Just as for the general HFREF population, any further medication (beyond beta-blockers, ACE-I and MRA) for heart failure in people with CKD should be prescribed by, or in liaison with, a heart failure specialist. The committee noted that ARBs for people with CKD showed only limited benefit, based on the evidence reviewed. For digoxin, there was no safety evidence, and the committee expressed concern that the risk of complete heart block and digitalis toxicity may be higher in those with CKD. As digoxin is primarily excreted by the kidneys, safe use of digoxin in people with CKD would include dose titration based on biochemistry and appropriate monitoring, such as the regimen used in the DIG trial 97 . The risk of hyperkalaemia is important in this group. Several studies showed high numbers of additional incidents of hyperkalaemia in the intervention arm. But the risk of hyperkalaemia in this group is not confined to the issue of these particular drugs, as the risk for patients with CKD is high even on placebo. In CKD stage IV, monitoring is already fairly intensive, so any incident hyperkalaemia should be identified and responded to quickly. For people with CKD stage III on heart failure medication, especially on triple therapy, the committee stressed the importance of monitoring of electrolytes and appropriate response to any deterioration. In general, the committee felt the evidence shows the efficacy and safety of specific drugs in this group of patients with renal impairment. Patients with HFREF and CKD stage IIIa or less should be offered standard double or triple therapy, with appropriate modifications to dosing and careful monitoring. The evidence in stage IIIb patients was more limited, and while this group Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. 