The loop diuretic dose may need to be adjusted based on close monitoring of weight and symptoms (46). In pa- tients using insulin or insulin-secretagogues (such as sulfonylureas), coordinating care through the inclusion of endocrinologists and primary care providers may be helpful in order to minimize the risk of hypoglycemia in patients with diabetes. For several reasons, HYD/ISDN-indicated therapy for HF is often neglected in eligible patients. However, given the bene ts of this combination (43% relative reduction in mortality and 33% relative reduction in HF hospitali- zation) and the favorable impact on health status (47), African-American patients should receive these drugs once target or maximally tolerated doses of beta-blocker, ARNI/ACEI/ARB, and aldosterone antagonists are ach- ieved (3). This combination of drugs is especially impor- tant for those patients with NYHA class III to IV symptoms. Finally, in patients whose heart rate remains $70 beats/min on target or maximally tolerated doses of beta- blockers, ivabradine (6) can be added and titrated at 2 weeks to lower the heart rate. 5.2.2. Barriers to Medication Titration In some instances, it may not be possible to titrate GDMT to the target doses achieved in clinical trials. Patients seen in clinical practice may differ substantially from those enrolled in trials. For example, patients seen in clinical practice are typically older, may experience more side effects including hypotension, and are likely to have more comorbidities that will limit titration. Although data are lacking, it is logical to assume that below-target doses of multiple classes of GDMT are likely more effective in reducing risk than large doses of 1 or 2 agents. Abnormal renal function and/or hyperkalemia are common barriers to initiation and titration of GDMT. In patients with hyperkalemia, education regarding a low potassium diet should be provided. 