Download Patient Group Direction for the supply of Lisinopril starting dose 2.5

Patient Group Direction for the supply of Lisinopril starting dose 2.5mg
daily titrating up to 30 mg daily to Patients with documented LVSD
attending Heart failure clinics or on home visits
This document authorises the supply of Lisinopril 2.5 mg daily up to 30
mg daily by cardiac/heart failure specialist nurses to patients with
documented LVSD who meet the criteria for inclusion under the terms of
the document
The cardiac/heart failure specialist nurses seeking to supply or
administer Lisinopril 2.5mg daily up to 30 mg daily must ensure that all
patients have been screened and meet the criteria before supply takes
place
The purpose of this Patient Group Direction is to ensure patients are on
optimum doses of ACE as SIGN guidelines. Reduce visits to GP. Allows
better continuity of care
This PGD was authorised on: October 2011
The direction will be reviewed by: October 2013
Clinician Responsible for Training and Review: Gillian Donaldson
PGD reviewed by: Helen Oxenham, Paul Neary, Gillian Donaldson
Cardiology PGD no 4: Lisinopril
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Patient Group Direction for Supply of Lisinopril 2.5mg once daily up to
30 mg once daily without a prescription for a named individual by
Cardiac/Heart failure specialist nurses employed by NHS Borders in
Borders general hospital/community
1. This Patient Group Direction relates to the following specific
preparation:
Name of medicine, Lisinopril 2.5mg, 5mg, 10mg, 20mg tablets
Strength,
Formulation
Legal status
Prescription only medicine (POM)
Storage
Store in a dry place below 25 degrees C and
protect from light.
Dose
Start dose 2.5mg (1.25mg in frail or elderly or renal
impairment) increase in increments of 2.5mg at no
less than two weekly intervals to maximum 20 mg
daily for the purposes of this PGD.
Route/method
Oral
Frequency
Once daily
Total dose Quantity
(Maximum/Minimu
m)
Advice to Patients
14-28 day supply depending on rate of titration
Explain that treatment given as much to prevent
worsening of heart failure and increase survival as
to improve symptoms and reduce admissions to
hospital
Symptoms may take from a few weeks to few
months to improve
Advise to report dizziness/symptomatic hypotension
rash or cough
Advise to avoid NSAIDS and salt substitutes high in
K+
Cardiology PGD no 4: Lisinopril
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Follow up
Arrangements
Contact G.P or heart failure nurse if any increased
dizziness/ heart failure symptoms.
Do not stop taking without consulting doctor or
heart failure nurse unless severe side effects
Encourage patients to weigh themselves daily and
to consult doctor or heart failure nurse if they have
persistent weight gain of 1kg for > 2days.
Heart failure nurse will follow up patient within two
weeks of commencement/up-titration to check
electrolytes. If baseline Creatinine increased by
more than 50% or 200micromol/l consider stopping
other vasodilators, NSAIDS or reducing diuretics if
no fluid retention. If renal impairment persistsreduce dose of lisinopril and recheck blood
chemistry within 1 week. See HFN Specialist
Guidelines.
Relevant Warnings
If potassium rises to 5.5mmol/l or greater reduce
dose of lisinopril.
If potassium remains above 5.5mmol/l despite
reducing lisinopril dose, stop lisinopril
If Creatinine increases by 100% or above
310micromol/l stop lisinopril.
If symptomatic hypotension (systolic BP90mmhg)
stop calcium channel antagonists, consider
reducing diuretic if no fluid retention, reduce dose
or stop lisinopril.
2. Clinical condition
Clinical Condition
Patients with heart failure due to left ventricular
to be treated
systolic dysfunction.
Criteria for inclusion





Documented LVSD
K+ level < 5.5mmol/l
Systolic BP > 90mmHg
Creatinine < 221 micromol/l
Urea < 15mmol/l
Criteria for
exclusion








Systolic BP < 90mmHg
Significant renovascular disease
Pregnancy/breastfeeding
Hypersensitivity to lisinopril or other ACEI
Severe aortic stenosis
K+ > 5.5mmol/l
History of angioedema
Cardiology PGD no 4: Lisinopril
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Action if excluded
Action if declines
Interactions with
other medicaments
and other forms of
interaction
1. Record reason for exclusion clearly in
notes/heart failure database
2. Consider alternative treatment eg ARB
3. Optimise other heart failure
medications
4. Inform consultant
cardiologist/physician
As for action if excluded
 Enhanced hypotensive effects with other
medications including nitrates, beta
blockers/calcium channel-blockers,
anxiolytics/hypnotics, antipsychotics, blockers (e.g. tamsulosin), MAOIs, nitrates,
angiotensien-ll receptor antagonists,
vasodilators (e.g. hydralazine), clonidine,
corticosteroids, diuretics, levodopa,
moxonidine, methyldopa, levodopa Alcohol
(See B.N.F)
 Enhanced hypoglycaemic effect with insulin,
metformin, and sulphonylureas
 Increased risk of renal impairment along with
NSAID.
 Increased risk of hyperkalaemia with
potassium sparing diuretics
e.g.spironolactone, eplerenone
 Lithium - reduced excretion (increased
plasma lithium concentrations)
3. Records- Cardiac nurse specialists office, dictated letter in patient
records in main stores and copy to G.P records. Heart Failure Database
when available.
1. The following records should be kept (either paper or computer
based)
The GP practice, clinic, hospital, and ward or department.
The patient name and CHI number.
The medicine name, dose, route, time of dose(s), and where
appropriate, start date, number of doses and or period of time, for
which the medicine is to be supplied or administered.
Drug batch number and expiry.
The signature and printed name of the approved healthcare
professional who supplied or administered the medicine.
The patient group direction title and/or number.
Whether patient met the inclusion criteria and whether the exclusion
criteria were assessed.
Reason for exclusion.
Quantity supplied / received and current stock balance
Cardiology PGD no 4: Lisinopril
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2.
Preparation, audit trail, data collection and reconciliationStock balances should be reconcilable with Receipts,
Administration,
Records and Disposals on a patient-by-patient basis.
3. Storage- Store in a dry place below 25 degrees C and protect from
light.
4. Professional Responsibility  All Health Professionals will ensure he/she has the relevant
training and is competent in all aspects of medication, including
contra-indications and the recognition and treatment of adverse
effects. He/she will attend training updates as appropriate. For
those involved in immunization, regular anaphylaxis updates are
mandatory.
 Nurses will have due regard for the NMC Code of Professional
Conduct, standards for conduct, performance and ethics (2010)
and NMC Standards for Medicines Management (2010)
 Sources of Evidence used for the PGD creation:
British National Formulary – current edition
SPC Zestril and Carace www.medicines.org.uk
NICE Heart Failure Guidance
Cardiology PGD no 4: Lisinopril
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