Hypertension
General Notes (Hypertension)
- Refer to NICE NG136 hypertension
- In hypertension associated with diabetes, ACE inhibitors are the drugs of first choice. They reduce proteinuria and slow the deterioration in renal function.
Prescribing Notes (ACE Inhibitors)
- First dose hypotension may occur when ACE inhibitors are introduced to patients who are already receiving diuretics. Temporary withdrawal of the diuretic may reduce this risk (see BNF).
- Monitoring is required for all patients. Patient should have their electrolytes and renal function (creatinine and eGFR) checked:
- before initiating treatment
- within 2 weeks of commencing treatment
- within 2 weeks of last dose increase
- annually
- Treatment with ACE inhibitors can be initiated in the community but close medical supervision is required. ACE inhibitors should be initiated under specialist supervision and with careful monitoring in those with severe heart failure or in those with a number of co-morbidities (see BNF).
- ACE inhibitors tend to cause potassium retention. To avoid dangerous hyperkalaemia, potassium supplements or potassium-sparing diuretics should not be used with ACE inhibitors. If spironolactone is prescribed, serum potassium must be monitored. Ask about potassium-containing salt substitutes that a patient may be taking: one serving of common salt substitutes can contain around the potassium content of one oral potassium supplement tablet.
- ACE inhibitors cause cough in some patients. In patients who are intolerant of ACE inhibitors, preferred alternatives depend on the type of heart failure. For full details see NG106.
- ACE inhibitors and ARBs are contra-indicated in pregnancy and should be avoided in patients who become pregnant.
- Prescribe perindopril as perindopril erbumine rather than perindopril arginine, as perindopril arginine has no clinical benefit over perindopril erbumine and is more costly.
Cautions (ACE inhibitors)
- Patients taking ACE inhibitors or ARBs should be informed that they are at an increased risk of Acute Kidney Injury (AKI) if they develop an illness associated with hypovolaemia and hypotension. ACE inhibitors and ARBs should be stopped temporarily Refer to ‘sick day guidance’ for further information.
- As elderly patients are at particular risk of renal impairment, renal function should be monitored pre-treatment in patients taking ACE inhibitors. Regular U&E checks may be needed after initiation.
- Initiation of ACE inhibitors or ARBs may precipitate hypotension in patients with severe aortic stenosis or outflow obstruction. Therefore use with caution and under the direction of a specialist.
- Caution is required in patients who may have renovascular disease. ACE inhibitors are contra-indicated in patients with renal artery stenosis.
Heart Failure
General Notes (Heart failure)
- Refer to NICE heart failure guidance NG106.
- In heart failure, ACE inhibitors have been shown to improve symptoms and prolong life. They also improve outcome after myocardial infarction, particularly in patients with left ventricular dysfunction.
- For further Prescribing Notes on ACE inhibitors see above.
- Cough is common in heart failure. ACE inhibitors cause cough in some patients. Do not rule out an ACE inhibitor until you are certain it is causing the cough.
Prescribing Notes
Sacubitril/Valsartan (ARNI)
- Primary care prescribers should consider seeking advice from a heart failure specialist before starting someone on an ARNI such as sacubitril/valsartan (Entresto®).
- Sacubitril /valsartan should not be co-administered with an ACE inhibitor.
- Due to the potential risk of angioedema when used concomitantly: sacubitril/valsartan must not be started until 36 hours after taking the last dose of ACE inhibitor therapy; ACE inhibitor therapy must not be started until 36 hours after the last dose of sacubitril/valsartan.
Cautions
- Please see here for ACE inhibitor cautions
Secondary Prevention
- please see above for prescribing notes and cautions