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:
- Prescribers are reminded that perindopril should be prescribed generically.
- Ramipril is included as it is excreted by dual pathways.
- 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).
- Healthcare Commission audit standards advise 6 monthly monitoring of renal function in patients with heart failure.
- More frequent monitoring may be required in patients on ACE inhibitors or angiotensien-II receptor agonists plus spironolactone because of increased risk of hyperkalaemia.
- 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
- 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. - 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:
- Amber 3 - This drug is for a heart failure specialist initiation and stabilisation within its licensed indication only. The specialist should have access to a multidisciplinary heart failure team.
- Used as an option in accordance to NICE TA388: Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction (April 2016) which states: Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
-
with New York Heart Association (NYHA) class II to IV symptoms and
- with a left ventricular ejection fraction of 35% or less and
- who are already taking a stable dose of angiotensin?converting enzyme (ACE) inhibitors or angiotensin II receptor?blockers (ARBs).
- Prescriber must ensure that the patient's current treatment regime is optimal and that they are taken as agreed. Exerpts from ESC Guidelines are:
- Therapeutic algorithm and Evidence-based doses for heart failure with reduced ejection fraction (Excerpt from ESC guidelines)
- Full ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (May 2016)
-
Dose titration and monitoring should be performed by the most appropriate team member as defined in NICE's guideline on Chronic heart failure in adults: diagnosis and management (September 2018)
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:
- Indication: Pulmonary Hypertension
- Use as per Clinical Commissioning Policy: Selexipag for treating pulmonary arterial hypertension (adults) Dec 2018
- Only available via an agreed Shared Care Agreement with an approved specialist centre
- NHS England funded via Blueteq system
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