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Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: solution for injection, eye drops Solution for injection ▶Phenylephrine hydrochloride (Non-proprietary) Phenylephrine (as Phenylephrine hydrochloride) 50 microgram per 1 ml Phenylephrine 500micrograms/10ml solution for injection pre-filled syringes | 1 pre-filled disposable injection P £15.00 | 10 pre-filled disposable injection P £150.00 Phenylephrine hydrochloride 100 microgram per 1 ml Phenylephrine 1mg/10ml solution for injection ampoules | 10 ampoule P £40.00 Phenylephrine hydrochloride 10 mg per 1 ml Phenylephrine 10mg/1ml solution for injection ampoules | 10 ampoule P £99.12 Cardiovascular system Phenylephrine 10mg/1ml concentrate for solution for injection ampoules | 10 ampoule P £99.12 Cardiovascular risk assessment and prevention Cardiovascular disease risk assessment and prevention Description of condition Cardiovascular disease (CVD) is a term that describes a group of disorders of the heart and blood vessels caused by atherosclerosis and thrombosis, which includes coronary heart disease, stroke, peripheral arterial disease, and aortic disease. The risk of CVD is greater in men, patients with a family history of CVD, and in certain ethnic backgrounds such as South Asians. CVD risk is also greater in patients aged over 50 years and increases with age; patients aged 85 years and over are at particularly high risk. CVD has several important and potentially modiﬁable risk factors such as hypertension, abnormal lipids, obesity, diabetes mellitus, and psychosocial factors such as depression, anxiety, and social isolation. Low physical activity, poor diet, smoking, and excessive alcohol intake are also modiﬁable risk factors. Aims of treatment The overall aim of treatment is to prevent the occurrence of a cardiovascular event by reducing modiﬁable risk factors through lifestyle changes and drug management. Cardiovascular disease risk assessment Recommendations on cardiovascular disease (CVD) risk assessment are from the National Institute for Health and Care Excellence (NICE)—Cardiovascular disease: risk assessment and reduction, including lipid modiﬁcation guideline (CG181, 2016), and Scottish Intercollegiate Guidelines Network (SIGN)—Risk estimation and the prevention of cardiovascular disease guideline (SIGN 149, 2017). SIGN 149 uses risk assessment strategies outlined by the Joint British Society (JBS)—Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (2014). Recommendations where NICE and SIGN differ have been highlighted. g NICE (2016) recommend that for primary prevention of CVD in primary care, a systematic approach be used to identify those who are likely to be at high risk. Patients should be prioritised based on an estimate of their CVD risk using risk factors already recorded in their medical records, before a full formal risk assessment. Priority for a full formal risk assessment should be given to patients with an estimated 10-year risk of 10% or more. Patients aged over 40 years should have their estimate of CVD risk reviewed on an ongoing basis. SIGN (2017) instead recommend that CVD risk assessments are offered at least every 5 years to all patients aged 40 years and over with no history of CVD, familial hypercholesterolaemia, chronic kidney disease or diabetes and who are not receiving treatment to reduce blood pressure or lipids. As well as to patients with a ﬁrst- degree relative who has premature atherosclerotic CVD or familial dyslipidaemia, regardless of their age. Risk assessment with a calculator is not required in patients who are at increased or high risk of CVD. This includes those with established CVD, chronic kidney disease stage 3 or higher (eGFR <60 mL/minute/1.73 m2), albuminuria, or familial hypercholesterolaemia. In addition to these patients, NICE (2016) do not recommend the use of a risk calculator in patients with other hereditary disorders Cardiovascular system of lipid metabolism, or type 1 diabetes mellitus. Whereas SIGN (2017) do not recommend the use of a risk calculator in patients with diabetes mellitus aged 40 years and over, and in those aged under 40 years with diabetes mellitus who have either had it for more than 20 years, present with target organ damage (such as proteinuria, albuminuria, proliferative retinopathy, or autonomic neuropathy), or have other signiﬁcantly elevated cardiovascular risk factors. h Risk calculators Cardiovascular risk assessment calculators are used to predict the approximate likelihood of a cardiovascular event occurring over a given period of time. g Standard risk scores may be underestimated in patients with additional risk due to existing conditions or medications that can cause dyslipidaemia (e.g. antipsychotics, corticosteroids, or immunosuppressants). CVD risk may also be underestimated in patients who are already taking antihypertensives or lipid- regulating drugs, or who have recently stopped smoking. Interpretation of risk scores as well as the need for further management of risk factors in those who fall below the CVD risk threshold, should always reﬂect informed clinical judgement. h QRISK® 2 and JBS3 QRISK® 2 and JBS3 risk calculators are used to assess CVD risk for patients in England and Wales. Both tools assess cardiovascular risk of coronary heart disease (angina and myocardial infarction), stroke, and transient ischaemic attack. This is based on lipid proﬁle, systolic blood pressure, gender, age, ethnicity, smoking status, BMI, chronic kidney disease (stage 4 or above), diabetes mellitus, atrial ﬁbrillation, treated hypertension, rheumatoid arthritis, social deprivation, or a family history of premature CVD. The QRISK® 2 risk calculator (www.qrisk.org/) is recommended by NICE clinical guideline 181, and the JBS3 risk calculator (www.jbs3risk.com/pages/risk_calculator.htm) is endorsed by the Joint British Society. QRISK® 3 is an updated version of the QRISK® 2 risk calculator. It considers additional risk factors such as chronic kidney disease (stage 3 or above), migraine, corticosteroid use, systemic lupus erythematosus, atypical antipsychotics use, severe mental illness, erectile dysfunction, and a measure of systolic blood pressure variability. The JBS3 calculator is not only able to estimate short term (10-year) risk, but also lifetime risk of CVD events. Patients with a 10-year risk of CVD of less than 10% may beneﬁt from an assessment of their lifetime risk using the JBS3 tool, and a discussion on the impact of lifestyle interventions and, if necessary, drug therapy. ASSIGN The ASSIGN cardiovascular risk assessment calculator is tailored to the Scottish population and uses factors such as age, sex, smoking, systolic blood pressure, lipid proﬁle, family history of premature CVD, diabetes mellitus, rheumatoid arthritis, and social deprivation to estimate cardiovascular risk. g Other risk factors not included in this CVD risk assessment calculator (such as ethnicity, BMI, atrial ﬁbrillation, psychological wellbeing, and physical inactivity) should also be taken into account when assessing and managing the patient’s overall CVD risk. SIGN (2017) recommend that asymptomatic patients without established CVD (or other conditions that are automatically associated with a high CVD risk) should be considered at high risk if they are assessed as having a 20% or more risk of a ﬁrst cardiovascular event within 10 years. h The online calculator tool can be found at www.assign- score.com/estimate-the-risk/. Full details can be found in the SIGN 149 clinical guideline (see Useful resources). Cardiovascular disease prevention Recommendations on cardiovascular disease (CVD) prevention are from the National Institute for Health and Care Excellence (NICE)—Cardiovascular disease: risk assessment and reduction, including lipid modiﬁcation guideline (CG181, 2016), and Scottish Intercollegiate Guidelines Network (SIGN)—Risk estimation and the prevention of cardiovascular disease guideline (SIGN 149, 2017). SIGN 149 uses strategies outlined by the Joint British Society (JBS)—Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (2014). Recommendations where NICE and SIGN differ have been highlighted. g All patients at any risk of CVD should be advised to make lifestyle modiﬁcations that may include beneﬁcial changes to diet (such as increasing fruit and vegetable consumption, reducing saturated fat and dietary salt intake), increasing physical exercise, weight management, reducing alcohol consumption, and Smoking cessation p. 520. An annual review should be considered to discuss lifestyle modiﬁcation, medication adherence and risk factors. The frequency of review may be tailored to the individual. Further preventative measures with drug treatment should be taken in individuals with a high risk of developing CVD (primary prevention), and to prevent recurrence of events in those with established CVD (secondary prevention). h Primary prevention Antiplatelet therapy g Aspirin p. 130 is not recommended for primary prevention of CVD due to the limited beneﬁt gained versus risk of side-effects such as bleeding. h Antihypertensive therapy g Antihypertensive drug treatment should be offered to patients who are at high risk of CVD and have a sustained elevated systolic blood pressure over 140 mmHg and/or diastolic blood pressure over 90 mmHg. For further guidance on prescribing antihypertensive drugs in patients without symptomatic CVD and for speciﬁc groups at high cardiovascular risk, see Hypertension p. 151. h Lipid-lowering therapy g A statin is recommended as the lipid-lowering drug of choice for primary prevention of CVD. All modiﬁable risk factors, comorbidities and secondary causes of dyslipidaemia (e.g. uncontrolled diabetes mellitus, hepatic disease, nephrotic syndrome, excessive alcohol consumption, and hypothyroidism) should be managed before starting treatment with a statin. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy. NICE (2016) recommend low-dose atorvastatin p. 215 for patients who have a 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator), and for patients with chronic kidney disease. Low-dose atorvastatin p. 215 should be considered in all patients with type 1 diabetes mellitus, and be offered to patients with type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors. Patients aged 85 years and over may also beneﬁt from low-dose atorvastatin p. 215 to reduce their risk of non-fatal myocardial infarction. SIGN (2017) recommend low-dose atorvastatin p. 215 for patients who are considered to be at high risk of CVD and not on dialysis. Patients taking statins should have an annual medication review to discuss medication adherence, lifestyle modiﬁcation, CVD risk factors, and non-fasting, non-HDL cholesterol concentration (if testing deemed appropriate). Total cholesterol, HDL-cholesterol, and non-HDL- cholesterol concentrations should be checked 3 months after starting treatment with a high-intensity statin. For statin intensity categorisation, see Dyslipidaemias p. 208. Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended. If this is not achieved, adherence to drug treatment should be checked and lifestyle modiﬁcations optimised. In patients deemed to be at a higher risk due to comorbidities, risk score, or clinical judgement, an increase in the statin dose should be considered. NICE (2016) recommend that the use of higher doses in those with chronic kidney disease with an eGFR less than 30ml/minute/1.73 m2 should be discussed with a renal specialist. Specialist advice should be sought regarding treatment options in patients at high risk of CVD who are intolerant of three different statins. SIGN (2017) recommend that ezetimibe p. 210 and bile acid sequestrants such as colestyramine p. 210 and colestipol hydrochloride p. 209 only be considered for primary prevention in patients with an elevated cardiovascular risk in whom statin therapy is contra-indicated, and in patients with familial hypercholesterolaemia. However, NICE (2016) recommend that ezetimibe p. 210 be considered for primary hypercholesterolaemia in line with National funding/access decisions for ezetimibe p. 210, and do not recommend bile acid sequestrants. Although ﬁbrates are not routinely recommended for primary prevention of CVD, SIGN (2017) recommend that they be considered in patients with a combination of high CVD risk, marked hypertriglyceridaemia and low HDL- cholesterol concentration. If cholesterol remains above the target concentration despite other tolerated lipid-lowering therapy in patients at high risk of vascular events, the use of PCSK9 inhibitors, such as alirocumab p. 219 and evolocumab p. 219 should be considered. h Lipid-lowering therapy recommendations from Joint British Societies’ consensus (2014), NICE Clinical guideline 181 (2016), and SIGN Clinical guideline 149 (2017) all differ in certain respects for prevention of CVD in patients with diabetes mellitus—see individual guidelines for further details. For further information on lipid-lowering therapy and familial hypercholesterolaemia, see Dyslipidaemias p. 208. Secondary prevention Antiplatelet therapy g Antiplatelet therapy with low-dose daily aspirin p. 130 should be offered to patients with established atherosclerotic disease. Alternatively, clopidogrel p. 131 can be considered in patients who are intolerant to aspirin or in whom it is contra-indicated. Clopidogrel p. 131 or a combination of dipyridamole with aspirin p. 133 should be considered to prevent recurrence of stroke and other vascular events in all patients with a history of stroke or transient ischaemic attack who are in sinus rhythm. h For further information, see Stroke p. 125. Antihypertensive therapy g Antihypertensive drug treatment is recommended in patients with established CVD and a sustained elevated systolic blood pressure over 140 mmHg and/or diastolic blood pressure over 90 mmHg. For further guidance on prescribing antihypertensive drugs in patients with CVD, see Hypertension p. 151. h Lipid-lowering therapy g A statin is recommended as the lipid-lowering drug of choice for secondary prevention of CVD. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy. Treatment with high-dose atorvastatin p. 215 should be offered to patients with established atherosclerotic CVD. However, a lower dose can be used if the patient is at an increased risk of side-effects or drug interactions. NICE (2016) recommend that low-dose atorvastatin p. 215 be offered to patients with established CVD and chronic kidney disease. High-dose simvastatin p. 217 is generally avoided due to the risk of myopathy, unless the patient has been stable on this regimen for at least one year. h Furthermore, the MHRA advise that high-dose simvastatin p. 217 only be Cardiovascular system considered for patients who have not achieved their treatment goals with lower doses and have severe hypercholesterolaemia and high risk of cardiovascular complications; beneﬁts should outweigh risks. g Patients taking statins should have an annual medication review to discuss medication adherence, lifestyle modiﬁcation, CVD risk factors, and non-fasting, non-HDL- cholesterol concentrations (if testing deemed appropriate). Total cholesterol, HDL-cholesterol, and non-HDL- cholesterol concentrations should be checked 3 months after starting treatment with a high-intensity statin. Patients who are stable on a low or medium-intensity statin should discuss the beneﬁts and risks of switching to a high-intensity statin at their next medication review. For statin intensity categorisation, see Dyslipidaemias p. 208. Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended. h JBS3 instead recommend a target non-HDL-cholesterol concentration below 2.5 mmol/litre. g If these targets are not achieved, adherence to drug treatment should be checked and lifestyle modiﬁcations optimised. In patients judged to be at a higher risk because of comorbidities, risk score, or clinical judgement, an increase in the statin dose (if started on less than maximum atorvastatin p. 215 dose) should be considered. NICE (2016) recommend that the use of higher doses in those with chronic kidney disease with an eGFR less than 30ml/minute/1.73 m2 be discussed with a renal specialist. Specialist advice should be sought regarding treatment options in patients with existing CVD who are intolerant of three different statins. If LDL-cholesterol remains inadequately controlled, SIGN (2017) recommend that ezetimibe p. 210 and bile acid sequestrants such as colestyramine p. 210 and colestipol hydrochloride p. 209, can be considered for use in combination with a statin at the maximum tolerated dose. However, NICE (2016) do not recommend bile acid sequestrants for the secondary prevention of CVD. Although ﬁbrates are not routinely recommended for secondary prevention of CVD, SIGN (2017) recommend that they be considered in patients with both marked hypertriglyceridaemia and low HDL-cholesterol concentrations. h For further information on lipid-lowering therapy and familial hypercholesterolaemia, see Dyslipidaemias p. 208. Psychological risk factors g Psychological treatment should be considered in patients with mood and anxiety disorders and comorbid CVD; complex patients may require referral to mental health services for assessment and delivery of high-intensity or specialist treatments. Selective serotonin re-uptake inhibitors (SSRIs) should be considered for treatment in patients with depression and coronary heart disease. h For guidance on prescribing of antidepressant drugs see Antidepressant drugs p. 376. Advanced Pharmacy Services Patients with or at risk of cardiovascular disease, may be eligible for the New Medicines Service / Medicines Use Review service provided by a community pharmacist. For further information, see Advanced Pharmacy Services in Medicines optimisation p. 18. Useful Resources Risk estimation and the prevention of cardiovascular disease. Scottish Intercollegiate Guidelines Network. Clinical guideline 149. June 2017. www.sign.ac.uk/sign-149-risk-estimation-and-the-prevention-of- cardiovascular-disease.html Cardiovascular disease: risk assessment and reduction, including lipid modiﬁcation. National Institute for Health Cardiovascular system and Care Excellence. Clinical guideline CG181. July 2014 (updated September 2016). www.nice.org.uk/guidance/cg181 Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). April 2014. www.jbs3risk.com/pages/report.htm Heart failure Chronic heart failure Description of condition Heart failure is a progressive clinical syndrome caused by structural or functional abnormalities of the heart, resulting in reduced cardiac output. It is characterised by symptoms such as shortness of breath, persistent coughing or wheezing, ankle swelling, reduced exercise tolerance, and fatigue. These symptoms may be accompanied by signs such as elevated jugular venous pressure, pulmonary crackles, and pulmonary oedema. The risk of heart failure is greater in men, smokers and diabetic patients, and increases with age. The most common cause of heart failure is coronary heart disease, however, patients of African or Afro-Caribbean origin are more likely to develop heart failure secondary to hypertension. In addition to coronary heart disease, heart failure often co-exists with other co-morbidities such as chronic kidney disease, atrial ﬁbrillation, hypertension, dyslipidaemia, obesity, diabetes mellitus, and chronic obstructive pulmonary disease. Patients with co-morbidities have a worse prognosis, and the presence of atrial ﬁbrillation or chronic kidney disease affects the management of heart failure in these patients. Complications of heart failure include chronic kidney disease, atrial ﬁbrillation, depression, cachexia, sexual dysfunction, and sudden cardiac death. Heart failure can be deﬁned as either having a reduced or preserved ejection fraction. Both conditions present with signs and symptoms of heart failure. In heart failure with reduced ejection fraction, the left ventricle loses its ability to contract normally and therefore presents with an ejection fraction of less than 40%. In heart failure with preserved ejection fraction, the left ventricle loses its ability to relax normally therefore the ejection fraction is normal or only mildly reduced. The New York Heart Association (NYHA) functional classiﬁcation tool is used to deﬁne the progression of chronic heart failure according to severity of symptoms and limitation to physical activity. Heart failure is considered to be stable or chronic when symptoms remain unchanged for at least one month despite optimal management. Aims of treatment The aims of treatment are to reduce mortality, relieve symptoms, improve exercise tolerance, and reduce the incidence of acute exacerbations. Non-drug treatment g Patients with heart failure should be advised to make lifestyle changes to reduce the risk of progression of their heart failure and associated co-morbidities. These include Smoking cessation p. 520, reducing alcohol consumption, increasing physical exercise if appropriate, weight control, and dietary changes such as increasing fruit and vegetable consumption and reducing saturated fat intake. Patients should be encouraged to weigh themselves daily at a set time of day and to report any weight gain of more than 1.5–2.0 kg in 2 days to their GP or heart failure specialist. Salt and ﬂuid intake should only be restricted if these are high, and a salt intake of less than 6 g per day is advised. Patients with dilutional hyponatraemia should only restrict their ﬂuid intake. Salt substitutes containing potassium should be avoided to reduce the risk of hyperkalaemia. Contraception and pregnancy should be discussed with women of childbearing potential and heart failure. Advice from a heart failure specialist and an obstetrician should be sought if pregnancy occurs or is being considered. Patients should be given the opportunity to join a personalised rehabilitation programme including education, psychological support, and exercise when appropriate. Implantable cardioverter deﬁbrillators and cardiac resynchronisation therapy are treatment options recommended in patients with heart failure and a reduced ejection fraction of less than 35%. If symptoms remain severe and unresponsive despite optimal drug treatment, specialist referral should be considered. h Drug treatment g The treatment of heart failure should include management of symptoms, risk factors and underlying causes and complications. Patients should have their medication reviewed, and any drugs that may cause or worsen their heart failure should be stopped if appropriate. Vaccination against pneumococcal disease, and annual inﬂuenza vaccination is recommended. h Chronic heart failure with reduced ejection fraction g Rate-limiting calcium-channel blockers (verapamil hydrochloride p. 175, and diltiazem hydrochloride p. 169) and short-acting dihydropyridines (e.g. nifedipine p. 174, or nicardipine hydrochloride p. 173) should be avoided in patients who have heart failure with reduced ejection fraction as these drugs reduce cardiac contractility. Patients with heart failure and angina may safely be treated with amlodipine p. 168. Diuretics are recommended for the relief of breathlessness and oedema in patients with ﬂuid retention. Loop diuretics such as furosemide p. 241, bumetanide p. 240, or torasemide p. 242 are usually the diuretics of choice. Thiazide diuretics may only be of beneﬁt in patients with mild ﬂuid retention and an eGFR greater than 30 mL/minute/1.73 m2. Diuretic doses should be titrated according to clinical response and adjusted if needed following the initiation of subsequent heart failure treatments, to minimise the risk of dehydration, renal impairment or hypotension. If symptoms persist despite optimal titration, advice from a heart failure specialist should be sought. An angiotensin-converting enzyme (ACE) inhibitor (e.g. perindopril, ramipril p. 184, captopril p. 179, enalapril maleate p. 180, lisinopril p. 181, quinapril p. 183 or fosinopril sodium p. 181) and a beta-blocker licensed for heart failure (e.g. bisoprolol fumarate p. 165, carvedilol p. 160, or nebivolol p. 167) should be given as ﬁrst-line treatment to reduce morbidity and mortality. Treatment with a beta- blocker should not be withheld because of age or the presence of diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, erectile dysfunction, or interstitial pulmonary disease. Patients who are already taking a beta-blocker for co-morbidities (e.g. angina or hypertension) and whose condition is stable should be switched to a beta-blocker licensed for heart failure. Clinical judgement should be used when deciding whether to start an ACE inhibitor or beta blocker ﬁrst. The additional drug should only be initiated when the patient is stable on their existing treatment. Treatment should be initiated at a low dose and slowly titrated up to the maximum tolerated dose. An angiotensin II receptor blocker (ARB) licensed for heart failure (e.g. candesartan cilexetil p. 186, losartan potassium p. 187, or valsartan p. 190) can be considered if ACE inhibitors are not tolerated. If heart failure symptoms persist or worsen despite optimal ﬁrst-line treatment, an aldosterone antagonist such as spironolactone p. 206 or eplerenone below should be offered as add-on therapy unless contra-indicated (e.g. due to hyperkalaemia or renal impairment). Hydralazine hydrochloride p. 192 combined with a nitrate can be considered under the advice of a heart failure specialist in patients who are intolerant of both ACE inhibitors and ARBs (in particular those of African or Caribbean origin with moderate to severe heart failure). If symptoms persist despite optimal treatment, advice from a heart failure specialist should be sought on the use of amiodarone hydrochloride p. 112, digoxin p. 116, sacubitril with valsartan p. 207, or ivabradine p. 225. For patients in sinus rhythm, digoxin is recommended as add-on therapy in worsening or severe heart failure despite optimal treatment. Although digoxin does not reduce mortality, it may decrease symptoms and hospitalisation due to acute exacerbations. Routine monitoring of serum levels is not recommended in patients with heart failure. Anticoagulation should also be considered for patients in sinus rhythm with heart failure if they have a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus. h For guidance in patients with atrial ﬁbrillation see Arrhythmias p. 106. Monitoring drug treatment g When initiating ACE inhibitors, ARBs and aldosterone antagonists, serum potassium and sodium, renal function, and blood pressure should be checked prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment. Once the target, or maximum tolerated dose is achieved, treatment should be monitored monthly for 3 months and then at least every 6 months, and if the patient becomes acutely unwell. When initiating beta blockers, heart rate, blood pressure and symptom control should be assessed at the start of treatment and after each dose change. In patients with chronic kidney disease, lower doses and slower dose titrations of ACE inhibitors, ARBs, aldosterone antagonists and digoxin should be considered. Advice from a renal specialist should be considered where appropriate. h Chronic heart failure with preserved ejection fraction g Patients with heart failure and preserved ejection fraction should be managed under the care of a heart failure specialist. For the relief of ﬂuid retention symptoms, a low to medium dose loop diuretic should be prescribed. If the patient fails to respond to treatment, advice from a heart failure specialist should be sought. h Advanced heart failure Breathlessness is a common symptom in advanced heart failure and may occur even with optimal management and in the absence of clinical pulmonary oedema. g Long-term oxygen therapy is not recommended in advanced heart failure, although it may be considered in patients with heart failure and additional co-morbidities that would beneﬁt from oxygen therapy such as chronic obstructive pulmonary disease. h Advanced Pharmacy Services Patients with heart failure may be eligible for the Medicines Use Review service provided by a community pharmacist. For further information, see Advanced Pharmacy Services in Medicines optimisation p. 18. Useful Resources Chronic heart failure in adults: diagnosis and management. National Institute of Health and Care Excellence. Clinical guideline 106. September 2018. www.nice.org.uk/guidance/ng106 Management of chronic heart failure. Scottish Intercollegiate Guidelines Network. Clinical guideline 147. March 2016. www.sign.ac.uk/assets/sign1472.pdf Other drugs used for Heart failure Bendroﬂumethiazide, Cardiovascular system p. 177. Chlortalidone, p. 244. Co-amilozide, p. 177. Glyceryl trinitrate, p. 232. Isosorbide dinitrate, p. 233. Isosorbide mononitrate, p. 234. Metoprolol tartrate, p. 166. Perindopril arginine, p. 182. Perindopril erbumine, p. 183. Prazosin, p. 827. Sodium nitroprusside, p. 193 DIURETICS › POTASSIUM-SPARING DIURETICS › ALDOSTERONE ANTAGONISTS

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Medicinal Forms

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Phenylephrine hydrochloride

Overview

Indications And Dose

Contra Indications

Cautions

Safety

Interactions

Side Effects

Pregnancy

Monitoring Requirements

Dose and formulations

Directions For Administration

Medicinal Forms

Dose text by age group

Phenylephrine hydrochloride

Overview

Indications And Dose

Contra Indications

Cautions

Safety

Interactions

Side Effects

Pregnancy

Monitoring Requirements

Dose and formulations

Directions For Administration

Medicinal Forms

Dose text by age group