RAG Arena &
Dynamic Routing

Based on the prescribing information (rev. 2024-Q3), the recommended starting dose is 10 mg once daily, with or without food. Titrate up to a maximum of 40 mg/day in 10 mg increments at minimum 2-week intervals based on therapeutic response.

Monitoring during the first 8 weeks: serum creatinine + eGFR, hepatic enzymes (ALT/AST), and blood pressure — at baseline, week 4, week 8, then quarterly thereafter.

Dose adjustments: No adjustment for mild renal impairment (eGFR > 60). Moderate-to-severe (eGFR 30–59) requires a 50% reduction. Severe hepatic impairment (Child-Pugh C): not recommended.

Interactions: Strong CYP3A4 inhibitors are contraindicated. With moderate inhibitors, limit to 20 mg/day.

Sources: clinical-guidelines-2024.pdf p.142–146 · pharmacology-handbook.pdf p.78

Dosing should begin at the lowest effective dose. The product label indicates 10–20 mg as the typical adult range. Patients should be monitored for adverse effects during the first two weeks of therapy.

Common side effects: nausea, headache, and mild dizziness — typically transient and resolve within the first month. Severe reactions are rare (<0.1%) but include hepatotoxicity; discontinue immediately if jaundice or unexplained transaminase elevation occurs.

Discontinuation: Taper gradually over 1–2 weeks to avoid withdrawal symptoms. The drug is metabolized primarily by CYP2D6; poor metabolizers may require lower doses or alternative agents.

Sources: prescribing-info-v3.pdf p.12 · safety-monitoring.pdf p.34–37