A pharmacy review provides an opportunity to review and rationalise medication.
| Drug | Survival improved | Symptom control improved | Side effects* | Assessment/review |
|---|---|---|---|---|
| ACE inhibiter (angiotensin converting enzyme inhibitors) | yes | yes: less dyspnoea/fatigue; improves functional capacity; can reduce hospital admissions | cough, hypotension, lightheadedness, hyperkalaemia, renal impairment | Stop during any intercurrent illness which causes hypovolaemia. Caution if renal impairment or on other potassium conserving medication. Should ideally be reviewed by heart failure team. |
| Amiodarone | no | yes: by lessening dysrhythmias especially AF | hepatic dysfunction, photosensitivity, thyroid dysfunction, nausea. Important adverse interaction with other drugs which prolong the QT interval. |
Effective drug, but significant risk of adversely affecting quality of life. Very long duration of action. May take weeks-months for effect to be lost after discontinuation. |
| ARB (angiotensin receptor blockers) | yes | yes: as for ACE inhibitor | hypotension, lightheadedness, hyperkalaemia worsening renal function, | Stop during any intercurrent illness which causes hypovolaemia. Caution if renal impairment or on other potassium conserving medication. Should ideally be reviewed by heart failure team. |
| Aspirin | yes | no | GI irritation/haemorrhage | Stop if causing any symptoms. No proven role in non-ischaemic heart failure. |
| B Blocker | yes | yes: as for ACE inhibitor | fatigue/muscle weakness, nightmares, depression, cold peripheries | Stop or reduce dose if worsening dypsnoea or fatigue. Avoid abrupt withdrawal if possible. |
| Digoxin | no | yes: as for ACE inhibitor | nausea, vomiting, bradycardia/heart block, bigeminy | Risk of toxicity (e.g. in renal impairment) hence monitor levels. Risk of significant drug interactions. (see Appendix 1 BNF). |
| Diuretic | no | yes: breathlessness, oedema, can reduce hospital admissions | dehydration (uraemia), hypotension, hypokalaemia, gout (most effective agent in acute phase is low dose prednisolone; watch for fluid retention. Use allopurinol forlong term prevention once symptoms controlled) | Require regular monitoring and readjustment of dose. Likely to be needed until the last days of life. |
| Hydralazine | yes, with long acting nitrates | no | flushing, GI upset, hypotension, systemic lupus syndrome with long term use | Very limited role. Only used if ACE inhibitor and ARB intolerant. |
| Nitrates | yes, with hydralazine | yes: sublingual nitrates may lessen dyspnoea | headaches | Standard treatment for angina. Very limited role in advanced heart failure. Only used if ACE inhibitor and ARB intolerant. |
| Spironolactone | yes | no | hyperkalaemia, GI disturbance, breast tenderness, gynaecomastia with spironolactone | Stop during any intercurrent illness which causes hypovolaemia. Stop if potassium rises (>5.5mmol/L). |
| Statin | yes | no | nausea, hepatic dysfunction, myalgia | Stop if side effects, and do not replace with other drugs. |
| * see current version of BNF or Summary of Product Characteristics for full list.
Note: advice on these issues can be sought from the most appropriate member of Bills care team which may be the GP, palliative care team or heart failure nurse |
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Reference: Scottish Partnership for Palliative Care (2008) Living & Dying with Advanced heart failure: a palliative care approach.
Scottish Partnership for Palliative Care: Publications
Page last reviewed: 29 Jul 2020
