Reversible symptoms and drugs to avoid

Potentially reversible symptoms


Reversible cause/s


fluid overload – optimise diuretic therapy – consider if SC or IV more appropriate

Nausea, Diarrhoea, Drowsiness, Confusion

Consider Digoxin toxicity

Dry mouth, Dizziness, Falls

Reduced blood pressure, Diuresis and fluid restriction


ACE inhibitor therapy

Malaise, Lethargy

Hypokalaemia, Beta-blocker therapy

Abdominal bloating

Gut wall oedema, Constipation

Drugs to avoid

Some drugs used generally in palliative care for symptom control may worsen heart failure and these should be avoided or used with caution. The following table gives guidance with regard to drugs which may cause particular problems. Advice should be sought from the Specialist Palliative Care Team or Heart Failure Team if there are particular concerns.

Drug to avoid

Problematic Side Effects In Heart Failure

Non-steroidal anti-inflammatory drugs

Cause sodium and water retention and can worsen renal function


Cause water retention.
Risk of hyperglycaemia


Cause water retention

Tricyclic antidepressants

Can cause cardiac arrhythmias

Hyponatraemia and postural hypotension

Should be avoided in heart disease particularly if there is a history of arrhythmias

SSRI’s and mirtazapine are safer


Anticholinergic antihistamine:
May cause arrhythmias and hypotension.

Avoid in severe heart failure

Glycopyrronium, Hyoscine, hydrobromide, Hyoscine butylbromide

Anticholinergic: Use with caution in heart disease.

Haloperidol and Levomepromazine

Avoid as contains high sodium load and requires increased fluid intake which may not be appropriate with heart failure


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.