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2.5 Antihypertensive therapy

Please see the NICE Clinical Guideline 127 for hypertension in adults

2.5.1 Vasodilator antihypertensive drugs

Hydralazine tablets, injection
Sildenafil tablets (resistant digital ulcers in systemic sclerosis – unlicensed indication). Rheumatologist use only RED drug
Iloprost infusion (resistant digital ulcers in systemic sclerosis). Rheumatologist use only
Bosentan tablets (resistant digital ulcers in systemic sclerosis). Rheumatologist use only RED drug
Sodium nitroprusside injection

Note: 

Sodium nitroprusside is unsuitable for use outside of critical care areas.

The Clinical Commissioning policy for sildenafil/bosentan in the treatment of digital ulceration in systemic sclerosis can be found here

 

2.5.2 Centrally acting agents

Methyldopa tablets, injection
Clonidine injection
Clonidine suspension 100micrograms/5ml (unlicensed)
Moxonidine tablets

Notes: 

1. Methyldopa is used for the management of hypertension in pregnancy.

2. Moxonidine should be used as a last line anti-hypertensive .

 

2.5.3 Adrenergic Neurone Blocking Drugs

Guanethidine injection

Note:

Specialist use in pain clinic only

 

2.5.4 Alpha-adrenoceptor blocking drugs

Doxazosin tablets.
Prazosin tablets
Phenoxybenzamine injection - critical care only
Phenoxybenzamine tablets - for phaeochromocytoma (prior to surgery)

Notes:

1. Alpha blockers should not normally be used for first line treatment of hypertension because of side effects. However they may be appropriate where hypertension is associated with marked hyperlipidaemia or diabetes.

2. Doxazosin is five times the cost of prazosin but tachyphylaxis is more likely to occur with prazosin.

 

2.5.5.1 Angiotensin-converting enzyme inhibitors

Captopril tablets
Enalapril tablets
Lisinopril tablets
Perindopril tablets (for hypertension in patients post-stroke)
Ramipril capsules

Notes:

1. Check renal function prior to starting treatment and at one week, one month, and then every six months (more frequently if deteriorating renal function). Particular care is needed in patients with diabetes and/or established vascular disease.

2. Start with a low dose given at bedtime. Use the maximum tolerated dose in heart failure.

3. Combination use of drugs acting on the renin–angiotensin system (ACE inhibitors, angiotensin ii receptor antagonists “sartans”) is associated with an increased risk of hyperkalaemia, hypotension and impaired renal function. Patients with diabetic nephropathy are especially at risk. Such combinations are not recommended – See MHRA Drug Safety update June 2014

4. Use in Pregnancy: ACE inhibitors and angiotensin II receptor antagonists should not be used at any stage of pregnancy unless absolutely necessary, and only then after the potential risks and benefits have been discussed with the patient. Captoprilenalapril, or quinapril use in breastfeeding is not recommended in the first few weeks after delivery because of the possibility of profound neonatal hypotension; preterm babies may be at particular risk.

NICE recommendations on the use of renin-angiotensin system drugs in various indications:

 

2.5.5.2 Angiotensin-II receptor antagonists

Candesartan Tablets - 1st line Sartan choice for heart failure
Losartan - 1st Line Sartan choice for hypertension
Irbesartan tablets - in type II diabetes patients with hypertension and nephropathy
Valsartan tablets
Valsartan / sacubitril tablets – see notes; NICE TA (note: RED drug – hospital prescribing only)

Notes:

1. These are expensive agents which should be reserved for those patients intolerant of other ACE inhibitors and antihypertensives. They are effective in heart failure but are not yet licensed for this use. Monitor renal function as for ACE-I.

2. Combination use of drugs acting on the renin–angiotensin system (ACE inhibitors, angiotensin ii receptor antagonists “sartans”) is associated with an increased risk of hyperkalaemia, hypotension and impaired renal function. Patients with diabetic neuropathy are especially at risk. Such combinations are not recommended – See MHRA Drug Safety update June 2014

3. Use in Pregnancy: ACE inhibitors and angiotensin II receptor antagonists should not be used at any stage of pregnancy unless absolutely necessary, and only then after the potential risks and benefits have been discussed with the patient.

 4. Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in adults:

  • with New York Heart Association class II to IV symptoms and
  • a left ventricular ejection fraction of 35% or less and
  • who are already taking a stable dose of ACE inhibitor or angiotensin II receptor-blockers.        
        

Sacubitril valsartan should be started by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration should be performed by the most appropriate team member

Click here for Derbyshire Heart Failure Guidelines


For link to BNF section: 2.5 Hypertension and heart failure