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 (SPS March 2023, updated June 2023)
Using angiotensin-II receptor antagonists during breastfeeding (SPS May 2023. updated June 2023)
For acute coronary syndromes, see Myocardial ischaemia.
For chronic heart failure, see Heart failure.
For chronic kidney disease, see Cardiovascular system.
For chronic kidney disease in type 2 diabetes , see Diabetes mellitus and hypoglycaemia.
| 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 (300ml) | |||
| 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. |
||
| 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 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 | For 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. |
||
| 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. For 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 |
||
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments | |
|---|---|---|---|---|
| Angiotensin-converting enzyme inhibitors (ACEi) | Lisinopril | 2.5mg tablet: £0.66 | For hypertension. Adult: initially 10 mg once daily; usual maintenance 20 mg once daily; maximum 80 mg per day. For secondary prevention following myocardial infarction. Adult: titrate to maximum tolerated/target dose and continue indefinitely. Maintenance 5-10 mg once daily. For heart failure. Adult: titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached. Maximum 35 mg per day. For diabetic nephropathy. Adult: initially 2.5–5 mg once daily, adjusted according to response; usual dose 10–20 mg once daily. | Measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment. Measure blood pressure before and after each dose increment of an ACE inhibitor. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults. Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell. ACE inhibitors should be avoided in pregnancy unless essential. They may adversely affect fetal and neonatal blood pressure control and renal function; skull defects and oligohydramnios have also been reported. |
| 5mg tablet: £0.75 | ||||
| 10mg tablet: £0.86 | ||||
| 20mg tablet: £0.88 | ||||
| 5mg/5ml oral solution sugar free: £218.00 (150ml) | ||||
| Ramipril | 1.25mg capsule: £1.09 | For hypertension. Adult: initially 1.25–2.5 mg once daily, increased if necessary up to 10 mg once daily, dose to be increased at intervals of 2–4 weeks. For secondary prevention following myocardial infarction. Adult: titrate to maximum tolerated/target dose and continue indefinitely. Maintenance dose 5 mg twice daily. For heart failure. Adult: titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached (10 mg daily in 1–2 divided doses, daily dose preferably taken in 2 divided doses). For diabetic nephropathy. Adult: initially 1.25 mg once daily for 2 weeks, then increased to 2.5 mg once daily for 2 weeks, then increased if tolerated to 5 mg once daily. |
||
| 2.5mg capsule: £1.03 | ||||
| 5mg capsule: £1.03 | ||||
| 10mg capsule: £1.11 | ||||
| 2.5mg/5ml oral solution sugar free: £196.00 (150ml) | ||||
| Perindopril erbumine | 2mg tablet: £0.95 (30) | Prescribe as Perindopril erbumine. Perindopril arginine is not cost effective. For hypertension. Adult: initially 4 mg once daily for 1 month, dose to be taken in the morning, then, adjusted according to response; maximum 8 mg per day. For secondary prevention following myocardial infarction. Adult: titrate to maximum tolerated/target dose and continue indefinitely. Maintenance dose 8 mg once daily. For heart failure. Adult: titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached (4 mg once daily). |
||
| 4mg tablet: £1.09 (30) | ||||
| 8mg tablet: £1.41 (30) | ||||
| NHS Somerset classify Fosinopril sodium as not recommended as per Traffic light guidance. | ||||
| NHS Somerset classify Enalapril maleate and hydrochlorothiazide as 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 (ARB) | Patients exhibiting ACEi cough should trial a second 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. |
||
| Losartan | 25mg tablet: £0.77 | For hypertension for people of African or Caribbean origin and those intolerant to ACEi. Adult: initially 25-50 mg once daily for several weeks, then increased if necessary to 100 mg once daily. For heart failure for people intolerant to ACEi. Adult: initially 12.5 mg once daily, increased if tolerated to up to 150 mg once daily, doses to be increased at weekly intervals. For diabetic nephropathy for people intolerant to ACEi. Adult: initially 25-50 mg once daily for several weeks, then increased if necessary to 100 mg once daily. |
|
| 50mg tablet: £0.86 | |||
| 100mg tablet: £0.96 | |||
| Candesartan | 2mg tablet: £0.76 (7) | For hypertension for people intolerant to ACEi. Adult: initially 8 mg once daily, increased if necessary up to 32 mg once daily, dose to be increased at intervals of 4 weeks; usual dose 8 mg once daily. For heart failure for people intolerant to ACEi. Adult: initially 4 mg once daily, increased to up to 32 mg once daily, dose to be increased at intervals of at least 2 weeks to 'target' dose of 32 mg once daily or to maximum tolerated dose. |
|
| 4mg tablet: £0.57 (7) | |||
| 8mg tablet: £1.02 | |||
| 16mg tablet: £1.16 | |||
| 32mg tablet: £1.35 | |||
| Valsartan | 40mg capsule: £5.51 | Third line for secondary prevention following myocardial infarction for people intolerant to ACEi. Adult: initially 20 mg twice daily, increased if necessary up to 160 mg twice daily, doses to be increased over several weeks if tolerated. Third line for heart failure for people intolerant to ACEi or in conjunction with an ACEi when a beta-blocker cannot be used. Adult: initially 40 mg twice daily, increased to up to 160 mg twice daily, doses to be increased at intervals of at least 2 weeks. |
|
| 80mg capsule: £7.58 | |||
| 160mg capsule: £6.85 | |||
| Sacubitril and valsartan as Entresto® | 24mg/26mg tablet: £45.78 | 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 angiotensin-converting enzyme (ACE) inhibitors or ARBs. Adult: initially 24/26 mg to 49/51mg twice daily for 2–4 weeks, increased if tolerated to 97/103 mg twice daily. |
|
| 49mg/51mg tablet: £91.56 (56) | |||
| 97mg/103mg tablet: £91.56 (56) | |||
| Centrally acting antihypertensive drugs | Methyldopa | 125mg tablet: £94.69 (56) | For hypertension in pregnancy Adult: initially 250 mg 2–3 times a day, dose should be increased gradually at intervals of at least 2 days; maximum 3 g per day. |
| 250mg tablet: £22.19 (56) | |||
| 500mg tablet: £16.62 (56) | |||
| Moxonidine | 200mcg tablet: £5.15 | For treatment of resistant hypertension as per NICE guidance at Step 4 where BP remains sub-optimally controlled despite standard therapies. Adult: 200 micrograms once daily for 3 weeks, dose to be taken in the morning, then increased if necessary to 400 micrograms daily in 1–2 divided doses (max. per dose 400 micrograms), maximum daily dose to be given in 2 divided doses; maximum 600 micrograms per day. |
|
| 300mcg tablet: £4.26 | |||
| 400mcg tablet: £3.95 | |||
| Alpha-blockers | Doxazosin | 1mg tablet: £0.76 | 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 |
| 2mg tablet: £0.78 | |||
| 4mg tablet: £0.86 | |||
