of action. Use of a potassium sparing diuretic can usually avoid the need for potassium supplement.
|
| |
| 2.2.1 Thiazides and related diuretics |
| GREEN Bendroflumethiazide tablets 2.5mg |
| GREEN Indapamide |
| tablets 2.5mg |
| tablets MR 1.5mg |
| N.B. Where Bendroflumethiazide is to be used for oedema or where an alternative to Metolazone (discontinued by |
| manufacturer) is needed, Bendroflumethiazide 5mg tablets would be suitable. |
| |
| 2.2.2 Thiazides Loop Diuretics |
First line treatment
|
GREEN Furosemide
|
tablets 20mg, 40mg
|
liquid 50mg in 5mL
|
AMBER Furosemide tablets 500mg
|
RED Furosemide injection 20mg/2mL, 50mg/5mL, 250mg/25mL
|
| |
Second line treatment - Only if poor response to furosemide
|
GREEN Bumetanide
|
| tablets 1mg, tablets 5mg |
| liquid 1mg/5mL |
| |
Metolazone –an unlicensed tablet is available and is approved for inclusion in formulary for secondary care use only.
|
| Before requesting primary care prescribing, patients must be established on a stable dose of metolazone for at least |
2 weeks, with stable urea and electrolytes (including creatinine) and a stable body wait before discharge.
|
Hypokalaemia may occur with thiazides and loop diuretics. The risk is greater with thiazides as they have a longer duration of action. Use of a potassium sparing diuretic can usually avoid the need for potassium supplement.
| | | | 2.2.1 Thiazides and related diuretics | | GREEN Bendroflumethiazide tablets 2.5mg | | GREEN Indapamide | | tablets 2.5mg | | tablets MR 1.5mg | | N.B. Where Bendroflumethiazide is to be used for oedema or where an alternative to Metolazone (discontinued by | | manufacturer) is needed, Bendroflumethiazide 5mg tablets would be suitable. | | | | 2.2.2 Thiazides Loop Diuretics | First line treatment
| GREEN Furosemide
| tablets 20mg, 40mg
| liquid 50mg in 5mL
| AMBER Furosemide tablets 500mg
| RED Furosemide injection 20mg/2mL, 50mg/5mL, 250mg/25mL
| | | Second line treatment - Only if poor response to furosemide
| GREEN Bumetanide
| | tablets 1mg, tablets 5mg | | liquid 1mg/5mL | | | Metolazone –an unlicensed tablet is available and is approved for inclusion in formulary for secondary care use only.
| | Before requesting primary care prescribing, patients must be established on a stable dose of metolazone for at least | 2 weeks, with stable urea and electrolytes (including creatinine) and a stable body wait before discharge.
| | Ongoing monitoring of urea and electrolytes (including creatinine) should be carried out on a monthly basis and the | |
| patients’ weight and blood pressure should be monitored at each clinic visit. |
| Metolazone has an established role in the treatment of resistant oedema in heart failure where it is combined with a |
| loop diuretic. The combination of metolazone and a loop diuretic is much more potent and needs to be initiated by |
| someone experienced in its use and needs careful monitoring of renal function and electrolytes. |
| It is routinely used in patients with renal impairment who do not respond to a loop diuretic. |
| **Metolazone must be prescribed by brand** |
| |
| UK-licensed metolazone tablets (Xaqua) [SPC] have up to two-fold difference in bioavailability compared to other |
| (unlicensed, imported) metolazone preparations. Between 2012 and 2022, patients needing metolazone in the UK |
| used unlicensed, imported tablets. Patients switching to the UK-licensed version may require dose adjustment |
| depending on clinical effect; patients should be monitored for dehydration and electrolyte disturbance. |
| |
| Metolazone (Zaroxolyn 2.5mg and 5mg tablets) are an unlicensed special order, imported, product from Canada. The |
| drug has a full monograph in the BNF with the Zaroxolyn brand listed in the medicinal forms section. |
| |
| AMBER Metolazone tablets PRESCRIBE BY BRAND |
| |
| 2.2.3 Potassium-sparing diuretics and aldosterone antagonists |
| Amiloride on its own is a weak diuretic. It causes retention of potassium and is used as a more effective alternative |
| to giving potassium supplements with thiazide or loop diuretics. |
| Spironolactone is licensed only for congestive cardiac failure, hepatic cirrhosis with ascites and oedema, malignant |
| ascites, nephrotic syndrome and the diagnosis and treatment of primary aldosteronism. |
| Both of these drugs have the potential to cause hyperkalaemia with drugs acting on the renin-angiotensin system. |
| |
| GREEN Amiloride |
| tablets 5mg |
| liquid 5mg/5mL |
| GREEN Spironolactone |
| tablets 25mg, 100mg |
| RED Spironolactone |
| liquid 5mg/5mL, 10mg/5mL, 25mg/5mL, 50mg/5ml, 100mg/5mL |
| for NICU use only |
| |
| Finerenone for treating chronic kidney disease in type 2 diabetes ICS Commissioned |
| NICE TA877 Finerenone is recommended as an option for treating stage 3 and 4 chronic kidney disease (with |
albuminuria) associated with Type 2 diabetes in adults. It is only recommended if:
|
| > it is an add-on to optimised standard care; this should include, unless they are unsuitable, the highest |
| tolerated licensed doses of: |
| > angiotensin - converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and |
| > sodium–glucose cotransporter‑2 (SGLT2) inhibitors and |
| > the person has an estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73 m2 or more. |
| |
| Eplerenone |
| For patients with symptoms and/or signs of heart failure and left ventricular systolic dysfunction (LVSD), initiate |
| treatment with eplerenone, an aldosterone antagonist. Eplerenone is licensed for post-MI treatment within 3–14 |
days of the MI, preferably after ACE inhibitor therapy. For patients with clinical heart failure and LVSD already being
|
| treated with an aldosterone antagonist for a concomitant condition (e.g. spironolactone), continue with the |
| aldosterone antagonist or an alternative, licensed for early post-MI treatment. |
| |
| Assessment/monitoring |
| Monitor renal function and serum potassium before and during treatment. If hyperkalaemia is a problem, |
| halve the dose or stop the treatment. |
| AMBER Eplerenone |
| tablets 25mg, 50mg |
| |
| 2.2.4 Potassium-sparing diuretics with other diuretics |
| Fixed dose combinations may be justified where compliance is a problem. |
| GREEN Co-amilofruse (amiloride, furosemide) |
| tablets 2.5/20, 5/40 |
| |
| 2.2.5 Osmotic diuretics |
| RED Mannitol intravenous infusion 10%, 20% |
| |
