Hypertension
Treatment of hypertension in paediatrics is managed by the specialist renal team, who assess, investigate, initiate and monitor treatment – choice(s) of medicine depends on aetiology of hypertension.
Age <55 years and not of black-African or African-Caribbean family origin.
Initially 10mg once daily; usual maintenance 20mg once daily; maximum 80mg per day.
Initially 10mg once daily; usual maintenance 20mg once daily; maximum 80mg per day.
Initially 10mg once daily; usual maintenance 20mg once daily; maximum 80mg per day.
Initially 10mg once daily; usual maintenance 20mg once daily; maximum 80mg per day.
Age 55 years and older or any age if of black-African or African-Caribbean family origin.
Initially 5mg once daily; max 10mg once daily.
Initially 5mg once daily; max 10mg once daily.
Age <55 years and not of black-African or African-Caribbean family origin. Intolerant of ACE inhibitors.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Age 55 years and older or any age if of black-African or African-Caribbean family origin. Reserved for those intolerant of amlodipine.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
Prescribing Notes:
- In patients who are intolerant of ACE inhibitors, an angiotensin-II receptor antagonist may be considered as an alternative.
- Angiotensin-II receptor antagonists should be reserved for patients who develop a persistent cough with ACE inhibitors.
- Urea and electrolytes should be checked within 2 weeks of commencing ACE inhibitor and Angiotension-II receptor antagonists and after any change in dose and then annually.
- Felodipine is substantially more expensive than amlodipine, so should be reserved for those with ankle swelling on amlodipine.
History Notes
16/02/2022
East Region Formulary content agreed.
If currently taking an ACEi or ARB, add amlodipine.
Initially 5mg once daily; max 10mg once daily.
Initially 5mg once daily; max 10mg once daily.
If currently taking a CCB, add lisinopril.
Initially 2.5mg daily, maintenance 10-20mg daily, max 40mg daily.
Initially 2.5mg daily, maintenance 10-20mg daily, max 40mg daily.
Initially 2.5mg daily, maintenance 10-20mg daily, max 40mg daily.
Initially 2.5mg daily, maintenance 10-20mg daily, max 40mg daily.
If currently taking a ACEi or ARB, but intolerant of amlodipine, add felodipine.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
Initially 5mg once daily, in the morning, usual maintenance 5-10mg once daily.
If currently taking a CCB, but intolerant of ACE inhibitors, add candesartan.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Initially 8mg (hepatic impairment 2mg, renal impairment or intravascular volume depletion 4mg) once daily, increased if necessary at intervals of 4 weeks to a max. 32mg once daily.
Prescribing Notes:
- In patients who are intolerant of ACE inhibitors, an angiotensin-II receptor antagonist may be considered as an alternative.
- Angiotensin-II receptor antagonists should be reserved for patients who develop a persistent cough with ACE inhibitors.
- Urea and electrolytes should be checked within 2 weeks of commencing ACE inhibitor and Angiotension-II receptor antagonists and after any change in dose and then annually.
History Notes
16/02/2022
East Region Formulary content agreed.
To be added to existing treatments as detailed in Step1 and Step 2 pathways.
1.5mg daily; dose to be taken in the morning.
To be added to existing treatments as detailed in Step1 and Step 2 pathways.
2.5mg daily; dose to be taken in the morning.
Prescribing Notes:
- Indapamide is claimed to lower blood pressure with less metabolic disturbance, particularly less aggravation of diabetes mellitus.
- Indapamide is more expensive then Bendroflumethiazide, but it has a better side effect profile and evidence base.
- Allow 4 weeks for maximal antihypertensive effect of bendroflumethiazide.
- Higher doses of bendroflumethazide may be used on the recommendation of a specialist.
History Notes
16/02/2022
East Region Formulary content agreed.
If serum potassium level less than 4.5
25mg daily increased to 50mg and then 100mg as necessary.
25mg daily increased to 50mg and then 100mg as necessary.
25mg daily increased to 50mg and then 100mg as necessary.
Usually 5-10mg once daily; max 20mg daily.
Usually 5-10mg once daily; max 20mg daily.
Usually 5-10mg once daily; max 20mg daily.
Usually 5-10mg once daily; max 20mg daily.
Usually 5-10mg once daily; max 20mg daily.
Usually 5-10mg once daily; max 20mg daily.
1mg daily, increased after 1-2 weeks to 2mg once daily and thereafter to 4mg once daily, if necessary; max 16mg daily.
1mg daily, increased after 1-2 weeks to 2mg once daily and thereafter to 4mg once daily, if necessary; max 16mg daily.
1mg daily, increased after 1-2 weeks to 2mg once daily and thereafter to 4mg once daily, if necessary; max 16mg daily.
Prescribing Notes:
- Consider co-morbidities when adding in additional treatments.
- Spironolactone may cause hyperkalaemia, renal function and electrolytes should be closely monitored.
- Concomitant use of spironolactone or epleronone with angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists increases the risk of severe hyperkalaemia, particularly in patients with marked renal impairment, and should be used with caution.
- Beta-blockers may cause bronchospasm; avoid in patients suffering asthma. If a beta-blocker is required a cardioselective beta-blocker should be selected, initiated at a low dose and the patient closely monitored.
- Use beta-blockers with caution in older patients.
- Consult product literature when prescribing potassium sparing diuretics for patients with renal impairment.
- Lower initial doses of diuretics should be used in older patients as they are more likely to suffer from side-effects including postural hypotension.
- Doxazosin is a fourth-line agent in the treatment of hypertension. It should be used with caution in patients with heart failure or impaired left ventricular function.
- Doxazosin may cause postural hypotension and first dose hypotension. Treatment should be initiated at the lowest dose possible and titrated upwards.
- Moxonidine may have a role when thiazides, calcium-channel blockers, ACE inhibitors, and beta-blockers are not appropriate or have failed to control blood pressure.
History Notes
16/02/2022
East Region Formulary content agreed.
Initially 250mg 2-3 times daily, increased gradually at intervals of 2 or more days; max 3g daily.
Initially 250mg 2-3 times daily, increased gradually at intervals of 2 or more days; max 3g daily.
Initially 250mg 2-3 times daily, increased gradually at intervals of 2 or more days; max 3g daily.
Labetalol or nifedipine may be used in the late second or third trimester. Caution with use of labetalol in asthmatic patients.
Initially 100mg twice daily; can be increased at intervals of 14 days to usual dose 200mg twice daily; max 2.4g daily.
Initially 100mg twice daily; can be increased at intervals of 14 days to usual dose 200mg twice daily; max 2.4g daily.
Initially 100mg twice daily; can be increased at intervals of 14 days to usual dose 200mg twice daily; max 2.4g daily.
On specialist advice. May need to be prescribed three times daily.
On specialist advice. May need to be prescribed three times daily.
On specialist advice. May need to be prescribed three times daily.
Prescribing Notes:
- New onset hypertension should be referred for specialist advice.
- In general, mild to moderate hypertension in pregnancy should not be treated.
- Labetalol or nifedipine may be used for hypertension requiring treatment in the late second or third trimester; nifedipine modified-release tablets (Coracten SR) may need to be prescribed 3 times daily during pregnancy. Caution with use of labetalol in asthmatic patients.
History Notes
16/02/2022
East Region Formulary content agreed.
Amlodipine is often first choice in paediatric hypertension, until aetiology is known.
ACEI is first line in diabetes or CKD.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Dosing follows specialist advice.
Dosing follows specialist advice.
Dosing follows specialist advice.
Dosing follows specialist advice.
For patients who are intolerant of ACEI.
Urea and electrolytes and renal function should be checked before and within 1 week of commencing therapy and monitored during treatment.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Choice of drug in treating hypertension is dependent on the underlying aetiology. Aim is to use a single agent if possible.
- ACEI would be first line choice in CKD with proteinuria, if there are no contraindications to use.
- Captopril and enalapril tablets can be halved and will disperse in water.
- Avoid ACEI in renovascular hypertension, or if renovascular hypertension suspected/not yet excluded, if unknown aetiology.
- Enalapril would be usually preferred ACEI as it is once daily; captopril preferred for smaller children requiring a liquid formulation or if a shorter acting preparation is indicated; ramipril is often used for adolescents.
- Renal function (urea and electrolytes) should be checked before and within 1 week of commencing treatment with ongoing monitoring during treatment.
- Amlodipine is generally first line, and once aetiology is known/response assessed treatment may be switched to another agent.
- Amlodipine tablets may be dispersed in water; liquid licensed from 6 years of age.
- ACEI and ARBs should not be used together.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.
Choice of agent depends on aetiology of hypertension. Medicines in this pathway are usually added on to first line medicines but may be used first line depending on aetiology.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, follow specialist advice.
For dose, refer to BNF for Children.
Prescribing Notes:
- Choice of drug in treating hypertension is dependent on the underlying aetiology. Aim is to use a single agent if possible.
- Beta-blockers may cause bronchospasm; they are usually avoided in patients suffering asthma but are sometimes used on specialist advice.
- Propranolol is a short acting option where a beta blocker is indicated.
- Chlorothiazide may be used in patients with CKD and hypertension and fluid overload; or in nephrotic syndrome and hypertension.
- There is good evidence to support the use of thiazide diuretics in regulating BP in paediatrics – particularly in combination with ACEI/ARB and/or beta-blocker.
- Doxazocin is the drug of choice for initial treatment of phaeochromocytoma related hypertension; and would also be used if bladder management is a requirement.
- Amiloride is rarely used as an antihypertensive – most often used in patients with monogenic forms of hypertension that are predisposed to low potassium states (e.g. Liddle syndrome, apparent mineralocorticoid excess).
- Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if given intravenously; duration of action, 6 to 8 hours. Half-life is very variable in the neonatal period and may be up to 24hours in preterm infants.
- Metolazone may be considered for resistant oedema (e.g. nephrotic syndrome, congestive heart failure) and hypertension associated with this. It is used in conjunction with a loop diuretic such as furosemide. It is traditionally given 30-60 minutes before furosemide to achieve a maximal synergistic effect.
- In an intensive care setting, continuous infusion of furosemide may be given.
- In children no longer in nappies, time doses to minimize social disruption.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Labetalol IV is used in hypertensive emergencies in the critical care setting.
- Use of nifedipine is in the acute setting and patients would be switched to amlodipine if calcium channel blocker treatment to continue.
- In hypertensive urgency, where there is a need to decrease BP fairly quickly the immediate release capsules of nifedipine would be used.
- Nifedipine oral drops are included for doses below 5mg.
- Use of hydralazine would be only in the acute setting.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, follow specialist advice.
Prescribing Notes:
- Additional or alternative medicines would follow direction from the UK specialist PAH service.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.