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Will NICE’s advice work for the NHS?

By A Hodgkinson, DipClinPharm, MRPharmS

The update of the National Institute for Health and Clinical Excellence’s guideline for managing hypertension poses challenges for primary care.

One challenge is capacity, specifically, the use of ambulatory blood pressure (BP) monitoring for diagnosing hypertension. Current capacity will not meet the demand this guideline will create and commissioners will need to address this issue.

Regarding treatment, the guideline introduces several considerable changes, including the use of a calcium-channel blocker, rather than a thiazide, for step 1 treatment for certain patients. Those patients who require a thiazide diuretic will now be offered either chlortalidone (12.5–25mg) or indapamide (2.5mg), rather than bendroflumethiazide. Given that chlortalidone is currently only available in the UK as a 50mg tablet, this could steer prescribers towards the use of standard-release indapamide unless generics manufacturers start to produce 12.5mg and 25mg chlortalidone tablets. Halving and quartering tablets is not practical for patients, even if they do not suffer from dexterity problems, and would not guarantee a consistent daily dose. On a practical note, I am pleased that NICE recognises that patients who are currently treated with bendroflumethiazide or hydrochlorothiazide, and whose BP is stable and well controlled, do not need to change therapy.  

Compared with previous guidance, this update recognises a wider role for ACE inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs). Also, this is the first guideline that highlights particular situations where an ARB is more appropriate than an ACEI. In some areas, this could pose problems for local and national “Quality, innovation, productivity and prevention” (QIPP) indicators. However, NICE does highlight that a low-cost ARB should be used if an ARB is indicated.

Although the changes highlighted in the treatment algorithms will result in cost pressures on the medicines budget, this should be offset by patient outcomes overall. Primary care and acute trusts will need to work together to ensure prescribing protocols are updated to reflect this new clinical guideline.  

Anna Hodgkinson is a senior prescribing adviser for Lambeth Business Support Unit, NHS South East London


Read the updated hypertension guidance.

Citation: Clinical Pharmacist URI: 11083372

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