Heart Failure: medications and paying cash

Overview

Heart failure means the heart cannot pump enough blood for the body’s needs. It has no cure, but treatment can extend life, keep people active and relieve symptoms. Early on, the main sign is shortness of breath during ordinary activity such as climbing stairs, or when lying flat; a cough, extreme tiredness and trouble concentrating follow when the left side of the heart is affected, and swelling of the ankles, legs and abdomen, weight gain, nausea and loss of appetite when the right side is. Older adults who are not very active may feel tired and confused rather than breathless. Treatment depends on the type: when the heart’s pumping strength (the ejection fraction) is reduced, several medicines are combined because each lowers the risk of death or hospital admission in a different way; when the ejection fraction is preserved, diuretics are the main treatment and blood pressure medicines may relieve symptoms. Alongside the medicines come less salt, which makes fluid buildup worse, a healthy weight, physical activity as the care team advises, no smoking, and treatment of blood pressure, heart rhythm problems and anemia, which can worsen heart failure, and of sleep disorders such as sleep apnea, which may improve symptoms.

The medicines fall into a few groups. ACE inhibitors (lisinopril, enalapril, quinapril) and ARBs (valsartan, candesartan) relax blood vessels so the heart pumps more easily; sacubitril-valsartan (Entresto) pairs an ARB with a second drug and is approved to reduce the risk of cardiovascular death and heart failure hospitalization, with the benefit clearest when the ejection fraction is below normal. All three carry a boxed warning: they can injure or kill a developing fetus, so they are stopped as soon as pregnancy is detected, and they can cause angioedema (swelling of the face, lips or throat), a drop in blood pressure, reduced kidney function and high potassium, so kidney function and potassium are checked by blood test. Sacubitril-valsartan is never taken with an ACE inhibitor, and 36 hours must pass between the last ACE inhibitor dose and the first dose. Beta blockers (carvedilol, metoprolol succinate, bisoprolol) slow the heart; carvedilol starts at 3.125 mg twice a day with food and metoprolol succinate at 12.5 mg or 25 mg once a day, each raised slowly, usually every two weeks, and neither is stopped suddenly, because abrupt withdrawal can worsen angina and, in people with coronary disease, lead to a heart attack. The aldosterone antagonists are approved to improve survival: spironolactone in Class III to IV heart failure with reduced ejection fraction, and eplerenone in heart failure with reduced ejection fraction after a heart attack. Both raise potassium, so potassium is checked within a week of starting or changing the dose and regularly after that; spironolactone can also cause breast swelling in men.

The SGLT2 inhibitors dapagliflozin (Farxiga) and empagliflozin (Jardiance) began as diabetes medicines and are now approved, at 10 mg once a day, to reduce the risk of cardiovascular death and heart failure hospitalization in adults with heart failure, with or without diabetes. Their labels warn of ketoacidosis (the drug is usually withheld for at least three days before surgery), dehydration and low blood pressure, especially in older people and those on diuretics, urinary and genital infections, and a rare serious infection of the tissue around the genitals that needs urgent care. Loop diuretics (furosemide, bumetanide, torsemide) remove excess salt and water to relieve swelling and breathlessness, with blood tests to watch potassium and kidney function. Digoxin strengthens the heartbeat and improves symptoms in mild to moderate heart failure without lowering the risk of death; its toxic level is only slightly above its effective level, so blood levels, kidney function and potassium are monitored, and nausea, vision changes and an irregular heartbeat are warning signs. Hydralazine with isosorbide dinitrate (BiDil, taken three times a day) is approved as an add-on in self-identified Black patients and must never be combined with sildenafil, tadalafil or similar drugs. Ivabradine lowers the heart rate in some patients. None of these medicines is stopped or changed without the prescriber, and over-the-counter ibuprofen or naproxen, sildenafil, and any herb or supplement are checked with the care team first.

Choosing between the options when you pay cash

Most of the heart failure regimen is generic. Lisinopril, enalapril, valsartan, candesartan, carvedilol, metoprolol succinate, bisoprolol, spironolactone, eplerenone, furosemide, bumetanide, torsemide and digoxin all come from many makers, and generic sacubitril-valsartan tablets, rated equivalent to Entresto in all three strengths, have been marketed since late 2024, with more makers added through 2025 and 2026; the Entresto Sprinkle pellets for children are a separate product. Generic dapagliflozin tablets rated equivalent to Farxiga are also on the market, though a generic’s label may list only the diabetes uses and not the heart failure use, so ask the pharmacist whether it can be substituted for your prescription. No generic empagliflozin is marketed, so Jardiance is filled as the brand, and a prescription for it cannot be switched to dapagliflozin at the counter: that is the prescriber’s decision. Because five or six medicines are often filled together every month, the dispensing fee on each one adds up, and a ninety-day supply of the stable ones, written once the doses are settled, means fewer fees and fewer trips.

Form matters. Metoprolol succinate (the once-daily extended-release tablet used for heart failure) and metoprolol tartrate are different products, and carvedilol tablets and Coreg CR capsules are not interchangeable, so a quote applies only to the form on the prescription. BiDil is a fixed combination of hydralazine and isosorbide dinitrate, and whether it or the separate tablets suits you is the prescriber’s call. Doses are raised in steps over weeks, so the strength on the bottle changes often early in treatment; ask for a quote on the exact strength and count written, and ask the prescriber whether a scored tablet, such as metoprolol succinate, can cover two steps.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Sacubitril/Valsartan
  Film-coated tablets, Oral pellets in capsules (Entresto Sprinkle)
  Generic: Yes · Twice a day
• Lisinopril
  Tablets (Zestril and generic), Oral solution (Qbrelis and generic)
  Generic: Yes · Once a day
• Enalapril
  Tablets, Oral solution (Epaned and generics), Tablets with hydrochlorothiazide
  Generic: Yes · Once or twice a day
• Quinapril
  Tablets
  Generic: Yes · Once or twice a day
• Valsartan
  Tablets (Diovan and generic), Oral solution (Prexxartan and generic), Tablets with hydrochlorothiazide (Diovan HCT and generic)
  Generic: Yes · Once a day
• Candesartan
  Tablets, Tablets (with hydrochlorothiazide)
  Generic: Yes · Once or twice a day
• Carvedilol
  Tablets (Coreg and generics), Extended-release capsules, carvedilol phosphate (Coreg CR and generics)
  Generic: Yes · Twice a day
• Metoprolol
  Tablets, tartrate (Lopressor and generics), Oral solution, tartrate (Lopressor), Extended-release tablets, succinate (Toprol-XL and generics)
  Generic: Yes · Twice a day, or once a day extended-release
• Bisoprolol
  Tablets, Tablets with hydrochlorothiazide (Ziac and generic)
  Generic: Yes · Once a day
• Spironolactone
  Film-coated tablets (Aldactone and generic), Oral suspension (CaroSpir and generic)
  Generic: Yes · Once a day
• Eplerenone
  Film-coated tablets
  Generic: Yes · Once or twice a day
• Dapagliflozin
  Tablets (Farxiga and generic)
  Generic: Yes · Once a day
• Empagliflozin
  Tablets (Jardiance)
  Generic: No · Once a day
• Furosemide
  Tablets, Oral solution, Subcutaneous infusor and autoinjector (Furoscix)
  Generic: Yes · Once or twice a day
• Bumetanide
  Tablets, Single-use nasal spray (Enbumyst), Injection (hospital use)
  Generic: Yes · Once a day
• Torsemide
  Tablets (generic torsemide), Soaanz tablets (brand only)
  Generic: Yes · Once a day
• Digoxin
  Tablets, Oral solution, Injection (hospital use)
  Generic: Yes · Once a day
• Hydralazine
  Tablets, Combination tablets with isosorbide dinitrate (BiDil and generic), Injection (hospital use)
  Generic: Yes · Two to four times a day
• Nitroglycerin
  Sublingual tablets (Nitrostat and generics), Sublingual spray (Nitrolingual Pumpspray, NitroMist and generics), Transdermal patch (Nitro-Dur, Minitran and generics)
  Generic: Yes · Every 12 hours

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Which of my heart failure medicines are generic, and can all of them be written for a ninety-day supply once my doses are settled?
• When are my potassium and kidney function blood tests due, and which results mean a dose should change?
• Which of my medicines must never be stopped suddenly, and what should I do if I run out before a refill?
• Which over-the-counter pain relievers, cold medicines and supplements are safe with my heart failure medicines?
• How much weight gain over a day or a week, and which breathing or swelling symptoms, should I report right away?

Related