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 Formulary Chapter 2: Cardiovascular system - Full Chapter
02.02.03  Expand sub section  Potassium-sparing diuretics and aldosterone antagonists
 note 
  • Amiloride and spironolactone are weak diuretics if given alone, but their diuretic and antihypertensive effects are additive with those of loop and thiazide diuretics. They should be used in preference to potassium supplements if hypokalaemia is a problem with loop or thiazide diuretics alone.
  • Combinations should not be used unnecessarily and in practice are often not justified when treating hypertension, as the risk of hyponatraemia is greater than with one agent alone.
  • Amiloride and spironolactone may take 2-3 days to become fully effective.
  • Potassium-sparing diuretics are contra-indicated in renal failure; the elderly may insidiously develop hyperkalaemia due to deterioration in renal function.
  • Close monitoring required if prescribed together with other agents that raise serum potassium. These include potassium supplements, ACE inhibitors and angiotensin-II antagonists. Non-steroidal anti-inflammatory drugs (NSAIDs) and ciclosporin may also increase the risk of hyperkalaemia. Serum potassium should be monitored 3 monthly and within 7-14 days after a dose change.
Amiloride
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02.02.03  Expand sub section  Aldosterone antagonists
Spironolactone
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Restricted Drug Restricted
Green
NICE recommends in patients with heart failure due to left ventricular systolic dysfunction who remain moderately to severely symptomatic despite optimal therapy of ACE inhibitors and β blocker. Specialist advice should be sought as monitoring required.
Can also be used when an aldosterone antagonist is clearly indicated (e.g. primary hyperaldosteronism or treatment of oedema and/or ascites in hepatic cirrhosis). 
Link  MHRA Advice: Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia
   
Eplerenone
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Green
Evidence supports the use in patients admitted to CCU following an MI with proven left ventricular failure in addition to other treatment. Second line as an alternative to spironolactone in patients who have chronic heart failure or hypertension and suffer from gynaecomastia.
 
   
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Traffic Light Status Information

Status Description

Black

Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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