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					                             POWYS LOCAL HEALTH BOARD



                  Heart Failure Medicine Protocol



     Rev             Date                Purpose of                                               Planned
                                         Issue/Description of                                     Review Date
                                         Change

     Ref:            Nov 2007 Initial issue                                                        Februar
                                                                                                   y 2011
     PLHB
     SP 003




     Responsibl                          Approved by                                              Date
     e Officer
     Cardiac                             Prescribing &                                            January
     Specialist                          Therapeutics Committee                                   2008
     Nurse
                                         Governance and Risk                                      Februar
                                         Management Committee                                     y 2008




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 1 of 23
     1.        Introduction

A heart failure specialist nurse service has been established in South
Powys since May 2007 to meet the ongoing care needs of patients with
heart failure. It has been funded by the British Heart Foundation for a
fixed term of 3 years. This service is described in detail in an operational
plan.

A specific requirement of the service is that the specialist nurse needs to
review prescribed medication regimes to ensure patients receive
appropriate pharmacotherapy in effective doses appropriate to the
individual.

These guidelines are to be used under the supervision of the patient’s
General Practitioner (GP) and the relevant Consultant Cardiologist (if
applicable) managing the care of the patient. They include detailed
protocols for the use of the evidence based treatments recommended by
NICE (2003) for patients with chronic heart failure caused by left
ventricular dysfunction and the more recently published SIGN guidelines
(2007) for the management of chronic heart failure.

The specialist nurse has successfully completed the supplementary
prescribing course and is registered as a supplementary prescriber by the
professional bodies register i.e. the NMC. She is responsible for working
to the Nursing and Midwifery Council Code of Practice. Only named
Registered General Nurses and Registered Pharmacists may undertake
this extended role. These named individuals must have been deemed as
competent in the management of heart failure by the clinical supervisors
and have written records of training, supervision and assessment.

Supplementary Prescribing has been defined by the Department of Health
(DoH) as a voluntary partnership between an independent prescriber
(doctor or dentist) and a supplementary prescriber, to implement an
agreed, patient specific clinical management plan (CMP) (Appendix 1).

An independent prescriber will be either an acute care consultant, or the
patient’s primary care physician (GP). This doctor takes responsibility for
discussing, agreeing, signing and reviewing the CMP which details which
medication can be altered within a specified range that is appropriate to the
individual patient.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 2 of 23
The GP may ask the Heart Failure Nurse to act as his or her intermediary and
seek advice about medication from the Cardiologist. All treatment initiations
and dose changes must be communicated to all relevant parties (GP,
hospital personnel involved in continuing care) and recorded in the Heart
Failure Nurse records.



Medications

The ranges of medications appropriate to be included in a patient’s CMP
are:

                   Diuretics

                   ACE inhibitors

                   Angiotensin II receptor Antagonists

                   Beta Blockers

                   Digoxin

                   Aldosterone Antagonists

A profile for each class of drug, or where appropriate for an individual
drug, has been developed. These profiles detail guidance and specific
instructions for the supplementary prescriber working within the heart
failure team regarding use of the drugs detailed in the CMP. These have
been agreed by clinical supervisors and will be reviewed annually or
sooner if appropriate.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 3 of 23
                                                      Diuretics

     Loop Diuretics

In the majority of patients with heart failure, fluid retention occurs,
causing ankle oedema, pulmonary oedema or both. Diuretic treatment
relieves oedema and dyspnoea.

In most cases the agent of choice will be a loop diuretic although a
thiazide might suffice where the fluid retention is very mild.

Care should be taken to select the dose of the loop diuretic, i.e. the dose
should eliminate ankle or pulmonary oedema without dehydrating the
patient and placing them at risk of renal dysfunction or hypotension.


Furosemide

Dose – 20mg – 500mg

The supplementary prescriber would not go above 160mg bd unless
specified in the CMP by the independent prescriber.

Frequency – Once or twice daily

Contraindications – as per BNF

Dose adjustment

The dose may be up-titrated if the patient shows a sustained (> 3 day)
and significant (> 2 kg) increase in weight above dry weight, especially if
this is accompanied by an

         Increase in peripheral oedema
         Increased JVP
         Increased breathlessness.

The maximum titration should be specified in the patients CMP and
consequently agreed by both the independent and supplementary
prescribers.

Increasing Schedule

If the supplementary prescriber concludes that an increased dose of
Furosemide is required, the following dose increasing schedule should be
followed.

20mg od → 40mg od (or 20mg bd)



PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 4 of 23
40mg od → 80mg od (or 40mg bd)

80mg od → 80mg morning & 40mg lunchtime

80mg morning & 40mg lunchtime → 80mg bd

80mg bd → 120mg morning & 80mg lunchtime

120mg morning & 80mg lunchtime → 120mg bd

120mg bd → 160mg morning & 120mg lunchtime

160mg morning & 120 mg lunchtime → 160mg bd

Patients should be contacted within 72 hours following an increase in dose
to assess the response and a U&E test carried out 7-10 days after any
increase in dose


Decreasing the Dose

This should be done cautiously and the patient contacted within 72 hours
to assess the response. The dose should only be reduced if there are
signs of volume depletion and hypo perfusion. This would include:

         Significant weight loss (≥1 kg)
         Rising blood Urea and Creatinine (>25%)
         Symptoms of dizziness (e.g. postural hypotension)
         Feeling “dried out” with a deterioration in biochemistry

Advice should be sought from the Independent Prescriber if there are
signs of hypo perfusion in conjunction with signs of deterioration in heart
failure symptoms.

Dose reduction should be carried out in the reverse of the up-titration
schedule outlined above. The dose should not be reduced to below 20mg
Furosemide without discussion with the independent prescriber.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 5 of 23
Bumetanide

Dose – 1- 5mg

Frequency – Once or twice daily

Contraindications - as per BNF

Dose adjustment

The dose may be up-titrated if the patient shows a sustained (> 3 day)
and significant (> 2 kg) increase in weight above dry weight, especially if
this is accompanied by an

         Increase in peripheral oedema
         Increased JVP
         Increased breathlessness.

The maximum titration should be specified in the patients CMP and
consequently agreed by both the independent and supplementary
prescribers.


Increasing dose Schedule

If the supplementary prescriber concludes that an increased dose of
Bumetanide is require, the following dose increasing schedules should be
followed.

1mg od → 2mg od (or 1mg bd)

2mg od → 2mg morning & 1mg lunchtime

2mg morning & 1mg lunchtime → 2mg bd

2mg bd → 3mg morning & 2mg lunchtime

3mg morning & 2mg lunchtime→ 3mg bd

3mg bd → 4mg morning & 3mg lunchtime

4mg morning & 3mg lunchtime → 4mg bd

4mg bd → 5mg morning & 4mg lunchtime

5mg morning & 4mg lunchtime → 5mg bd




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 6 of 23
Patients should be contacted within 72 hours following an increase in dose
to assess the response and a U&E test carried out 7-10 days after any
increase in dose

Decreasing the Dose

This should be done cautiously and the patient contacted within 72 hours
to assess the response. The dose should only be reduced if there are
signs of volume depletion and hypo perfusion. This would include:

         Significant weight loss (≥1 kg)
         Rising blood Urea and Creatinine (>25%)
         Symptoms of dizziness (e.g. postural hypotension)
         Feeling “dried out” with a deterioration in biochemistry

Advice should be sought from the Independent Prescriber if there are
signs of hypo perfusion in conjunction with signs of deterioration in heart
failure symptoms.

Dose reduction should be carried out in 1mg increments i.e. the reverse
of the up-titration schedule outlined above. The dose should not be
reduced to below 1mg Bumetanide daily without discussion with the
Independent Prescriber.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 7 of 23
  Thiazide Diuretics and Metolazone

These diuretics may be used as an alternative to loop diuretics in patients
with less severe heart failure or in addition to loop diuretics in patients
with severe heart failure. Combination of thiazide / metolazone and loop
diuretic must be used with extreme caution and only after medical
consultation.

Close biochemical monitoring of combination therapy is mandatory for the
first four weeks. If blood chemistry remains stable over this period and
thiazide/metolazone therapy is to continue, monthly checks thereafter are
sufficient provided there is no change in the diuretic dose, ACE inhibitor or
spironolactone, the addition of any other drug or intercurrent illness that
might affect renal function.

Metolazone

Dose – 2.5mg – 10mg

Frequency – Once weekly to once daily

Contraindications - as per BNF

Criteria for Exclusion - Patients with significant renal impairment
(Urea>35, Creatinine>300) unless specifically requested by the
Independent Prescriber and specified in the CMP.

Dose adjustment

Metolazone is considered as add-in diuretic therapy for patients with more
severe heart failure, in whom a loop diuretic (Furosemide or Bumetanide)
alone is not sufficient to control symptoms of sodium and water retention.

Metolazone may be initiated or the dose up-titrated by the SP if the
patient develops signs of deterioration in heart failure conditions, that is:
a sustained (> 3 day) and significant (> 2kg) increase in weight above
dry weight, especially if this is accompanied by an

         Increase in peripheral oedema
         Increased JVP
         Increased breathlessness.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 8 of 23
Increasing the Dose

Metolazone may be given in a dose of 2.5 - 5mg at the following
frequencies:

Once weekly
Twice weekly
Three times weekly
Alternate days
Once daily

If the supplementary prescriber concludes that there should be an
increase in dose of Metolazone they may increase the dose within the
ranges specified in the CMP.
The maximum titration should be specified in the patients CMP and
consequently have been agreed by both the independent and
supplementary prescribers.

Patients should be contacted within 72 hours following an increase in dose
to assess the response and a U&E test performed where possible within 7
days of the change in therapy (sooner if deemed clinically necessary by
SP)

If there is no improvement in symptoms despite an increase in the dose
of Metolazone then advice should be sought from the Independent
Prescriber.

Decreasing the Dose

This should be done cautiously and the patient contacted within 72 hours
to assess the response. The dose should only be reduced if there are
signs of volume depletion and hypo perfusion. This would include:

                   Significant weight loss (≥1 kg)
                   Rising blood Urea and Creatinine (>25%)
                   Symptoms of dizziness (e.g. postural hypotension)
                   Feeling “dried out”.

Metolazone may be discontinued if deemed clinically appropriate by the
supplementary prescriber.

Advice should be sought from the Independent Prescriber if there are
signs of hypo perfusion (as described above) in conjunction with signs of
clinical deterioration (as described above)

Advice should also be sought if the patient is taking ≥5mg Metolazone
daily with signs of clinical deterioration in heart failure.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 9 of 23
                                         ACE Inhibitors

All patients with left ventricular systolic dysfunction should be prescribed
an ACE inhibitor unless there is a clear contra-indication.

Name of medication - Captopril, Enalapril, Lisinopril, Perindopril.
                     Ramipril

Target doses -                          Captopril   50mg tds
                                        Enalapril    10-20mg bd
                                        Perindopril 4mg daily
                                        Lisinopril     30 - 35 mg daily
                                        Ramipril      10mg daily (or 5mg bd)


Contraindications - as per BNF

Before initiation of an ACE inhibitor, base-line biochemistry and blood
pressure should be checked.

Every effort should be made to achieve the target dose (or as high as
tolerated).

The dose of ACE inhibitor should be increased in the absence of severe
asymptomatic hypotension (SBP <90mm Hg), symptomatic hypotension,
or significant renal impairment (i.e. Creatinine ≥200micromol/L and/or
Urea ≥15mmol/L). If any of these contra-indications are present in a
patient receiving a below target dose of ACE inhibitor seek advice from
the Independent Prescriber.

Dose adjustment

In the absence of a contraindication, increase the dose to the next dose
increment at not less than 2 weekly intervals using the following
incremental increase for each drug:

Captopril 12.5mg tds→25mg tds→50mg tds

Enalapril 2.5mg bd→5mg bd→10mg bd (occasionally increased up to
          20mg bd under instructions from IP)

Perindopril 2mg od→4mg od

Ramipril 1.25mg od→2.5mg od→5mg od→10mg od

Lisinopril 2.5mg od →5mg od→10mg od→20mg od (may be increased
          further, at request of Independent Prescriber)




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 10 of 23
It may be more appropriate to use smaller or larger incremental
increases in dose, at the discretion of the Supplementary Prescriber, (e.g.
a larger dose on alternate days)

The drug and target dose specific to that patient will be specified in the
patient’s CMP

Blood pressure and blood biochemistry should be checked within 7-14
days of a dose increment and before the next dose increment, as deemed
clinically necessary.

Problems

Cough, hypo perfusion (cerebral and renal) and angio-oedema are the
major adverse effects associated with ACE inhibitor therapy. If the
patient has a genuinely troublesome cough clearly related to the ACE
inhibitor an angiotensin ll receptor antagonist should be substituted.

Cerebral hypo perfusion presents as dizziness, blackouts or light-
headedness. Often this may be resolved by a reduction in concomitant
medication i.e. diuretics, especially nitrates, beta-blockers and calcium
channel blockers. If this problem arises seek advice from Independent
Prescriber.

Often heart failure patients may have a low blood pressure but no
symptoms (asymptomatic hypotension). This finding does not necessitate
any action unless there is renal hypo perfusion.

Renal hypo perfusion leads to an increase in Urea, Creatinine and often
Potassium. Small increases in all three of these are common and
acceptable consequences of using an ACE inhibitor. If Potassium rises to
>6.0mmol/L the ACE inhibitor must be stopped immediately, at least
temporarily and advice sought from the Independent Prescriber.

If Potassium rises to between 5.5mmol/L and 5.9mmol/L recheck within
1-4 days, as deemed clinically appropriate. If after a further check the
Potassium level remains between 5.5mmol/L to 5.9mmol/L discuss with
the Independent Prescriber.

  If Urea increases to ≥20mmol/L (or by >10mmol/L) and/or Creatinine to
  ≥300micromol/L (or by >100micromol/L) the ACE inhibitor should also
  be stopped immediately, and subsequently discussed with the
  Independent Prescriber.

Very    often,  deteriorating  renal   function  is   due   to   over
diuresis/dehydration (e.g. due to diarrhoea/vomiting) or concomitant
medication (especially NSAIDs, potassium sparing diuretics).   These
should always be taken into account and if necessary advice should be
sought from the Independent Prescriber with respect to adjustment of


PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 11 of 23
the concomitant medication. Less serious increases i.e. urea 5-10 mmol/l
or creatinine 50 – 100 mmol/l should be monitored very closely. Blood
chemistry should be rechecked and advice sought from the Independent
Prescriber if the change is sustained. Small changes in urea (<5 mmol/l)
and creatinine (<50 mmol) can be ignored provided these changes are
stable i.e. show no progression between two blood tests at least two
weeks apart.

For patients with a known high biochemical profile, it may be reasonable
not to reduce the ACE inhibitor. This will always be at the discretion of
the Independent Prescriber. In such a case, this will have been discussed
with the Supplementary Prescriber and included in the CMP.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 12 of 23
           Angiotensin II Receptor Antagonists (AIIRA’s)

All patients should be prescribed an ACE inhibitor unless there is a clear
contra-indication or they are intolerant of them.

For patients who are intolerant of ACE inhibitors (e.g. dry cough) the ACE
inhibitor may be substituted for an AIIRA. This decision, and which drug
to change to will be decided by the Independent Prescriber.

Name of Medication - Candesartan, Irbesartan, Losartan, Valsartan

Target Doses -                       Candesartan               16mg od
                                     Irbesartan                  300mg od
                                     Losartan                    50-100mg od
                                     Valsartan                  160mg od

Contra-indications - As per BNF

Before initiation of an AIIRA, base-line biochemistry and blood pressure
should be checked.
Every effort should be made to achieve the target dose (or as high as
tolerated)

The dose of AIIRA inhibitor should be increased in the absence of severe
asymptomatic hypotension (SBP <90mmHg), symptomatic hypotension,
or significant renal impairment (i.e. Creatinine ≥200micromol/L) and/or
Urea ≥15mmol/L). If any of these contra-indications are present in a
patient receiving a below target dose of AIIRA seek advice from
Independent Prescriber.

In the absence of a contraindication, increase the dose to the next dose
increment using the follow incremental increases for each drug:

Candesartan 2mg od→ 4mg od→ 8mg od→16mg od

Irbesartan 150mg od→ 300mg od (occasionally initial dose may be
75mg od, increase this to 150mg od)

Losartan 25mg od→ 50mg od (occasionally increased up to 100mg od
under instructions from IP)

Valsartan 40mg od→ 80mg od→ 120mg od→ 160mg od

There should be at least 2 weeks between dose increments.
Blood pressure and blood biochemistry should be checked within 7-14
days of a dose increment and before the next dose increment, as deemed
clinically appropriate.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 13 of 23
Problems

Cerebral hypo perfusion presents as dizziness, blackouts or light-
headedness. Often this may be resolved by a reduction in concomitant
medication i.e. diuretics, especially nitrates, beta-blockers and calcium
channel blockers. If this problem arises seek advice from Independent
Prescriber. Often heart failure patients may have a low blood pressure
but no symptoms (asymptomatic hypotension). This finding does not
necessitate any action unless there is renal hypo perfusion.

Renal hypo perfusion leads to an increase in urea, Creatinine and often
Potassium.   Small increases in all three of these are common and
acceptable consequences of using an AIIRA.

If Potassium rises to >6.0mmol/L the AIIRA must be stopped
immediately, at least temporarily and advice sought from the
Independent Prescriber.    A comprehensive review of treatment will have
to be undertaken with other nephrotoxic drugs reviewed, e.g.:
Spironolactone/loop diuretics/thiazide diuretics.

If Potassium rises to between 5.5mmol/L and 5.9mmol/L recheck within
1- 4 days, as deemed clinically appropriate. If after a further check the
Potassium level remains between 5.5mmol/L to 5.9mmol/L discuss with
the Independent Prescriber.

If Urea increases to ≥20mmol/L (or by > 10mmol/L) and/or Creatinine to
≥300micromol/L (or by > 100mmol/L) the AIIRA inhibitor should also be
stopped immediately, and subsequently discussed with the Independent
Prescriber. If the Creatinine increase to >220mmol/L the prescription
should be reviewed with the Independent Prescriber before
discontinuation of the AIIRA

If there is a less serious increase in blood biochemistry e.g. a rise of 5-
10mmol/L in Urea, or 50-100 micromol/L in Creatinine, this should be
monitored very closely. Blood chemistry should be rechecked and advice
sought from the Independent Prescriber if the change is sustained.

Small changes in Urea (5mmol/L) and Creatinine (<50 micromol/L) may
be ignored provided these changes are stable i.e. show no progression
between two blood tests at least two weeks apart.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 14 of 23
                                                      Beta Blockers

All Patients will be considered for beta-blocker therapy by the
independent prescriber if they are considered to have stable heart failure.

The initial prescription for a beta blocker will always be provided
by the independent prescriber. The patient may start taking the beta-
blocker, having received the prescription, under instructions from the
supplementary prescriber.

Name of medication - Carvedilol, Bisoprolol, Nebivolol

Target doses - Carvedilol                        25mg bd (patients >85kg - 50mg bd)
               Bisoprolol                        10mg daily
               Nebivolol                         10mg daily

Contra-indications - As per BNF
                     Asthma

It is not advised that patients should be initiated or up-titrated on their
beta-blocker if they have experienced a de-compensation in their heart
failure within the previous month.

Before up-titrating the beta-blocker the supplementary prescriber will
assess the patient’s clinical stability, blood pressure and pulse.

If there are signs of a de-compensation in the patient’s condition do not
up-titrate the beta-blocker. Occasionally it may be necessary to reduce
the dose depending upon the severity of the symptoms. However, an
increase in diuretic therapy may be sufficient to control the symptoms.

If extra diuretics or a reduction in beta-blocker dose are required, do not
increase the dose again until clinical stability resumes, ideally with no
change in diuretic therapy for one month.           Seek advice from the
independent prescriber if unsure how best to manage the patient.

If the pulse is <60 bpm then an ECG must be performed prior to titration
to assess for first degree heart block. In such cases the supplementary
prescriber will liaise with the independent prescriber after the ECG had
been performed before any change in drug therapy.

The dose of beta-blocker may be increased if the systolic blood pressure
(SBP) is ≥90 mmHg, so long as the patient does not describe symptoms
of hypotension. If the SBP is <90mmHg discuss with the independent
prescriber before any change in dose. If the patient is experiencing
symptomatic hypotension, discuss with the independent prescriber prior
to up-titration.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 15 of 23
In the absence of a contraindication, increase the dose to the next dose
increment using the following incremental increases for each drug:

Carvedilol 3.125mg bd→ 6.25mg bd→ 12.5mg bd→ 25mg bd (→ 50mg
bd for patients >85kg)

Bisoprolol 1.25mg od→ 2.5mg od→ 3.75mg od→ 5mg od→ 7.5mg od→
10mg od

Nebivolol 1.25mg od→ 2.5mg od → 5mg od → 10mg od

There should be at least 2 weeks between dose increments. In most
cases it is advisable to allow 1 month between dose increments, to allow
the patients to stabilise on the new dose.

Blood pressure and pulse should be checked within 7-14 days of a dose
increment and before the next dose increment.

Patient Counselling

The patient must                         be       made          aware           of      the       following            before
initiation/titration.

Many patients will experience a period of feeling tired and lethargic after
initiation or titration of their beta-blocker. It is important that they
understand that this is usually transient in nature, and as long as the
symptoms are not serious then they should continue to take the
prescribed dose.

It is common to feel slightly dizzy after initiation/titration of beta-
blockers. If the dizziness is severe patients are encouraged to contact the
Heart Failure Nurse.

Occasionally patients experience a worsening of heart failure symptoms
after initiation/titration of beta-blocker, commonly around 4 days after
the drug change. They are advised to contact the Heart Failure Nurse,
should this occur, for advice.

Problems

If a patient reports tiredness and lethargy after beta-blocker initiation/up
titration then they are counselled, as above that this is common,
especially in the first few weeks of a dose change. They will be reviewed
and if such symptoms do not resolve after a period of one month then the
supplementary prescriber will review the need to reduce the
dose/discontinue the beta blocker (the opposite to the up-titration
schedule). The independent prescriber will be contacted if unsure of how
best to proceed.



PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 16 of 23
If a patient reports dizziness after beta-blocker initiation/up-titration the
supplementary prescriber will asses the severity of the dizziness. If
appropriate, arrangements will be made for sitting and standing blood
pressures to be taken, and if necessary the dose may be reduced or
discontinued (the opposite to the up-titration schedule), depending upon
the severity of the symptoms. The independent prescriber will be
contacted if unsure of how best to proceed.

If the patient reports a deterioration in their condition (increasing
shortness of breath/increasing peripheral oedema / >2kg increase in
weight) then the change in symptoms should be monitored. If symptoms
are mild then an increase in loop diuretic therapy may be enough to
control the symptoms (see Bumetanide and Furosemide drug profiles). If
the patient is not currently receiving diuretic therapy but reports a
worsening in symptoms, contact the independent prescriber for advice,
and if necessary issue a prescription for diuretics. If symptoms are
severe, this may necessitate a reduction in beta-blocker dose (opposite to
up-titration schedule). The independent prescriber will be contacted if
unsure of how best to proceed.

If, on routine pulse check after initiation/up-titration of beta-blockers it is
found that the pulse is <55 bpm perform a 12 lead ECG and discuss with
the independent prescriber. It may be appropriate to decrease other drug
therapy, Digoxin etc.

If, on routine blood pressure check after initiation/up-titration of beta-
blockers it is found that the blood pressure is <85mmHg systolic, even if
the patient is asymptomatic, discuss with the independent prescriber. (It
is often advisable to check sitting and standing blood pressure in this
situation).

Rarely, acute renal failure and renal function abnormalities in patients
with diffuse vascular disease and/or impaired renal function may occur.
For this reason, in patients with these risk factors and low blood pressure
(systolic BP<100mmHg) additional U&E checks should be made.               If
worsening renal function occurs, the dosage of beta-blocker should be
reviewed, contact the independent prescriber if unsure of how best to
proceed.

The beta-blocker should not be withdrawn abruptly. It is advisable to use
a gradual reducing schedule, e.g. halve the dose at no less than 3-day
intervals. Contact the independent prescriber if unsure of how best to
proceed.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 17 of 23
                                                         Digoxin

Digoxin would never be initiated by the Supplementary Prescriber.

Digoxin may be used in 2 contexts:

         Ventricular rate control for patients with atrial fibrillation
         For symptomatic benefit in patients with CCF on otherwise optimal
          medical therapy even if they are in sinus rhythm.

Dose - 62.5 – 375mcg daily

Frequency – once daily

Contraindications - As per BNF

Increasing the Dose

The SP will check the pulse of the patient receiving Digoxin. If the
ventricular rate is deemed too high (>85 bpm) and the SP feels that this
is compromising the patient’s heart failure, provided that the renal
function of the patient is stable with a Creatinine <150micromol/L, the SP
may increase the dose of Digoxin by 62.5mcg.

The dose may be increased by greater than 62.5mcg increments if so
deemed by the IP in the CMP. The SP must also be confident that the
patient’s renal function is sufficient to clear the higher dose and that the
ventricular rate is such that a higher dose increment would be tolerated.

If plasma drug levels are taken it is important to ensure that the level is
such that a higher dose increment would not give the patient a toxic drug
level. Routine plasma levels of Digoxin are not necessary. If plasma
Digoxin concentrations are needed refer to Hospital Formulary.


Reducing the Dose

Digoxin toxicity can occur with any dose of Digoxin but is more common
when the therapeutic concentration is exceeded.           Anorexia, nausea,
vomiting, xanthopsia (yellow tint to the vision), bradycardia and
ventricular arrhythmias are all recognised effects of Digoxin toxicity.
Gynaecomastia may also occur with long-term use. In elderly patients
symptoms may be more non-specific and may include confusion,
deteriorating mobility and falls. If any of these occur, and Digoxin toxicity
is suspected a serum Digoxin concentration should be measured and
advice sought from the IP.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 18 of 23
Certain drugs may interact to increase the serum Digoxin concentration
and the supplementary prescriber must be aware of these, and the
potential need to reduce if signs of toxicity occur, e.g. Amiodarone,
Erythromycin, Quinine, and possibly Atorvastatin.

Warnings, including potential adverse drug reactions

Potential side-effects are often related to toxicity. Patients are particularly
liable to this if renal function deteriorates resulting in reduced excretion of
Digoxin, or if excessive dosage is administered. See above regarding
signs and symptoms of toxicity.           It is important to note that the
symptoms of toxicity in elderly patients may be very non-specific. It is
vital to bear this in mind when assessing elderly patients and not to
confuse their multiple pathologies with Digoxin toxicity.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 19 of 23
                                      Aldosterone Antagonists

Spironolactone

Generally used in patients with a confirmed diagnosis of heart failure who
remain symptomatic on less than ordinary activity (i.e. NYHA Class III or
IV) despite optimal medical therapy. Patients with persistent signs of
sodium and water retention may be particularly suitable for this
treatment.

Dose – 12.5 – 25mg

Frequency – Daily

Contraindications – as per BNF

Initiation

Treatment will only be started or re-started after discussion with either
the Independent Prescriber or patient’s GP.

Baseline blood chemistry should be checked prior to initiation.

Once Spironolactone has been initiated, or the dose been changed the
following blood chemistry monitoring is advised

Check blood chemistry at 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6
monthly thereafter.

Problems

If Potassium levels increase to between 5.5 and 5.9mmol/L or creatinine
rises to 200 mmol/l the dose will need to be reduced to 25 mg on
alternate days and blood chemistry monitored closely.

If Potassium rises to >6 mmol/l or creatinine to >200 the spironolactone
needs to be discontinued, and the Independent Prescriber informed.

If the patient develops diarrhoea and/or vomiting (or any other cause of
sodium and water loss) then Spironolactone may need to be discontinued.

If a change in renal function cannot be controlled with these changes in
drug treatment, then advice should be sought from the Independent
Prescriber.

The patient may become sodium and water depleted and hypovolaemic
when taking Spironolactone, necessitating a reduction in the dose of
Spironolactone. This can be expected if:



PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 20 of 23
         The patient complains of postural dizziness/light headedness
         The patients blood pressure falls excessively and in a sustained way
         The patient exhibits a significant and sustained weight loss (e.g.
          ≥1kg, sustained over ≥1 week)
         The patient has some intercurrent illness causing sodium and water
          depletion (e.g. diarrhoea and vomiting – If this occurs
          Spironolactone may need to be discontinued) or if the patient has
          not been drinking sufficient fluids or been in a hot climate,
          perspiring excessively.

The blood chemistry should be checked if any of the above occurs.

Side effects

Gastro-intestinal disturbances, impotence, gynaecomastia, menstrual
irregularities, lethargy, headache, confusion and rashes.
Hyperkalaemia or hyponatraemia may occur, these will be monitored with
the regular blood chemistry measurement, and appropriate action taken.

Eplerenone

Epleronone can be recommended as an additional therapy which is
started between 3 and 14 days post MI in patients with LVSD and CHF or
diabetes.

Dose – 25 - 50mg

Frequency – Daily

Contraindications – as per BNF

Problems

Although Epleronone produces less gynaecomastia than Spironolactone it
can still produce hyperkalaemia and renal dysfunction and blood urea,
creatinine and potassium should be monitored after initiation and
throughout therapy.

It is now recommended that Epleronone can be substituted for
Spironolactone in patients who develop gynaecomastia.




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 21 of 23
References

National Institute of Clinical Excellence (2003) Management of chronic
heart failure in adults in primary and secondary care www.nice.org

Scottish Intercollegiate Guidelines Network (2007)Management of chronic
heart failure www.sign




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 22 of 23
Appendix 1
                                               Heart Failure
                                        Clinical Management Plan

Name of Patient:                                                  Medication sensitivities/allergies:


Patient identification number or date of birth:


Independent Prescriber:                                           Supplementary Prescriber:


Medicines that may be prescribed by SP:
Preparation                             Dose schedule                                              Specific indication
                   Indication                                                                      for referral back
                                                                                                   to the IP




Guidelines or protocols supporting Clinical Management Plan:
NICE (2003) Management of chronic heart failure in adults in primary and secondary
care
SIGN (2007) Management of chronic heart failure
Heart Failure Medicine Protocol (2007) Powys LHB
British National Formulary – Current Edition
Frequency of review and monitoring by:
Supplementary prescriber                     Supplementary      prescriber    and
                                             independent prescriber



Process for reporting adverse drug reactions:
     Report to Independent Prescriber
     Completion of yellow card
     Record in patient notes
Shared record to be used by IP and SP:
Clinical Management Plan to be kept in the patient’s notes which will be accessible to
both the Independent prescriber and the Supplementary prescriber

Agreed by                        Date       Agreed by                                Date            Date agreed with
independent                                 supplementary                                            patient/carer
prescriber(s)                               prescriber(s)




PLHB SP 0003 Heart Failuire Medicines Protocol. Author: Cardiac Nurse Specialist, Approved: Governance and Risk Management
Committee February 2008. Review: February 20111. Page 23 of 23

				
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