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Prescribing advice

BNF updates advice on dual blockade and ivabradine use

Avoid combination therapy with drugs that affect the renin-angiotensin system and monitor patients taking ivabradine.

ECG monitoring machine

Source: Zayacskz /

Patients taking ivabradine should be monitored for bradycardia (a resting heart rate below 60 beats per minute)

Warnings on “dual blockade” — the concomitant use of drugs that affect the renin-angiotensin system (RAS) — and on a cardiovascular risk associated with ivabradine are highlighted in the August 2014 update from the British National Formulary (BNF).

The BNF advice on combining drugs affecting the RAS — the hormone system that regulates blood pressure and water balance — recommends avoidance of combination therapy with two drugs that affect the RAS system (ACE [angiotensin converting enzyme] inhibitors, angiotensin II receptor agonists and aliskiren). Compared with the use of a single drug, there is an increased risk of hyperkalaemia, hypotension and renal impairment when two drugs are used.

The advice has been updated in the light of new guidance from the Medicines and Healthcare products Regulatory Agency (MHRA), which is itself the product of a European review.

The update points out there is evidence that the benefits of combined use of an ACE inhibitor with candesartan or valdesartan may outweigh the risks for some heart failure patients for whom other treatments are not suitable. But the use of this combination at the same time as an aldosterone agonist or a potassium-sparing diuretic is not recommended.

The need for continued review of patients who are currently taking combination therapy is also highlighted.

Patients taking ivabradine should be monitored for bradycardia

The BNF update draws attention to an increased cardiovascular risk with ivabradine, which is prescribed for patients with long-term stable angina or long-term heart failure. It warns that patients taking the drug should be monitored for bradycardia (a resting heart rate below 60 beats per minute), after results from the Signify trial showed a small increased risk of cardiovascular events that may be associated with the condition.

Advice on new TB and hepatitis C drugs

The update includes advice about the new antimycobacterial drug delamanid (Deltyba; Otsuka), which has been licensed, in combination with other drugs, for the treatment of multiple drug resistant pulmonary tuberculosis.

The update also contains information about simeprevir (Olysio; Janssen/Medivir), a new protease inhibitor that has been licensed for use in combination with ribavirin and peginterferon alfa for the treatment of chronic hepatitis C infection of genotypes 1 or 4. Simeprevir may also be used in combination with sofosbuvir, with or without ribavirin, for urgent treatment of the infection only when peginterferon cannot be used owing to intolerance or contraindications, and simeprevir monotherapy is not recommended.



Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20066216

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