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Medicines Optimisation Key Messages – Bulletin 9
Medicines Optimisation of CCBs
1 KEY MESSAGE: Prescribe generic amlodipine or lercanidipine first line • In Norfolk & Waveney CCGs amlodipine is a 1st line option1 when a calcium channel blocker (CCB) is indicated for hypertension or angina • Lercanidipine is an alternative 1st line option licensed for hypertension1,2 • They are both available generically in the UK and are relatively inexpensive compared with other dihydropyridine CCBs e.g. felodipine, lacidipine, nifedipine, nicardipine, isradipine • The 2nd choice CCB licensed for hypertension and angina is felodipine1,2
Regional Drugs & Therapeutics Centre (Newcastle) http://rdtc.nhs.uk/sites/default/files/cost-comparison-charts-oct-2015.pdf
Anglia Prescribing & Medicines Management Team Version: 3.1 Issued: January 2016 Review date: January 2017
Reviewing Your Practice 1. Use generic amlodipine or generic lercanidipine* first line for newly treated patients as per licensed indications
2. Identify patients who have NOT tried amlodipine / lercanidipine* for hypertension and consider changing:
a. Run a search to identify patients on felodipine or lacidipine, for hypertension (including brand names). b. Exclude those who have had amlodipine / lercanidipine previously c. Invite patient for a BP review, discuss with patient and consider suitability for switch to amlodipine – see table below for suggested dose equivalence3, 4 OR Write a letter to inform the selected patients of the drug switch d. Review BP after 4 weeks
Suggested dose equivalence to amlodipine 5mg for hypertension3,4
Lercanidipine 10mg Lacidipine 2-4mg Felodipine M/R 5mg
*For patients who also take simvastatin: use lercanidipine to avoid the interaction with amlodipine MHRA Aug 12 (maximum licensed simvastatin dose is 20mg with amlodipine due to increased risk of myopathy)
Ankle oedema associated with CCBs
• Ankle swelling is an adverse effect of all calcium-channel blockers.
• It is not related to fluid retention, but possibly caused by increasing capillary pressure leading to leakage of fluids into the surrounding tissues. Diuretics therefore have little effect on CCB induced oedema.
Treatment strategies include5: ♦ Non-pharmacological interventions i.e. elevation of legs or graduated compression stockings ♦ Dosage adjustment as oedema can be dose-related ♦ Adding an angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor antagonist (A2RA) if an ACEI cannot be tolerated. ♦ Switching to alternative CCB ♦ Discontinuation and switching to an antihypertensive from another class of drugs
References: 1. NEL CSU (North,Norwich,South & West Norfolk CCGs) Cardiovascular Formulary accessed 14.12.15 nww.knowledgeanglia.nhs.uk/prescribing_nhsn/formulary/formulary_cardiovascular.pdf 2. Electronic Medicines Compendium accessed 14.12.15 www.medicines.org.uk/emc 3. UKMi Medicines Q&A What-are-appropriate-doses-to-use-when-switching-hypertensive-patients-to-amlodipine-from-lercanidipine-or-lacidipine? 10th May 2012 See link below 4. UKMi Medicines Q&A How-do-amlodipine-and-felodipine-compare-for-the-treatment-of-hypertension-or-prophylaxis-of-stable-angina ? 17th October 2012. See link below 5. UKMi Medicines Q&A How-should-ankle-oedema-caused-by-calcium-channel-blockers-be-treated? 14TH August 2013. See link below www.evidence.nhs.uk/Search?om=[{"srn":[" ukmi "]}]&q=calcium+channel+blockers
Anglia Prescribing & Medicines Management Team Version: 3.1 Issued: January 2016 Review date: January 2017
Title KEY MESSAGES Bulletin 9- Medicines Optimisation of CCBs
Description of policy To inform healthcare professionals
Scope Prescribing info on Calcium Channel Blockers Prepared by Prescribing & Medicines Management Team (AA.LS.MC) Evidence base / Legislation Level of Evidence: A. based on national research-based evidence and is considered best evidence B. mix of national and local consensus C. based on local good practice and consensus in the absence of national research based information. Dissemination Is there any reason why any part of this document should not be available on the public web site? Yes / No Approved by NHSN&W Prescribing Reference Group 2/8/12 (version 1) Authorised by NHSN&W Drug & Therapeutics Commissioning Group 16/8/12 (version 1). Prescribing & Medicines Management Senior Team 19/11/13 (version 2),26.11.14 (V3.0), 25.2.16 (V3.1) Review date and by whom January 2017 Prescribing & Medicines Management Team Date of issue January 2016
Version Date Author Status Comment 0.1 5/4/12 Prescribing & Meds draft Man Team AA,LS 0.2 16/4/12 Prescribing & Meds draft Ref. added. Indications added to CCBs in key Man Team AA,LS,MC message. 0.3 22/5/12 Prescribing & Meds draft Replaced cost table with April 12 version Man Team AA LS,MC 0.4 28/6/12 Prescribing & M LS,MC draft Removed some CCBs from switch search and eds Man Team AA nifedipine from equivalence table. 0.5 13/7/12 Prescribing & Meds draft Updated following network group comments Man Team AA LS,MC 0.5 2/8/12 Prescribing & Meds draft Passed by Prescribing Ref Group Man Team AA LS 0.5 16/8/12 Prescribing & Meds draft Ratified by D & T Commissioning Group Man Team AA LS 1.0 5/9/12 Prescribing & Meds Final Man Team AA LS 1.1 9.9.13 Prescribing & Meds draft New format. Cost comparison update. Man Team MC Lercanidpine added as 1st line, ref to new CV formulary. Syntax changes to key messages. Clarification of which CCBs are dihydropyridines. Remove 2012 QIPP saving details. Reviewing practice box changed to include lercandipine as option to switch to. Approved by Prescribing & Medicines Management Senior Team. 19.11.13 2.0 20.11.13 Prescribing & Meds Final Man Team MC 2.1 6.11.14 Prescribing & Meds draft Logo changed . Ref to amlostin removed as 5mg Man Team MC no longer available. Cost table updated. Approved by Prescribing & Medicines Management Senior Team addition of information on interaction with amlodipine/simvastatin 2.2 19.11.14 Prescribing & Meds draft Section added for amlodipine/simvastatin Man Team MC interaction
2.3 24.11.14 Prescribing & Meds draft Further amendment of above interaction to use Man Team MC lercanidipine.
Key Messages Bulletin Page 3 0f 4 ver 3.1 – January 2016 3.0 26.11.14 Prescribing & Meds final Approved by Senior Prescribing Team Man Team MC 3.1 14.12.15 Prescribing & Meds Draft Cost table updated. Slight syntax change. Man Team MC update Reference links checked and updated. Approved by Senior Prescribing Team 25.2.16
Key Messages Bulletin Page 4 0f 4 ver 3.1 – January 2016