ACE-inhibitors (ACEIs) should be used in line with NICE / CCG guidance for hypertension and heart failure. All should be prescribed in a single daily dose where possible. Lisinopril and Ramipril are the recommended first line options. Monitoring requirements U+Es at baseline, repeated 1-2 weeks after each dose increase for heart failure and after final dose increase in hypertension, annually thereafter.

ACE inhibitors and ARBs can cause hyperkalaemia, particularly if co-prescribed with potassium sparing diuretics (eplenerone, spironolactone, triamterene, bumetanide, amiloride) and certain antibiotics (trimethoprim,co-trimoxazole. Section 12 of the UK Renal Council’s Clinical practice guidelines treatment of acute hyperkalaemia in adults(2014) is especially relevant to primary care. It recommends that all patients with severe hyperkalaemia (K+ ≥ 6.5 mmol/L) are referred to secondary care for immediate assessment and treatment but that patients with mild (K+ ≥ 5.5-5.9 mmol/L) or moderate (K+ 6.0-6.4 mmol/L) hyperkalaemia have a review of their medication and diet and regular monitoring of serum potassium; the urgency of assessment and frequency of potassium monitoring will depend on individual circumstances.

Patients exhibiting ACE cough on first choice ACEI should trial a second choice ACEI before an ARB.

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
ACE-inhibitorsLisinopril2.5mg tablets: £0.77
5mg tablets: £0.74
10mg tablets: £0.78
20mg tablets: £0.85
Lisinopril is included in the formulary for:
Hypertension: in line with NICE guidance. Usual dose range 2.5mg-20mg daily. May be commenced at dose of 10mg daily in patients without renal impairment and not on diuretics.
Post-MI: titrated to 5-10mg daily if possible
Heart failure: Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved
• Diabetic nephropathy: initially 2.5mg once daily, adjusted to achieve sitting diastolic BP of <75mmHg in normotensive IDDM and <90mm Hg in hypertensive NIDDM, usual range 10-20mg once daily
orRamipril capsules1.25mg capsules:£1.29
2.5mg capsules: £1,49
5mg capsules: £1.26
10mg capsules: £1.29
Ramipril is included in the formulary for:
Hypertension: 1.25mg to 10mg daily, in line with NICE guidance.
Post-MI: titrated to 10mg daily if possible
Heart failure: Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved
orPerindopril Erbumine tablets2mg tablets: £1.03
4mg tablets: £1.30
8mg tablets: £1.60

Ensure Perindopril is prescribed as Perindopril Erbumine, rather than Perindopril Arginine, which is more expensive.
Perindopril Erbumine is included in the formulary for:
Hypertension:Treatment of hypertension
Heart failure:Treatment of symptomatic heart failure. Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved
Stable Coronary Artery Disease: Reduction of risk of cardiac events in patients with a history of myocardial infarction and/or revascularisation.

ARBs should only be used in patients with persistent troublesome ACEI induced cough. The percentage of patients’ reporting a cough was between 2-10% in randomised controlled trials. ACEIs have a better evidence base and are more cost-effective.

ARBs should be used in line with NICE / CCG guidance for hypertension and heart failure.

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Angiotensin-II receptor blockers (ARBs)Patients exhibiting ACE cough on first choice ACEI should trial a second choice ACEI before switching to an ARB.
Dual therapy ACEI+ARB is not recommended for any indication, other than under specific conditions for patients with heart failure.
(NICE CG108 (2010): Chronic heart failure)

Patients with gout or raised uric acid would benefit from losartan which lowers urate levels, whereas the other ACEIs and sartans raise levels.
First line:

Losartan25mg tablets: £0.81
50mg tablets: £0.87
100mg tablets: £1.04
Losartan is included in the formulary for:
Hypertension: (where intolerant to ACEI except for people of African or Caribbean origin at step 2 where ARB are preferred to ACE) in line with NICE guidance, dose range 25-100mg once daily
• Renal protection in Type 2 DM with nephropathy: (where intolerant to ACEI) initially 50mg daily, increased after one month to 100mg daily according to blood pressure
Heart failure: (>60 yrs; ACE intolerant; LVEF <40% & clinically stable). Patients with heart failure who have been stabilised with an ACE inhibitor should not be switched to losartan. Initially 12.5mg, titrated at weekly intervals to usual maintenance dose of 50mg, as tolerated by patient.
Second line:Candesartan 2mg tablets:£1.03 (7)
4mg tablets:£0.67 (7)
8mg tablets:£1.07
16mg tablets: £1.28
32mg tablets: £1.82
Candesartan is included in the formulary for:
Hypertension: (where intolerant to ACEI) in line with NICE guidance, dose range 2-16mg daily
Heart failure: (where intolerant to ACEI) as per guidelines, titrated to 32mg daily if possible.
Third line:Valsartan capsules40mg capsules:£1.41
80mg capsules:£1.49
160mg capsules:£1.51
Valsartan is included in the formulary for:
• Essential hypertension in adults and hypertension in children and adolescents 6-18 yrs of age
• Recent MI-Treatment of clinically stable patients with symptomatic heart failure or asymptomatic left ventricular systolic dysfunction after a recent (12 hours-10 days) myocardial infarction.
Heart failure - Treatment of adult patients with symptomatic heart failure when (ACE) inhibitors are not tolerated or in beta-blocker intolerant patients as add-on therapy to ACE inhibitors when mineralocorticoid receptor antagonists (spironolactone, eplenerone) cannot be used.
AlternativeSacubitril/ Valsartan24mg/26mg £45.78 (28)
49mg/51mg £45.78 (28)
£91.56 (56)
97mg/103mg £91.56 (56)
Draft NICE guidance published Dec 15 provisionally recommended Sacubitril Valsartan for treating chronic heart failure with reduced ejection fraction in people with New York Heart Association class II to III symptoms who are on a stable dose of ACE inhibitors (or angiotensin II receptor blockers for people who are intolerant of ACE inhibitors) and who have a left ventricular ejection fraction of 35% or less. Approved for use in Somerset after specialist initiation (PAMM Jan 16). Shared care agreement
Remember to stop original ACEi or ARB medication
Centrally acting antihypertensive drugsMethyldopa125mg tablets: £112.95 (56)
250mg tablets: £5.37 (56)
500mg tablets: £9.57 (56)
Methyldopa is included in the formulary for:
Hypertension in pregnancy
Moxonidine200mcg tablets: £1.54
300mcg tablets: £1.53
400mcg tablets: £1.70
Moxonidine is included in the formulary for:
Hypertension: For treatment of resistant hypertension at Step 4 where BP remains sub-optimally controlled despite standard therapies.
Alpha-blockersDoxazosin



as Doxadura®
1mg tablets: £0.72
2mg tablets: £0.74
4mg tablets: £0.83

1mg tablets: £0.64
2mg tablets: £0.66
4mg tablets: £0.73
Alpha blocker monotherapy is not recommended.
Doxazosin is included in the formulary for:
Hypertension: For treatment of resistant hypertension at Step 4 where BP remains sub-optimally controlled despite standard therapies.
• Benign prostatic hyperplasia: See section 7
NB. Doxazosin MR (Cardura XL®) tablets are specifically not recommended for maintenance in hypertension and maximum licensed dose for other indications is 8mg. Stabilised hypertensive patients on Doxazosin MR tablets should be switched to standard 4mg tablets:
• Doxazosin MR 4mg one daily → Doxazosin 4mg one daily
• Doxazosin MR 8mg one daily → Doxazosin 4mg two daily