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2.5 Hypertension and Heart Failure
    2.5.1 Vasodilator antihypertensive drugs
                   Potent drugs. Hydralazine is a useful adjunct to other treatment. 
                   GREEN      Hydralazine tablets 25mg, 50mg 
                   RED           Hydralazine injection 20mg 
                   RED           Sodium nitroprusside intravenous infusion 50mg/5mL
                   Pulmonary arterial hypertension
                   Sildenafil and bosentan are licensed for use in pulmonary arterial hypertension (PAH).  Treatment of this condition is 
                   commissioned nationally through a small number of PAH centres based in hospitals across the UK.  All patients should 
                   be referred to one of these centres, who carry out all prescribing of these therapies through a home  delivery company. 
                   Funding for treatment will be authorised by the patients CCG prior to initiation by a PAH centre.  The nearest
                   PAH centre is at the Royal Hallamshire Hospital, Sheffield.

                   RED           Bosentan tablets 62.5mg, 125mg 
                   RED           Sildenafil tablets 20mg (Revatio® brand, NOT Viagra®)     
     2.5.2 Centrally Acting antihypertensive drugs 
                  Not widely used, but may be useful in pregnancy and asthma. Moxonidine to be used in resistant hypertension only.
                  GREEN       Methyldopa tablets 125mg, 250mg, 500mg 
                  AMBER       Moxonidine tablets 200microgram, 300microgram, 400microgram
     2.5.4 Alpha-adrenoceptor blocking drugs 
                 Doxazosin also has vasodilator properties.  
                 It is a fourth-line choice of antihypertensive only – see NICE guideline on hypertension [NG136] 
                 GREEN       Doxazosin tablets 1mg, 2mg, 4mg

                 The use of doxazosin m/r is not recommended. In hospital, all prescriptions for doxazosin m/r will be changed to  
                 standard release tablets as above.
                 Phenoxybenzamine is used in its management
                 AMBER      Phenoxybenzamine capsules 10mg 
                 RED            Phenoxybenzamine injection 100mg/2 mL
                   BACK to main chapter
     2.5.5 Drugs affecting the renin-angiotensin system
 Angiotensin-converting enzyme inhibitors
                 For hypertension, heart failure, immediate and long term management post MI. For heart failure and Mi aim to 
                 increase lisinopril to 30mg/day and ramipril to10mg/day to gain maximum effects.
                 GREEN      Lisinopril tablets 2.5mg, 5mg, 10mg, 20mg 
                 GREEN      Ramipril capsules 1.25mg, 2.5mg, 5mg, 10mg     

                 Perindopril is restricted to use in hypertension for secondary prevention of stroke. It should be administered as a single  
                 daily dose 30 minutes before breakfast in order to minimise considerable variations in bioavailability.
                 GREEN      Perindopril tablets 2mg, 4mg
                 (reduction of proteinuria in children with nephritis - Paediatrics use only)
                 AMBER      Enalapril tablets 2.5mg
                 Post-natal Hypertension only
                 AMBER      Enalapril tablets 2.5mg , 5mg, 10mg
                 BACK to main chapter
 Angiotensin-II receptor antagonists
                Do not use first lineUse only if cough is troublesome on ACE inhibitors but bear in mind that cough may be
                a symptom of cardiac failure. Improvement in ACE inhibitor related cough can be expected within four weeks of stopping 
                therapy. Check product licenses in BNF before prescribing as they differ between products.
               Heart failure or hypertension
                First Line
                GREEN      Losartan tablets 12.5mg, 25mg, 50mg, 100mg
                Second Line (to be used when patient is intolerant of Losartan) 
                GREEN      Candesartan tablets 2mg, 4mg, 8mg, 16mg
                Heart failure with reduced ejection fraction
                Dapagliflozin NICE TA679 is recommended as an option for treating symptomatic chronic heart failure with reduced 
                ejection fraction in adults, only if it is used as an add-on to optimised standard care with:
                              >  angiotensin-converting enzyme (ACE) inhibitors or angiotensin‑2 receptor blockers (ARBs), with beta blockers, 
                                  and, if tolerated, mineralocorticoid receptor antagonists (MRAs), or
                              >  sacubitril valsartan, with beta blockers, and, if tolerated, MRAs.
                AMBER  Dapagliflozin 5mg, 10mg tablets (Forxiga®)
                Chronic heart failure with preserved or mildly reduced ejection fraction
                Dapagliflozin is recommended, within its marketing authorisation, as an option in NICE TA902 for treating symptomatic 
                chronic heart failure with preserved or mildly reduced ejection fraction in adults.
                AMBER  Dapagliflozin 5mg, 10mg tablets (Forxiga®)                                                                         ICB Commissioned
                Chronic heart failure with reduced ejection fraction
                Empagliflozin NICE TA773 is recommended as an option for treating symptomatic chronic heart failure with reduced 
                ejection fraction in adults, only if it is used as an add-on to optimised standard care with:
                               > an angiotensin-converting enzyme (ACE) inhibitor or angiotensin 2 receptor blocker (ARB), with a beta blocker 
                                  and, if tolerated, a mineralocorticoid receptor antagonist (MRA), or
                               > sacubitril valsartan with a beta blocker and, if tolerated, an MRA.
                 AMBER  Empagliflozin 10mg, 15mg tablet (Jardiance®)
               See SGLT2i Desktop Guide
               Diabetic nephropathy in type II diabetes mellitus
                First Line 
                GREEN      Irbesartan tablets 75mg, 150mg, 300mg
              Monitoring hypertension and post MI
                           >     Assess LV function in all patients who have had an MI.
                           >     Monitor BP, renal function and serum electrolytes:
                                   >  before starting an ACE/ARB and within 1 to weeks,
                                   >  after each dose increase
                                   >  periodically once the dose is stable; annually is suggested, but more often if at risk of deterioration in renal 
               AMBER      Sacubitril valsartan (Entresto®)   
                                  24 mg/26 mg,49 mg/51 mg,97mg/103 mg film-coated tablets
                                  (heart failure specialist only)
                As an option in NICE TA388  for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
                           >  with New York Heart asscoiation (NYHA) class II to IV symptoms and
                           >  with a left venticular 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)
           BACK to main chapter
 Renin Inhibitors
               Chronic Kidney Disease: assessment and management NICE CG203,
               Monitoring ACEI/ARB treatment in CKD only 
               Test eGFR and serum potassium before starting treatment, 102 weeks later and after each dose increase.
                           >  Monitor more frequently if the patient is taking other drugs that cause hyperkalaemia
                           >  if serum potassium >5.0mmol/L:
                                   >  Do NOT start ACEIs/ARBs
                                   >  Investigate and treat other factors known to cause hyperkalaemia then 
                                   >  recheck serum potassium
                           >  If serum potassium >6.0mmol/L: STOP ACEIs/ARBs
               eGFR and serum creatinine
                           >  If there is a decrease in eGFR <25% or an increase in serum creatinine <30%
                                   >   Do NOT change the dose,
                                   >   repeat test after 1-2 weeks.
                           >  If  the eGFR decrease is > 25% or serum creatinine increase 30% 
                                   >   investigate other causes,
                                   >   if no other cause: STOP ACEI/ARB or reduce dose,
                                   >   add alternative antihypertensive if required.
           BACK to main chapter


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