily for 3-4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5-5 mg twice daily, heart rate at rest should not be allowed to fall below 50 beats per minute, discontinue treatment if no improvement in symptoms within 3 months.
**Mild to severe chronic heart failure**
- **Adult** (By Mouth): 75 years and over Initially 2.5 mg twice daily for 2 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5-5 mg twice daily, heart rate at rest should not be allowed to fall below 50 beats per minute.
Cautions
Atrial fibrillation or other arrhythmias (treatment ineffective); elderly; in angina, consider stopping if there is no or limited symptom improvement after 3 months; intraventricular conduction defects; mild to moderate hypotension (avoid if severe); retinitis pigmentosa
Contraindications
Acute myocardial infarction; cardiogenic shock; congenital QT syndrome; do not initiate for angina if heart rate below 70 beats per minute; do not initiate for chronic heart failure if heart rate below 75 beats per minute; immediately after cerebrovascular accident; patients dependent on pacemaker; second- and third-degree heart block; severe hypotension; sick-sinus syndrome; sino-atrial block; unstable angina; unstable or acute heart failure
Side effects
Common or very common Arrhythmias; atrioventricular block; dizziness; headache; hypertension; vision disorders Uncommon Abdominal pain; angioedema; constipation; diarrhoea; eosinophilia; hyperuricaemia; hypotension; muscle cramps; nausea; QT interval prolongation; skin reactions; syncope; vertigo
Interactions
**Severe interactions:**
- As ivabradine may cause bradycardia, the resulting combination of hypokalemia and bradycardia is a predisposing factor to the onset of severe arrhythmias, especially in patients with long QT...
- CYP3A4 inhibitors and inducers are liable to interact with ivabradine and influence its metabolism and pharmacokinetics to a clinically significant extent.
- Other concomitant use Specific drug-drug interaction studies have shown no clinically significant effect of the following medicinal products on pharmacokinetics and pharmacodynamics of ivabradine:...
- In addition there was no clinically significant effect of ivabradine on the pharmacokinetics of simvastatin, amlodipine, lacidipine, on the pharmacokinetics and pharmacodynamics of digoxin, warfarin...
**Other interactions (17):**
- Pharmacodynamic interactions Concomitant use not recommended QT prolonging medicinal products - Cardiovascular QT prolonging medicinal products (e.g.
- The concomitant use of cardiovascular and non cardiovascular QT prolonging medicinal products with ivabradine should be avoided since QT prolongation may be exacerbated by heart rate reduction.
- Concomitant use with precaution Potassium-depleting diuretics (thiazide diuretics and loop diuretics): hypokalemia can increase the risk of arrhythmia.
- Pharmacokinetic interactions Cytochrome P450 3A4 (CYP3A4) Ivabradine is metabolised by CYP3A4 only and it is a very weak inhibitor of this cytochrome.
- Ivabradine was shown not to influence the metabolism and plasma concentrations of other CYP3A4 substrates (mild, moderate and strong inhibitors).
- Drug-drug interaction studies have established that CYP3A4 inhibitors increase ivabradine plasma concentrations, while inducers decrease them.
Pregnancy
Manufacturer advises avoid- toxicity in animal studies.
Breast feeding
Present in milk in animal studies-manufacturer advises avoid.
Hepatic impairment
Manufacturer advises caution in moderate impairment; avoid in severe impairment-no information available.
Renal impairment
Caution if creatinine clearance less than 15 mL/minute (no information available). M See Prescribing in renal impairment .
Medicinal forms
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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