| 2.5.5.2 Angiotensin-II receptor antagonists |
| Do not use first line. Use 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 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®) |
| |
| 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 |
| function. |
| 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 |
| |
| 2.5.5.3 Renin Inhibitors |
| Chronic Kidney Disease NICE CG182, |
| Monitoring ACEI/ARB treatment in CKD only |
| Test eGFR and serum potassium before starting treatment, 102 weeks later and after each dose increase. |
| |
| Potassium |
| > 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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