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2.4 Blood pressure conditions

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

2.4.1 Hypertension

Angiotensin-converting enzyme inhibitors  (ACE inhibitors)

Enalapril maleate

  •  Tablets 2.5mg, 5mg, 10mg, 20mg 

Lisinopril

  • Tablets 2.5mg, 5mg, 10mg, 20mg 

 

Captopril (Amber 3) 

  • Tablets 12.5mg, 25mg, 50mg 
  • Noyada® Oral solution sugar free 5mg/5mL, 25mg/5ml (Paediatric use only)

 

Stroke

Perindopril erbumine

  • Tablets 2mg, 4mg, 8mg 

Ramipril

  • Capsules 1.25mg, 2.5mg, 5mg, 10mg

Notes:

  1. Prescribers are reminded that perindopril should be prescribed generically. 
  2. Ramipril is included as it is excreted by dual pathways.
  3. A review in the BMJ by Kalra et al (ref: BMJ 1999: 234-237) recommended that renal function should be assessed before and 7–10 days after starting ACE inhibitors in all patients and thereafter regularly (for example annually) in those with risk factors. Renal function should also be assessed in all patients at times of relevant intercurrent illness (and if concomitant drug treatment is modified).
  4. Healthcare Commission audit standards advise 6 monthly monitoring of renal function in patients with heart failure.
  5. More frequent monitoring may be required in patients on ACE inhibitors or angiotensien-II receptor agonists plus spironolactone because of increased risk of hyperkalaemia.
  6. In heart failure, it is important that ACE inhibitors are titrated up to their target dose (or maximum tolerated), as advised by NICE:
    • Ramipril = 5mg twice daily or 10mg once daily
    • Lisinopril = 30mg – 35mg once daily
    • Perindopril = 4mg once daily
  7. Up-titrating ACE inhibitors and Beta-blockers post MI:
    Patients discharged from hospital following an acute coronary syndrome have usually been started on ACE inhibitors and beta-blockers. However the doses are usually suboptimal and need up-titrating.
  8. Following an infarct with significant damage to the left ventricle it is important that the ACE inhibitor is up-titrated first. Similarly the beta-blocker needs up-titrating with similar time intervals.   

  

Angiotensin-II receptor antagonists 

Candesartan cilexetil 

  • Tablets 2mg, 4mg, 8mg, 16mg, 32mg

 

Irbesartan 

  • Tablets 75mg, 150mg, 300mg

 

Losartan potassium

  • Tablets 12.5mg, 25mg, 50mg, 100mg 

 

Valsartan 

  • Tablets 40mg, 80mg, 160mg, 320mg

 

 

Sacubitril / Valsartan (Amber 3)

  • Entresto® film-coated tablets 24mg/26mg, 49mg/51mg, 97mg/103mg

Notes:

  1. with New York Heart Association (NYHA) class II to IV symptoms and
  2. with a left ventricular ejection fraction of 35% or less and
  3. who are already taking a stable dose of angiotensin?converting enzyme (ACE) inhibitors or angiotensin II receptor?blockers (ARBs). 

 

  

 

Antihypertensives (Centrally acting)

Methyldopa

  • Tablets 125mg, 250mg, 500mg

Notes: 

  • Methyldopa is included for the treatment of hypertension in pregnancy only. 

 

 

Clonidine

  • Tablets 100 micrograms and 25 micrograms
  • Injection 150 micrograms/1mL

Notes: Other uses of clonidine

  • Licensed: Prevention of recurrent migraine; prevention of vascular headache
  • Unlicensed: Tourette syndrome and sedation 

 

 

Moxonidine (Amber 3)

  • Tablets 200mcg, 300mcg, 400mcg

 

 

Beta-adrenoceptor blocking drugs

Atenolol

  • Tablets 25mg, 50mg, 100mg
  • Syrup - Sugar free 25mg/5mL
  • Injection 5mg/10mL (Hospital only)

 

Bisoprolol fumarate

  • Tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg

 

Carvedilol

  • Tablets 3.125mg, 6.25mg, 12.5mg, 25mg

 

Esmolol hydrochloride

  • Injection 10mg/mL (10mL vial) For testing for suitability for beta blockade only

 

Labetalol hydrochloride

  • Tablets 100mg, 200mg, 400mg
  • Injection  5mg/mL (20-mL amp) Hospital only

 Notes: 

  • Labetalol may be used for the treatment of hypertension in pregnancy.

 

Metoprolol tartrate

  • Tablets 50mg, 100mg
  • Injection 1mg/mL (5-mL amp)

Note: 

  • Metoprolol is a short-acting agent that may be used in secondary care post myocardial infarction (unlicensed indication).

 

Propranolol hydrochloride

  • Tablets 10mg, 40mg, 80mg and 160mg
  • Capsules - Modified release 80mg, 160mg
  • Oral solution 5mg in 5ml 

 

Calcium-channel blockers

Amlodipine

  • Tablets 5mg, 10mg

 

 

Diltiazem (once daily dosing)

  • Modified release capsules 120mg, 180mg, 240mg, 300mg (Zemtard XL)
  • Modified release capsules 200mg, 300mg (Tildiem LA)   

Diltiazem (twice daily dosing)

  • Modified release capsules 90mg, 120mg, 180mg (Adizem SR)
  • Modified release capsules 60mg, 90mg, 120mg (Dilcardia SR)
  • Modified release tablets 90mg, 120mg (Tildiem Retard)  

Diltiazem (three times daily dosing) Amber 2

  • Modified release generic tablets 60mg. Although labelled as MR, it is not slow-release and can be crushed for a small cohort of patients with swallowing difficulties in hospital
  • Patients to be converted to bd or od preparations on discharge if appropriate
  • There is no need for brand name prescribing

 

Notes:

  • Please specify the brand when prescribing a modified release diltiazem preparation in order to avoid bioavailability differences. (This does not apply to the 60mg tds tablet).
  • A once a day modified release preparation improves concordance.

 

 

Felodipine

  • Tablets modified release 2.5mg, 5mg, 10mg 

 

Nicardipine

  • Capsules 30mg
  • Capsules Modified Release 30mg
  • Injection 1mg/mL (10-mL amp)

Notes:

  • Second line choice after beta-blockers unless beta-blockers are contra-indicated

 

 

Nifedipine

Adalat LA (once daily)

  • Nifedipine modified release tablets 20mg, 30mg, 60mg 

Adalat Retard (twice daily)

  • Nifedipine modified release tablets 10mg, 20mg 

Coracten XL (once daily)

  • Nifedipine modified release capsules 30mg, 60mg 

Coracten SR (twice daily)

  • Nifedipine modified release capsules 10mg, 20mg 

Nifedipine

  • Capsules 5mg, 10mg

 

Notes:

  • Please specify the brand when prescribing a modified release preparation of nifedipine.
  • Short-acting nifedipine is not recommended for angina or long-term management of hypertension; their use maybe associated with large variations in blood pressure and reflex tachycardia.
  • Modified release “retard” formulations of nifedipine designed for twice daily dosing are not suitable for patients with angina as they may not produce smooth blood pressure control over 24 hours. N.B Does not include LA or XL products.

 

 

Verapamil

  • Tablets 40mg, 80mg, 120mg, 160mg
  • Modified release tablet 120mg (Half Securon SR)
  • Modified release tablet 240mg (Securon SR)
  • Injection 5mg in 2mL

 

 

Peripheral vasodilators 

Hydralazine

  • Tablets 25mg, 50mg
  • Injection 20mg ampoule

Note: 

  • Hydralazine may be used in combination with long acting nitrates in moderate to severe chronic congestive cardiac failure when an ACE inhibitor is contra-indicated or not tolerated.

 

 

Thiazides and related diuretics

Bendroflumethiazide

  • Tablets 2.5mg, 5mg

 

Chlorothiazide (unlicensed)

  • Suspension 250mg/5mL

Note:

  • For Paediatric use only.
  • Tertiary Care Specialist Service / Hospital initiation with secondary care continuation

 

Co-amilozide

  • Tablets 2.5mg/25mg, 5mg/50mg  (amiloride/hydrochlorothiazide) 

 

Indapamide

  • Tablets 2.5mg

 

 

2.4.2 Hypertension associated with phaeochromocytoma

Phentolamine mesilate (unlicensed)

  • Injection 10mg/1mL

Note:

  • Sourced from Oxford Pharmacy Store

 

 

 

 

 

2.4.4 Pulmonary hypertension

Antiplatelet Drugs

Selexipag

  • Tablet 200 microgram, 400 microgram, 600 microgram, 800 microgram, 1mg, 1.2mg, 1.4mg, 1.6mg.

Notes:

 

Prostaglandins (Cardiovascular)

Iloprost

  • Injection 50mcg in 0.5mL

Note:

  • Local guidance can be found here.

 

 


2.4.5 Hypotension and shock 

Sympathomimetics (vasoconstrictor)

 

Dopamine hydrochloride

  • Injection 200mg in 5mL
  • Injection 800mg in 5mL 

 

Ephedrine

  • Injection 3mg in 1mL (30mg/10ml pre-filled syringes)
  • Injection 30mg in 1mL (ampoules)

 

Metaraminol

  • Injection 10mg in 1mL

(Available from 'special order' manufacturers or specialist importing companies)

 

Noradrenaline/norepinephrine

  • Injection 4mg in 4mL 

 

Phenylephrine hydrochloride

  • Injection 10mg in 1mL

 

 

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

Return to Chapter: 2. Cardiovascular system

Last updated by: Dupe Fagbenro on 19-02-2019 15:25