Related guidance:
- Hypertension in adults: diagnosis and treatment visual summary (see below)
- How do I control my blood pressure? Lifestyle options and choice of medicines patient decision aid
Hypertension: Calcium-channel blockers (NICE Clinical knowledge summaries, updated July 2022)
- Visual summaries to explain assessment, treatment and other aspects of care for various conditions relating to hypertension in pregnancy:Planning care for women at moderate and high risk of pre-eclampsia
Assessment of proteinuria and care plans
Chronic hypertension: pre-pregnancy advice
Chronic hypertension: antenatal care
Gestational hypertension: antenatal care
Intrapartum care and place of care
Criteria for choice of critical care level (hypertension, pre-eclampsia and eclampsia)
Follow-up care and postnatal review
Antihypertensive treatment during the postnatal period
Risk of long-term cardiovascular disease
Pre-eclampsia: antenatal care
Risk of recurrence of hypertensive disorders of pregnancy
Hypertension: treatment during pregnancy (SPS January 2022)
Using beta-blockers during breastfeeding (SPS June 2023, updated August 2023)
Using calcium-channel blockers during breastfeeding (SPS June 2023)
Using ACE inhibitors during breastfeeding (March 2023, updated June 2023)
Using angiotensin-II receptor antagonists during breastfeeding (SPS May 2023. updated June 2023)
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Beta-adrenoceptor blockers, selective | Bisoprolol | 1.25mg tablet: £0.74 | For hypertension and angina. Adult: Initially 5 mg once daily, usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily. For adjunct in heart failure. Adult: Initially 1.25 mg once daily for 1 week, dose to be taken in the morning, then increased if tolerated to 2.5 mg once daily for 1 week, then increased if tolerated to 3.75 mg once daily for 1 week, then increased if tolerated to 5 mg once daily for 4 weeks, then increased if tolerated to 7.5 mg once daily for 4 weeks, then increased if tolerated to 10 mg once daily. For post myocardial infarction (off-label). |
| 2.5mg tablet: £1.06 | |||
| 3.75mg tablet: £0.84 | |||
| 5mg tablet: £0.72 | |||
| 7.5mg tablet: £0.90 | |||
| 10mg tablet: £0.78 | |||
| Atenolol | 25mg tablet: £1.31 | For hypertenion. Adult: 25–50 mg daily, higher doses are rarely necessary. For angina. Adult: 100 mg daily in 1–2 divided doses. |
|
| 50mg tablet: £1.23 | |||
| 100mg tablet: £1.11 | |||
| 25mg/5ml oral solution sugar free: £10.47 (300ml0 | |||
| Metoprolol | 50mg tablet: £1.48 | For hypertension: Adult: Initially 100 mg daily, increased if necessary to 200 mg daily in 1–2 divided doses, high doses are rarely required; maximum 400 mg per day. For angina: Adult: 50–100 mg 2–3 times a day. For post myocardial infarction (off-label). The 50mg tablet can be divided into equal doses as the 25mg tablet is not cost effective. |
|
| 100mg tablet: £2.06 | |||
| Sotalol is no longer recommended for Atrial fibrillation. | |||
| Beta-adrenoceptor blockers, non-selective | Propranolol | 10mg tablet: £0.77 | For migraine prophylaxis. Adult: 80-240mg daily in divided doses. |
| 40mg tablet: £0.79 | |||
| 80mg tablet: £1.58 (56) | |||
| 10mg/5ml oral solution sugar free: £33.21 (150ml) | |||
| 40mg/5ml oral solution sugar free: £45.82 (150ml) | |||
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Calcium channel blockers | All calcium-channel blockers can precipitate heart failure in predisposed people. Calcium-channel blockers should not be used in people with heart failure with reduced ejection fraction or history of significantly impaired left ventricular function, even when controlled. Although dihydropyridines rarely aggravate heart failure (any negative inotropic effect is offset by a reduction in left ventricular work), they should not be initiated in people with uncontrolled heart failure. Amlodipine may be used cautiously in stable heart failure. |
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| Dihydropyridines | Amlodipine | 5mg tablet: £0.71 | For angina and hypertension. Adult: initially 5 mg once daily; increased if necessary up to 10 mg once daily. Please prescribe as Amlodipine (prescriptions for Amlodipine besilate will result in the supply of Istin® which is not cost effective). The 5mg tablet can be divided into equal doses as the 2.5mg tablet is not cost effective. |
| 10mg tablet: £0.76 | |||
| 5mg/5ml oral suspension sugar free: £70.00 (150ml) | |||
| NHS Somerset classify Olmesartan medoxomil and amlodipine and Olmesartan medoxomil, amlodipine and hydrochlorothiazide as a Black drug (not recommended) as per Traffic light guidance. | |||
| Advise patients taking hydrochlorothiazide-containing products of the cumulative, dose-dependent risk of non-melanoma skin cancer, particularly in long-term use, and the need to regularly check for (and report) any suspicious skin lesions or moles. Counsel patients to limit exposure to sunlight and UV rays and to use adequate sun protection. See MHRA (November 2018) for Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use. | |||
| Felodipine as Delofine XL® | 2.5mg modified-release tablets: £4.25 | Prophylaxis of angina. Adult: initially 5 mg once daily, to be taken in the morning; increased if necessary to 10 mg once daily. Elderly: initially 2.5 mg once daily, to be taken in the morning; increased if necessary up to 10 mg once daily. For Hypertension. Adult: initially 5 mg once daily, to be taken in the morning; usual maintenance 5–10 mg once daily, doses above 20 mg per day rarely needed. Elderly: initially 2.5 mg once daily, to be taken in the morning; usual maintenance 5–10 mg once daily, doses above 20 mg per day rarely needed. |
|
| 5mg modified-release tablet: £1.98 | |||
| 10mg modified-release tablet: £1.98 | |||
| Lacidipine | 2mg tablet: £3.36 | For hypertension. Adult: initially 2 mg daily; increased if necessary to 4 mg daily, then increased if necessary to 6 mg daily, dose increases should occur at intervals of 3–4 weeks, to be taken preferably in the morning. |
|
| 4mg tablet: £3.65 | |||
| 6mg tablet: £5.75 | |||
| Lercanidipine | 10mg tablet: £3.29 | For mild to moderate hypertension. Adult: initially 10 mg once daily; increased if necessary to 20 mg daily, dose can be adjusted after 2 weeks. |
|
| 20mg tablet: £7.09 | |||
| Rate limiting | Verapamil and diltiazem should not be used in people with left ventricular failure. | ||
| Diltiazem | Prescribers should specify the brand. Once daily dose formulations. |
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| as Slozem® | 120mg modified-release capsule: £5.49 | For angina and mild to moderate hypertension. Adult: initially 240 mg once daily; increased if necessary to 360 mg once daily. Elderly: initially 120 mg once daily; increased if necessary to 360 mg once daily. |
|
| 180mg modified-release capsule: £5.58 | |||
| 240mg modified-release capsule: £5.67 | |||
| 300mg modified-release capsule: £6.03 | |||
| as Zemtard XL® | 120mg modified-release capsule: £6.10 | For angina. Adult: 180–300 mg once daily, increased if necessary to 480 mg once daily. Elderly: initially 120 mg once daily, increased if necessary to 480 mg once daily. For mild to moderate hypertension. Adult: 180–300 mg once daily, increased if necessary to 360 mg once daily. Elderly: initially 120 mg once daily, increased if necessary to 360 mg once daily. |
|
| 180mg modified-release capsule: £6.20 | |||
| 240mg modified-release capsule: £6.30 | |||
| 300mg modified-release capsule: £6.70 | |||
| Verapamil | Verapamil should not be combined with a beta-blocker for any indication due to high risk of bradycardia and heart-block. | ||
| 40mg tablet: £1.43 (84) | For angina. Adult: 80–120 mg 3 times a day. For hypertension. Adult: 240–480 mg daily in 2–3 divided doses. Treatment of supraventricular arrhythmias. Adult: 40–120 mg 3 times a day. |
||
| 80mg tablet: £2.09 (84) | |||
| 40mg/5ml oral solution sugar free: £158.85 (150ml) | |||
| as Half-Securon SR® | 120mg modified-release tablet: £7.71 | For hypertension in patients new to verapamil. Adult: initially 120 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided doses. For hypertension. Adult: 240 mg daily, increased if necessary up to 480 mg daily, doses above 240 mg daily as 2 divided doses. For angina. Adult: 240 mg twice daily, may sometimes be reduced to once daily. |
|
| as Securon SR® | 240mg modified-release tablet: £5.55 |
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| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Angiotensin-converting enzyme inhibitors | Lisinopril | 2.5mg tablet: £0.74 | 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 |
| 5mg tablet: £0.82 | |||
| 10mg tablet: £0.92 | |||
| 20mg tablet: £1.04 | |||
| 5mg/5ml oral solution sugar free: £198.00 (150ml) | |||
| Ramipril | 1.25mg capsule: £1.19 | 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 |
|
| 2.5mg capsule: £1.13 | |||
| 5mg capsule: £1.08 | |||
| 10mg capsule: £1.22 | |||
| 2.5mg/5ml oral solution sugar free: £179.00 (150ml) | |||
| Perindopril erbumine | 2mg tablet: £0.95 (30) | 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. |
|
| 4mg tablet: £1.09 (30) | |||
| 8mg tablet: £1.41 (30) | |||
| NHS Somerset classify Enalapril maleate and hydrochlorothiazide as a Black drug (not recommended) as per Traffic light guidance. | |||
| Advise patients taking hydrochlorothiazide-containing products of the cumulative, dose-dependent risk of non-melanoma skin cancer, particularly in long-term use, and the need to regularly check for (and report) any suspicious skin lesions or moles. Counsel patients to limit exposure to sunlight and UV rays and to use adequate sun protection. See MHRA (November 2018) for Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use. | |||
| Therapeutic Area | Formulary Choices | Cost 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 CG106 (2018): Chronic heart failure) |
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| First line: | Losartan | 25mg tablets: £3.07 50mg tablets: £3.64 100mg tablets: £4.64 | 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: £2.17 (7) 4mg tablets: £0.93 (7) 8mg tablets: £4.72 16mg tablets: £5.37 32mg tablets: £4.02 | 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 | 40mg capsules: £6.09 80mg capsules: £7.79 160mg capsules: £10.92 | 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. |
| Sacubitril and valsartan as Entresto® | 24mg/26mg tablet: £45.78 | Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people: *with New York Heart Association (NYHA) class II to IV symptoms and *with a left ventricular ejection fraction of 35% or less and *who are already taking a stable dose of ACE inhibitors or ARBs. |
|
| 49mg/51mg tablet: £45.78, £91.56 (56) | |||
| 97mg/103mg tablet: £91.56 (56) | |||
| Centrally acting antihypertensive drugs | Methyldopa | 125mg tablets: £112.95 (56) 250mg tablets: £5.37 (56) 500mg tablets: £9.57 (56) | Methyldopa is included in the formulary for: • Hypertension in pregnancy |
| Moxonidine | 200mcg tablets: £1.26 300mcg tablets: £1.36 400mcg tablets: £1.31 | 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. |
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| Alpha-blockers | Doxazosin | 1mg tablets: £0.76 2mg tablets: £0.77 4mg tablets: £0.88 | 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 |
