Drugs Affecting the Renin–Angiotensin System and Some Other Antihypertensive Drugs

NHSL Medicines Guidance
NHS Lanarkshire

Alpha-Adrenoceptor Blocking Drugs

Preferred list (P)

DOXAZOSIN standard release tablets

  • Modified-release preparation is non-formulary.

  • Standard and modified-release preparations have a similar half-life allowing once daily administration. Therefore, using modified-release formulations does not improve patient compliance.

  • DOXAZOSIN may cause postural hypotension and first dose hypotension. Treatment should be initiated at the lowest dose possible and patients advised that if they experience any dizziness or lightheadedness, to avoid situations in which they could injure themselves.

  • DOXAZOSIN is a fourth-line agent in the treatment of hypertension. It should be used with caution in patients with heart failure or impaired left ventricular function and should not be used as monotherapy.

  • DOXAZOSIN may be prescribed with other antihypertensive drugs, particularly beta-blockers, in the treatment of hypertension. It may be especially useful in patients with prostatism.

Angiotensin-Converting Enzyme Inhibitors (ACE Inhibitors)

Preferred list (P)

RAMIPRIL

Total list (T)

LISINOPRIL

Angiotensin-II Receptor Antagonists (ARBs)

Preferred list (P)

LOSARTAN

Total list (T)

CANDESARTAN

IRBESARTAN

Prescribing Notes:

  • ACE inhibitors and ARBs have a class effect and so choice should be based on licensed indication (see link to BNF) and factors such as co-morbidities, compliance and cost effectiveness.

  • In addition, drugs affecting the renin-angiotensin system have a cardioprotective effect and should be considered as part of plans for managing cardiovascular risk associated with diabetes mellitus and chronic kidney disease in line with relevant guidelines:

  • ACE inhibitors also inhibit the breakdown of bradykinin and other kinins which can lead to development of a persistent dry cough.

  • ARBs do not inhibit the breakdown of kinins and so are a useful alternative in patients who experience a persistent dry cough as a result of taking an ACE inhibitor.

  • All patients prescribed an ACE inhibitor or ARB should have their blood pressure, renal function and electrolyte levels checked prior to commencing treatment. These should be rechecked 1-2 weeks after commencing treatment, following any dose adjustments and then periodically once treatment is stabilised.

Angiotensin Receptor Neprilysin Inhibitors

Specialist initiation (S1)

SACUBITRIL WITH VALSARTAN (Entresto®)

  • Indication: symptomatic chronic heart failure with reduced ejection fraction in adult patients.

  • Entresto® should not be co-administered with an ACE inhibitor or an ARB. Potential risk of angioedema when used concomitantly with an ACE inhibitor. Must not be started for at least 36 hours after discontinuing ACE inhibitor therapy.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.