2.4 Blood pressure conditions

Angiotensin Converting Enzyme (ACE) Inhibitors

MHRA guidance for recommendations on use during pregnancy

Recommended: (TLS Green)

Ramipril

Lisinopril

Alternative: (TLS Blue)

Perindopril erbumine

Stroke

Recommended: (TLS Green)

Ramipril

Perindopril erbumine

Angiotensin-II Receptor Antagonists

MHRA guidance for recommendations on use during pregnancy.

Recommended: (TLS Green)

Candesartan

Losartan

Alternatives: (TLS Blue)

Irbesartan

Telmisartan

Antihypertensives (Centrally acting)

Specific indications: (TLS Blue)

Methyldopa

• Hypertension in pregnancy
• Treatment resistant cases

Alternatives: (TLS Blue)

Clonidine

Moxonidine

Alpha-adrenoceptor Blockers

Doxazosin (TLS Blue)

• Not including Doxazosin m/r preparation

Beta-adrenoceptor Blocking Drugs

Recommended: (TLS Green)

Atenolol

Bisoprolol

Specific indications:

Carvedilol (TLS Blue)

Esmolol (intravenous) (TLS Red)

Labetalol (intravenous) (TLS Red)

Labetalol (oral) (TLS Blue)

Metoprolol (TLS Blue)

• Renal patients and obstetrics only

Metoprolol (intravenous) (TLS Red)

• Cardiac rate control for CT coronary angiography

Nadolol (TLS Blue)

• Portal hypertension

Nebivolol (TLS Blue)

• On recommendation of Cardiology specialist only

Propranolol (TLS Blue)

• Anxiety, portal hypertension and thyrotoxicosis

Bisoprolol, carvedilol and Nebivolol (mild/moderate heart failure in patients over 70) are the only beta-blockers licensed for use in heart failure. Use of these in heart failure should be initiated cautiously, titrated very slowly and adequately monitored.

Calcium-channel Blockers

For most Calcium channel blockers it is best to prescribe by brand. When patients are initiated they should be started on the brand with the lowest acquisition cost

Recommended: (TLS Green)

Amlodipine

Alternatives: (TLS Blue)

Nifedipine modified-release (Prescribe by brand) (TLS Blue)

Diltiazem modified-release (Prescribe by brand) (TLS Blue)

Lercanidipine (TLS Blue)

• For treatment of hypertension as a second line calcium channel blocker option when amlodipine is not tolerated or suitable

Felodipine modified-release (TLS Blue)

• For those who need low doses (2.5mg), unable to take amlodipine, existing patients

Verapamil modified-release

Specific indications:

Nimodipine (TLS Red)

• Subarachnoid haemorrhage only

Nicardipine (intravenous) (TLS Red)

• for acute hypertension in critical care/intensive care units where labetalol/GTN is not effective of contraindicated or most suitable.

Nifedipine capsules non modified-release (TLS Blue) - Raynaud's Phenomenon / ITU / Renal

Peripheral Vasodilators

• For use as an adjunct, or where other treatments have failed

Recommended:

Hydralazine (intravenous) (TLS Red)

Hydralazine (oral) (TLS Green)

Alternative: (TLS Blue)

Minoxidil

Renin Inhibitors

Specific indication: (TLS Red)

Aliskiren

• As a 4th/5th line treatment antihypertensive, but not for patients with significant comorbidities such as diabetes who were specifically excluded from the trials.

Benign Prostatic Hyperplasia - see section 7.1

Thiazides and Related Diuretics

Recommended: (TLS Green)

Indapamide 2.5mg tablets

• First line post-stroke and hypertension
• Not first line for heart failure

2.4.2 Hypertension associated with phaeochromocytoma

Specific indications: (TLS Red)

Phentolamine

• Management of phaeochromocytoma

Phenoxybenzamine

• Management of phaeochromocytoma

2.4.3 Hypertensive crises

Diazoxide

• Hypertensive crisis

Sodium nitroprusside

• Hypertensive crisis (may be delays in obtaining unlicensed product)

2.4.4 Pulmonary hypertension

Specific indications: (TLS Red)

According to NHS England Policy A11/P/a Targeted Therapies for Pulmonary Hypertension Functional Class II

Sildenafil (oral & parenteral)

• Pulmonary Arterial Hypertension (PAH) - UHB only

Tadalafil (oral)

• Pulmonary Arterial Hypertension (PAH) - UHB only

Bosentan (oral)

• Pulmonary Arterial Hypertension (PAH) - UHB only
• As per NHS England Clinical Commissioning Policy: National policy for targeted therapies for pulmonary hypertension in adults. A11/P/b and amendment to National Policy to include functional class II. NHSCB A11/P/a
• As per NHS England Clinical Commissioning Policy A13/P/b: Sildenafil and Bosentan for the Treatment of Digital Ulceration in Systemic Sclerosis; NHS England funded via Prior Approval Scheme on Blueteq

Ambrisentan (oral)

• Pulmonary Arterial Hypertension (PAH) - UHB only
• As per NHS England Clinical Commissioning Policy: National policy for targeted therapies for pulmonary hypertension in adults. A11/P/b and amendment to National Policy to include functional class II. NHSCB A11/P/a

Epoprostenol (intravenous)

• Pulmonary Arterial Hypertension (PAH) - UHB only
• As per NHS England Clinical Commissioning Policy: National policy for targeted therapies for pulmonary hypertension in adults. A11/P/b and amendment to National Policy to include functional class II. NHSCB A11/P/a

Riociguat

• According to NHSE Policy Riociguat in the treatment of Pulmonary Hypertension

Prostaglandins (Cardiovascular)

Iloprost (TLS Red)

• For use in Pulmonary Arterial Hypertension (PAH)
• As per NHS England Clinical Commissioning Policy: National policy for targeted therapies for pulmonary hypertension in adults. A11/P/b and amendment to National Policy to include functional class II. NHSCB A11/P/a

2.4.5 Hypotension and shock

Sympathomimetics (vasoconstrictor)

Recommended:

Adrenaline (epinephrine) 1 in 1000 (1mg/mL) (TLS Green)

Adrenaline (epinephrine) 1 in 10,000 (100micrograms/mL) only in secondary care (TLS Red)

Ephedrine (TLS Red)

Metaraminol (TLS Red)

Noradrenaline (norepinephrine) (TLS Green)

Phenylephrine (TLS Red)

Specific indication:

Ephedrine hydrochloride tablets (unlicensed indication) (TLS Red)

• For use post spinal cord injuries

2.4.6 Other

Midodrine (TLS Red)

• For hepatorenal syndrome

Midodrine (TLS Amber Specialist Initiated)

• For orthostatic hypotension/intradialytic hypotension

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