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 |
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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 |
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) |
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BACK to main chapter |
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2.5.5.3 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. |
|
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. |
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BACK to main chapter |
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