NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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2 Cardiovascular system

2.5 Hypertension and heart failure

The choice of therapeutic class for the management of hypertension is dependent on individual patient parameters. See the NHSGGC Guidelines for the Management of Hypertension, available on the Clinical Guidelines store on StaffNet.

2.5.1 Vasodilator antihypertensive drugs

Total Formulary
AMBRISENTAN

Restrictions: Restricted to initiation and prescribing by specialists in the Scottish Pulmonary Vascular Unit or similar specialists.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201149.htm

BOSENTAN

Restrictions: Restricted to initiation and prescribing by specialists in the Scottish Pulmonary Vascular Unit or similar specialists. Use in the reduction of the number of digital ulcers in patients with systemic sclerosis and ongoing digital ulcer disease and for pulmonary arterial hypertension WHO class II is non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/119710.htm

ILOPROST

Restrictions: Iloprost nebules are restricted to use as an alternative in patients receiving other forms of prostacyclin treatment and to use by specialists in the Scottish Pulmonary Vascular Unit or similar specialists.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/128452.htm

MACITENTAN (OPSUMIT) (tablets)

Restrictions: Use as monotherapy or in combination is indicated for the long-term treatment of pulmonary arterial hypertension in adult patients of World Health Organisation Functional Class II to III is restricted to initiation and prescribing by specialists in the Scottish Pulmonary Vascular Unit or similar specialists.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP34437-macitentan.htm?q=macitentan&t=search&ss=text&p=1#_hit

MINOXIDIL

Restrictions: Restricted to specialist use only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2540.htm

RIOCIGUAT

Restrictions: For Formulary indications and restrictions, see Prescribing Notes.

Prescribing Notes:

Chronic thromboembolic pulmonary hypertension (CTEPH): Treatment of adult patients with World Health Organisation (WHO) functional class II to III with inoperable CTEPH or  persistent or recurrent CTEPH after surgical treatment to improve exercise capacity. It is restricted to initiation and prescribing only by specialists in the Scottish Pulmonary Vascular Unit for use in patients in whom a PDE5 inhibitor is inappropriate, not tolerated, or ineffective.

Pulmonary Arterial Hypertension (PAH): Restricted to use as a PAH-specific monotherapy as an alternative treatment option to endothelin receptor antagonist (ERA) monotherapy in adult patients with PAH of WHO FC II to III. It is restricted to initiation and prescribing by specialists in the Scottish Pulmonary Vascular Unit or by similar specialists.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP34610-adempas.htm?q=riociguat&t=search&ss=text&p=3#PHP34610-adempas

SILDENAFIL CITRATE (Revatio)

Restrictions: Restricted to specialists working in the Scottish Pulmonary Vascular Unit or similar specialists and by physicians experienced in the management of pulmonary vascular disease.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129682.htm#_129682

SODIUM NITROPRUSSIDE

Restrictions: Restricted to specialist use only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2542.htm

TADALAFIL (ADCIRCA) (tablets)

Restrictions: The treatment of adults with pulmonary arterial hypertension (PAH) classified as World Health Organisation functional class (WHO-FC) II and III, to improve exercise capacity is restricted to prescribing by specialists in the Scottish Pulmonary Vascular Unit or similar specialists.

Prescribing Notes:

The relevant SMC advice can be accessed here

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/213711.htm?q=adcirca&t=search&ss=text&p=1#_213711

2.5.2 Centrally acting antihypertensive drugs

Total Formulary
MOXONIDINE

Restrictions: Restricted to clinicians experienced in treating hypertension.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/39984.htm

2.5.3 Adrenergic neurone blocking drugs

2.5.4 Alpha-adrenoceptor blocking drugs

Preferred list
DOXAZOSIN

Restrictions: Excluding MR preparations.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2564.htm

2.5.5 Drugs affecting the renin-angiotensin system

Any ACE Inhibitor or angiotensin-II antagonist may cause deterioation in renal function. Urea and electrolytes should be checked prior to initiation and within 7 days of commencing therapy or a change in dose.

2.5.5.1 Angiotensin-converting enzyme inhibitors

Preferred list
LISINOPRIL

Restrictions: Excluding combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2591.htm

RAMIPRIL

Restrictions: Excludes combination preparations

Prescribing Notes:

The capsules are more cost-efficient compared to the tablet formulation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/128495.htm#_128495

Total Formulary
CAPTOPRIL

Prescribing Notes:

Excludes combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2579.htm

ENALAPRIL

Prescribing Notes:

Excludes combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2585.htm

PERINDOPRIL ERBUMINE (TERTBUTYLAMINE)

Prescribing Notes:

Excludes combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2597.htm

2.5.5.2 Angiotensin-II receptor antagonists

There are no indications where angiotensin-II receptor antogonists should be used as first-line therapy and they should only be used as second-line agents in patients who develop a significant cough with ACE inhibitors.

Preferred list
CANDESARTAN

Restrictions: Candesartan should only be used as a second line agent in patients who develop a significant cough with ACE inhibitors. Use as add-on therapy with ACE inhibitors for heart failure and left ventricular systolic dysfunction is restricted to initiation by specialists.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/64864.htm

LOSARTAN

Restrictions: Losartan should only be used as a second line agent in patients who develop a significant cough with ACE inhibitors.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/27526.htm

Total Formulary
IRBESARTAN

Restrictions: Restricted to second line use in patients with a significant cough on an ACE inhibitor. The Formulary also excludes combination preparations.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/64883.htm

SACUBITRIL AND VALSARTAN (ENTRESTO) (tablets)

Restrictions:

Restricted to initiation by a consultant with special interest in heart failure in patients with heart failure class II to IV who have a left ventricular ejection fraction (LVEF) of <40% and ongoing symptoms despite optimal treatment (e.g. beta blocker, ACEI or ARB and either spironolactone or eplenerone) as outlined in SIGN Guideline 147.

Prescribing Notes:

  • Patients commenced on this medicine should have access to a multidisciplanary heart failure team
  • If the patient is already on an ACE inhibitor, the ACE inhibitor should be stopped for 36 hours before initiating sacubitril/valsartan to minimise the risk of angioedema.
  • Guidance on initiation and up-titration of sacubitril and valsartan can accessed here (requires access to the NHSGGC intranet, StaffNet)

TELMISARTAN

Restrictions: Restricted to second line use only for hypertension in patients with a significant cough on an ACE inhibitor.

Prescribing Notes:

The use in cardiovascular prevention or type 2 diabetes mellitus with documented target organ damage is not recommended by SMC and is non-Formulary. The Formulary also excludes combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/81217.htm

VALSARTAN

Restrictions: Restricted to second line use in patients with a significant cough on an ACE inhibitor. Restricted to second line alternative in patients following myocardial infarction with evidence of left ventricular systolic dysfunction who cannot tolerate ACE inhibitors.

Prescribing Notes:

Excludes combination products.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/56945.htm

2.5.5.3 Renin inhibitors