The following local guidance is available for cardiovascular disease: Area Prescribing Committee website or CDDFT Intranet
South Tees Hospitals Cardiology Formulary
Northern England Evaluation and Lipid Intensification guideline [NEELI]
Dapagliflozin in Heart Failure - CD&TV APC Prescribing Guidance
Prescribing Anticoagulants in NVAF - CD&TV APC Guideline
County Durham and Darlington DVT Pathway: County Durham and Darlington DVT Pathway Information
NICE CG172: MI – Secondary Prevention
NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism
NICE NG148: Acute kidney injury: prevention, detection and management
NICE NG171: COVID-19 rapid guideline: acute myocardial injury
NICE NG185: Acute coronary syndromes
NICE NG186: COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19
NICE NG196: Atrial fibrillation: diagnosis and management
NICE NG208: Heart valve disease presenting in adults: investigation and management
Other NICE Cardiovascular Guidelines are available via this link
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/
Prescribing of medicines available to purchase over the counter for self-care
Tablets - 62.5microgram, 125microgram, 250microgram
Elixir - 50microgram/ml
Drug Protocol – digoxin loading dose (CDDFT intranet access only)
Please note – metolazone has been discontinued in the UK and as such has been removed from the formulary. Please see advice from the British Society for Heart Failure which recommends bendroflumethiazide as the most suitable alternative.
Tablets - 2.5mg
For indapamide use standard release only (not modified release)
Tablets - 20mg, 40mg,
Oral Solution - 20mg/5ml, 40mg/5ml, 50mg/5ml
20mg in 2ml, 50mg in 5ml & 250mg in 25ml injections
Drug protocols: (CDDFT intranet access only)
IV Furosemide in the community
When given as an infusion rate should not exceed 4mg/min
Single doses of 40-80mg can be given as a slow bolus
Tablets - 25mg, 50mg, 100mg
Suspension - 10mg/5ml, 50mg/5ml u
Suspension - 50mg/5ml - Recommended strength in children as per NPPG/RCPCH Position Statement: Using Standardised Strengths of Unlicensed Liquid Medicines in Children.
Prescribe Oral Solution as Rosemont brand
Notes: post-acute myocardial infarction patients and patients with heart failure treatment should be initiated on instructions from a cardiologist or GP with a specialist interest in cardiology. Spironolactone is first choice (ahead of eplerenone) for severe heart failure.
MHRA Drug Safety Update (Feb 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia
MHRA Drug Safety Update (Dec 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia—clarification, December 2016
Please set up recall for potassium monitoring on initiation, as per South Tees HFT Cardiology guidelines
Tablets - 25mg, 50mg, 100mg
Suspension - 10mg/5ml, 50mg/5ml u
Suspension - 50mg/5ml - Recommended strength in children as per NPPG/RCPCH Position Statement: Using Standardised Strengths of Unlicensed Liquid Medicines in Children.
Prescribe Oral Solution as Rosemont brand
Notes: post-acute myocardial infarction patients and patients with heart failure treatment should be initiated on instructions from a cardiologist or GP with a specialist interest in cardiology. Spironolactone is first choice (ahead of eplerenone) for severe heart failure.
MHRA Drug Safety Update (Feb 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia
MHRA Drug Safety Update (Dec 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia—clarification, December 2016
Please set up recall for potassium monitoring on initiation, as per South Tees HFT Cardiology guidelines
25mg & 50mg tablets
Indication: to reduce the risk of cardiovascular mortality and morbidity in stable patients with left ventricular dysfunction and clinical evidence of heart failure after myocardial infarction, usually initiated on day 4 or 5 post-acute MI.
Notes: Eplerenone may have a place in those patients unable to tolerate spironolactone (due to gynaecomastia or nausea).
Restrictions: treatment should only be initiated on instructions from a consultant cardiologist or a GP with a specialist interest in cardiology.
Please set up recall for potassium monitoring on initiation, as per South Tees HFT Cardiology guidelines
BNF: less suitable for prescribing
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
The use of combination diuretics is not recommended.
There is sufficient concern over safety that it is not appropriate to be prescribed due to K+ supplements increasing levels.
Tablets - 100mg, 200mg
Initiated and titrated to maintenance dose only under specialist supervision
Drug protocols: Amiodarone IV and oral (CDDFT intranet access only)
Tees Amiodarone Prescribing Guidance
Patient information leaflet (CDDFT intranet access only)
Amiodarone is associated with a number of drug interactions check before prescribing. Amiodarone interactions
Limit simvastatin to 20mg when given with amiodarone. Atorvastatin does not require a dose reduction but if there are signs of adverse effects half atorvastatin dose
NHS England (June 2019) advises that prescribers should not initiate amiodarone in primary care for any new patient. in exceptional circumstances, where there is a clinical need for amiodarone to be prescribed, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional
Amiodarone has an important place in the treatment of severe cardiac rhythm disorders where other treatments either cannot be used or have failed. It has potential major toxicity and its use requires monitoring both clinically and via laboratory testing
NICE clinical guideline on Atrial Fibrillation (AF) CG 180 puts greater emphasis on rate rather than rhythm control and has clarified the place of amiodarone in the treatment pathway:
NICE have issued the following “Do not do” recommendation: Do not offer amiodarone for long-term rate control.
MHRA Drug Safety Update (Mar 2022): Amiodarone (Cordarone X): reminder of risks of treatment and need for patient monitoring and supervision
400mg tablets
As recommended by NICE approved for patients who are unsuitable for or not tolerant of amiodarone. Treatment is to be initiated by cardiologists.
Dronedarone (Cardiology) Shared Care Guideline
NHS England (June 2019) advises that prescribers should not initiate dronedarone in primary care for any new patient. If, in exceptional circumstances, there is a clinical need for dronedarone to be prescribed, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional.
NICE clinical guideline on Atrial Fibrillation (AF) CG 180 puts greater emphasis on rate rather than rhythm control and has clarified the place of dronedarone in the treatment pathway
Tablets- 50mg, 100mg
MR Capsules - 200mg
Initiated and titrated to maintenance dose only under specialist supervision
Flecainide IV: CDDFT Drug Protocol
167mg capsules
Unlicensed for use management of cardiac arrhythmias.
Unlicensed treatment for arrhythmias and neuropathic pain with a poor evidence base and not a cost
effective use of NHS resources.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Tablets - 150mg, 300mg
Initiated and titrated to maintenance dose only under specialist supervision
500mg/25ml concentrate for solution for infusion vials
Not approved in accordance with the following NICE TAs:
Drug protocol: magnesium sulphate infusion (CDDFT intranet access only)
MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
First Choice
Bisoprolol - Cardioselective
Propranolol - non-cardioselective
Alternatives
Atenolol
Meteoprolol - metoprolol indication: for less stable patients
Labetalol - for the management of hypertension in pregnancy
Carvedilol - for use in the treatment of heart failure only
Sotalol
Tablets - 10mg, 40mg, 80mg, 160mg
Oral Solution - 5mg/5ml, 10mg/5ml, 40mg/5ml, 50mg/5ml
Non-cardioselective
Propranolol indication: for migraine prophylaxis and to control somatic symptoms associated with anxiety
Drug protocol: paediatric oral propranolol in haemangioma (CDDFT intranet access only)
Tablets - 3.125mg 6.25mg, 12.5mg, 25mg
Carvedilol indication: for use in the treatment of heart failure only
2nd choice in heart failure
50mg, 100mg & 200mg tablets
Labetalol indication: for the management of hypertension in pregnancy
Tablets - 50mg
Liquid - 50mg/5ml
Metoprolol indication: for less-stable patients
5mg or 10mg Tablets
5mg tablets can be halved or quartered
2nd choice in heart failure
Tablets - 25mg , 50mg
Hydralazine restriction: usually hospital initiation
5mg & 10mg tablets
For hypertension. All other indications considered RED drug.
Treatment should only be on the advice of a cardiologist/ nephrologist.
Red drug for Raynaud's (Unlicensed indication)
Tablets - 25mg and 50mg
MHRA Drug Safety Update (Nov 2018): Sildenafil (Revatio and Viagra): reports of persistent pulmonary hypertension of the newborn (PPHN) following in-utero exposure in a clinical trial on intrauterine growth restriction
Not approved in accordance with the following NICE TA:
25 microgram and 100 microgram tablets -
BNF: less suitable for prescribing - because of significant side effects.
Clonidine is not generally recommended for migraine prophylaxis; may aggravate depression/cause insomnia.
NICE NG23: Menopause: diagnosis and management - “Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone.”
When used for hypertension: Sudden withdrawal may cause a hypertensive crisis
25 microgram tablets = RED drug when used for sedation on ITU.
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
NICE ES24: COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
Capsules - 1.25, 2.5mg, 5mg, 10mg
Ramipril dosage form restriction: use capsules – do not use tablets
NHS England (November 2017) supports the deprescribing of perindopril arginine preparations.
Perindopril arginine is significantly more expensive than perindopril erbumine and a PrescQIPP review of the topic found there was no clinical advantage of the arginine salt
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
2mg capsules u and 5mg in 5ml (1mg/ml) oral suspension u
– treatment should only be on the advice of a hospital
paediatrician.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Second line in patients who have tried and were unable to tolerate at least two ACE inhibitors.
24mg/26mg, 49mg/51mg & 97mg/103mg tablets
See CD&D Place in therapy for Sacubitril valsartan in both newly diagnosed and existing heart failure
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
NHS England (June 2019) advises that aliskiren should not be initiated for any new patient and supports the deprescribing of aliskiren
NICE NG 136 does not recommend the use of aliskiren for treating hypertension.: Whilst aliskiren has shown comparable efficacy to other antihypertensive agents in terms of blood pressure reduction,
its effects on mortality and long-term morbidity are currently unknown
Pulmonary Arterial Hypertension – specialist centres only (Freeman, Newcastle)
62.5mg & 125mg tablets
NHS England – NHSE policy Clinical Commissioning Policy: Sildenafil and Bosentan for the Treatment of Digital Ulceration in Systemic Sclerosis in adults Reference: NHS England 210302P. NHS England will now commission sildenafil and bosentan for patients requiring treatment of digital ulceration in systemic sclerosis in adults.
Commissioner: NHS England - Pulmonary Hypertension.
10mg tablets
Commissioner: NHS England - Policy - A11/P/a & A11/PS/b
20mg tablets (Revatio®)
25mg, 50mg and 100mg tablets u
Commissioner: NHS England - Policy - A11/P/a & A11/PS/b
MHRA Drug Safety Update (Nov 2018): Sildenafil (Revatio and Viagra): reports of persistent pulmonary hypertension of the newborn (PPHN) following in-utero exposure in a clinical trial on intrauterine growth restriction
50 microgram in 0.5ml & 100 microgram in 1ml inj
10 microgram in 1ml and 20 microgram in 2ml nebules
Commissioner: NHS England - Policy - A11/PS/b
Tablets - 10mg, 20mg, 40mg
Modified release tablets 60mg - only when non-modified release are unsuitable e.g. to improved compliance.
Standard release isosorbide mononitrate should be prescribed using twice daily asymmetric dosing (e.g. 8am & 4pm)
5mg in 5ml , 50mg in 10ml & 50mg in 50ml injections
Glyceryl Trinitrate IV Infusion: CDDFT Drug Protocol
IV should be given using polyethylene giving set not PVC
Tablets- 5mg, 10mg
Notes: if a 10mg dose is not tolerated e.g. due to leg/ankle oedema, consider reducing dose before changing to an alternative such as lercanidipine
Hypertension Guidelines (based upon NICE CG127) Primary Care Website
MR Tablets - 60mg
MR Tablets/Capsules (BD preparations) - 90mg, 120mg, 180mg
MR Tablets/Capsules (OD preparations) - 120mg, 180mg, 240mg, 300mg, 360mg.
Different versions of modified release diltiazem containing more than 60mg may not have the same clinical effect. Specify brand to avoid confusion
Brand – Viazem XL is the Formulary brand of choice for starting new patients on long acting diltiazem
Tablets - 10mg, 20mg
Indication: for use as a 2nd line calcium channel blocker where amlodipine is not tolerated
Once Daily formulations (Preferred)
20mg controlled release tablets (Adalat LA), 30mg &
60mg m/r capsules (Coracten XL)
Other Formulations
5mg & 10mg capsules
10mg & 20mg retard tablets
20mg per ml (1mg/drop) dropsu
Nifedipine Modified Release Brand: Coracten XL is the once daily brand of choice
30mg tablets
Nimodipine indication: only for the prevention of vascular spasm following subarachnoid haemorrhage
10mg in 50ml (200 micrograms/ml) for IV infusion
Nimodipine indication: only for the prevention of vascular spasm following subarachnoid haemorrhage
Tablets - 40mg, 80mg, 120mg, 160mg
MR Tablets - 240mg
Oral Solution - 40mg/5ml
Verapamil indication: arrhythmias or angina
Tablets - 10mg, 20mg
MHRA Drug Safety Update (Jan 2016): Nicorandil (Ikorel): now second-line treatment for angina - risk of ulcer complications
Tablets - 5mg, 7.5mg
Indication: for symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm for whom heart rate control is desirable and who have a contra-indication or intolerance for beta-blockers and rate-limiting calcium-channel blockers.
Restrictions: for initiation on advice from consultant cardiologists in patients with contra-indications to or intolerance of standard therapy
MHRA Drug Safety Update (Dec 2014): Ivabradine (Procoralan) in the symptomatic treatment of angina: risk of cardiac side effects
Approved for use in accordance with the following NICE TAs:
100mg capsules
In Raynaud’s phenomenon some patients may require treatment with a vasodilator. Nifedipine may be of use, especially in primary Raynaud’s syndrome.
Poor evidence base and not recommended as per NICE TA223.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Poor evidence base and not recommended as per NICE TA223.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Poor evidence base and not recommended as per NICE TA223.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Poor evidence base and not recommended as per NICE TA223.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Poor evidence base and not recommended as per NICE TA223.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
250mg in 20ml injection
250mg in 50ml injection
Dobutamine: CDDFT Drug Protocol
100 microgram in 2ml injection, 200microgram/ml injectionu , 2mg in 2ml injectionu
Isoprenaline: CDDFT Drug Protocols
2mg in 2ml & 4mg in 4ml (1 in 1,000) injections
See Letter Sent to Healthcare Professionals (March 2016): Noradrenaline (Norepinephrine) 0.08 mg/ml (4 mg in 50 mil solution for infusion in a vial with potential risk of medication errors
To be prescribed by brand name to prevent prescribing/dispensing errors.
Biosimilars are available – note that indications can differ between different products – prescribe by brand. Consult with individual trust pharmacy department for details of preferred biosimilar brand.
Clexane Brand
2,000 IU (20 mg)/0.2 ml solution for injection in pre-filled syringe
4,000 IU (40 mg)/0.4 ml solution for injection in pre-filled syringe
6,000 IU (60 mg)/0.6 ml solution for injection in pre-filled syringe
8,000 IU (80 mg)/0.8 ml solution for injection in pre-filled syringe
10,000 IU (100 mg)/1 ml solution for injection in pre-filled syringe
12,000 IU (120 mg)/0.8 ml solution for injection in pre-filled syringe
15,000 IU (150 mg)/1 ml solution for injection in [pre-filled syringe
Inhixa Brand▼
20mg/0.2mll solution for injection in pre-filled syringe
40mg/0.4mlsolution for injection in pre-filled syringe
60mg/0.6ml solution for injection in pre-filled syringe
80mg/0.8ml solution for injection in pre-filled syringe
100mg/ml solution for injection in pre-filled syringe
Arovi Brand (formerly Enoxaparin Becat)▼
20mg/0.2ml solution for injection in pre-filled syringe
40mg/0.4mlsolution for injection in pre-filled syringe
60mg/0.6ml solution for injection in pre-filled syringe
80mg/0.8ml solution for injection in pre-filled syringe
100mg/ml solution for injection in pre-filled syringe
120mg/0.8ml solution for injection in pre-filled syringe
150mg/ml solution for injection in pre-filled syringe
See Letter Sent to Healthcare Professionals (June 2017) - Clexane (enoxaparin sodium):
50 units in 5ml & 200 units in 2ml – for flushing cannulae
Drug protocol: heparin in general medicine (CDDFT intranet access only)
Drug protocol: Unfractionated Heparin (treatment dose) for use in Vascular Surgery (CDDFT intranet access only)
1.5mg in 0.3ml injection, 2.5mg in 0.5ml injection,
5mg in 0.4ml injection, 7.5mg in 0.6ml injection &
10mg in 0.8ml injection in pre-filled syringes
Fondaparinux indication: for the treatment of unstable angina or non ST-elevation myocardial infarction. CDDFT Drug Protocol
750 units in 0.6ml injection (1,250 units/ml)
Danaparoid notes: for use on specific advice from haematologists in patients who develop thrombocytopaenia with heparins - cross reactivity with heparin antibodies is probably <10%
Epoprostenol (as sodium salt) 500 microgram & 1.5mg injection injection (Folan®)
Epoprostenol (as sodium) 500 microgram & 1.5mg injection injection (Veletri®)
CAUTION TWO BRANDS AVAILABLE
Epoprostenol PVD CDDFT Drug Protocol
Commissioner: NHS England - Policy - A11/PS/b
See Letter Sent to Healthcare Professionals (Sept 2016):
Flolan® (epoprostenol) – Introduction of new sterile solvent with different pH; temporary availability of two different formulations.
See Letter Sent to Healthcare Professionals (April 2017) - Floran (epoprostenol): reminder of replacement of Flolan (with Solvent pH 10.5) with Flolan (with Solvent pH 12)
250 mg powder for concentrate for solution for injection or infusion
Approved: NICE TA230
Prescribing Anticoagulants in NVAF - CD&TV APC Guideline
County Durham and Darlington DVT Pathway: County Durham and Darlington DVT Pathway Information
Tees Warfarin Guidelines for Primary Care
MHRA Warning: Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
MHRA Drug Safety Update (June 2020): Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
Tablets - 500micrograms(white), 1mg (brown), 3mg(blue), 5mg(pink)
CDDFT Intranet Oral anticoagulation with warfarin - adult patient management guidelines (including bleeding with NOACs)
Tees Warfarin Guidelines for Primary Care
MHRA Drug Safety Update (July 2016): Warfarin: reports of calciphylaxis
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
Tablets - 2.5mg, 10mg, 15mg, 20mg
MHRA Drug Safety Update (Oct 2013): Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
MHRA Drug Safety Update (Oct 2018): Rivaroxaban (Xarelto▼) after transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial
MHRA Drug Safety Update (July 2019): Rivaroxaban (Xarelto▼): reminder that 15 mg and 20 mg tablets should be taken with food
MHRA Drug Safety Update (Jun 2019): Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
Approved for use in accordance with the following NICE TAs
Tablets - 2.5mg, 5mg
Approved for use in accordance with the following NICE TAs
MHRA Drug Safety Update (Jun 2019): Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
Tablets - 75mg, 110mg and 150mg
NICE Guidance: NICE TA249, NICE TA157, NICE TA327
MHRA Drug Safety Update (March 2013): Dabigatran - contraindicated in patients with prosthetic heart valve(s) requiring anti-coagulant treatment, because of the risk of thrombosis and haemorrhage
MHRA Drug Safety Update (Oct 2013): Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
MHRA Drug Safety Update (Jun 2019): Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
Tablets - 15mg, 30mg, 60mg
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (Jun 2019): Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
10mg and 25mg tablets
For use in patients intolerant of warfarin
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
1mg tablets
For use in patients intolerant of warfarin
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
2.5mg tablets
AMBER SPECIALIST INITIATION
Rivaroxaban co-administered with acetylsalicylic acid (ASA), is indicated for the prevention of atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischaemic events.
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
200mg powder for solution for infusion
Approved for use in accordance with the following NICE TAs:
Antiplatelet Drugs – Guidance for the use in Primary Care & NECVN Network Guidelines for Antiplatelet Use in STEMI, NSTEMI & Unstable Angina
Primary Care Website or CDDFT Intranet
NICE CG172: MI – Secondary Prevention
Tablets - 75mg
Aspirin dosage form restrictions: ONLY plain tablets. e/c tablets are not recommended for use.
Tablets - 75mg, 300mg
Clopidogrel: the APC recommends the use of generic 75mg clopidogrel tablets in all the approved indications for clopidogrel
300mg tablets also available for use in giving loading dose prior to percutaneous coronary interventions (PCI)
MHRA Drug Safety Update (December 2013): Clopidogrel - risk of acquired haemophilia with clopidogrel
200mg m/r capsules
Dipyridamole indication: as per guideline and NICE TA210
Tablets - 5mg, 10mg
Prasugrel: NICE TA317 (review of TA182)
MHRA Drug Safety Update (January 2014): increased risk of bleeding – advice around timing of loading dose for prasugrel
Specialist initiation only post PCI. Use for up to 12 months following PC
60mg and 90mg tablets
Ticagrelor: NICE TA236, NICE TA420
Approved in line with NICE TA236 Use for up to 12 months following cardiac event.
Approved in line with NICE TA420 Use for up to 3 years in patients following myocardial infarction and who are at high risk of a further event
N.B. Primary Percutaneous Coronary Intervention (PCI) is now preferred to thrombolysis in patients with myocardial infarction with ST segment elevation (STEMI)
Alteplase indication: Acute Ischaemic Stroke NICE TA264
Drug protocol: alteplase (CDDFT intranet access only)
Prothrombin complex concentrate
For use in reversing the effects of oral anticoagulants in patients with life or limb threatening bleeding in accordance with a regional protocol – see CDDFT Intranet Oral anticoagulation with warfarin - adult patient management guidelines (including bleeding with NOACs)
Commissioner: NHS England - BCSH Guidelines
Northern England Evaluation and Lipid Intensification guideline [NEELI]
An MHRA (May 2014) summary of the risks and benefits of statins can be found here
Not a cost effective use of NHS resources
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Tablets - 10mg, 20mg, 40mg, 80mg
Tablets May be crushed and administered immediately in water
5mg, 10mg, 20mg & 40mg tablets
Only to be considered as an option when patient has proven intolerance to, or lack of desired result from simvastatin, pravastatin and atorvastatin and in accordance with local Lipid Modification Guidelines OR as per FATS Guidelines.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Tablets - 10mg
Ezetimibe restrictions: see guideline
NICE guidance: NICE TA385
FATS7 Strategy for the Use of Cholesterol Lowering Drugs Primary Care Website
NICE has published a range of “do not do” recommendations regarding the prescribing of omega-3 fatty acids in the context of; myocardial infarction, CVD prevention, non-alcoholic fatty liver disease, children and young people with autism, familial hypercholesterolaemia and MS.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
See also CD&T APC Position Statement on Prescribing of Omega-3
See also NICE CG172 “do not do recommendation”
75mg/1ml & 150mg/1ml solution for injection in prefilled pen
See also NTAG recommendation
Nilemdo® 180 mg film-coated tablets
Nustendi® 180 mg/10 mg film-coated tablets - Each film-coated tablet contains 180 mg of bempedoic acid and 10 mg of ezetimibe.
Approved for use in accordance with the following NICE TAs:
284mg pre-filled syringe (Leqvio®)
Inclisiran (Leqvio) is the first of a new type of cholesterol-lowering treatment which uses RNA interference (RNAi) to boost the liver’s ability to remove LDL-cholesterol from the blood. It is given by subcutaneous injection, either on its own or alongside statins or other cholesterol-lowering drugs. Patients receive a 2nd dose three months after an initial dose, and then two more doses each year.
Approved for use in accordance with the following NICE TA:
NICE technology appraisal (TA) 733 recommends inclisiran injection (Leqvio ®▼) as an option for treating primary
hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia as an adjunct to diet in
adults. It is recommended only if:
there is a history of any of the following cardiovascular events:
− acute coronary syndrome (such as myocardial infarction or unstable angina needing hospitalisation)
− coronary or other arterial revascularisation procedures
− coronary heart disease
− ischaemic stroke or
− peripheral arterial disease, and
low‑density lipoprotein cholesterol (LDL-C) concentrations are persistently 2.6 mmol/l or more, despite
maximum tolerated lipid‑lowering therapy, that is:
− maximum tolerated statins with or without other lipid-lowering therapies or
− other lipid-lowering therapies when statins are not tolerated or are contraindicated and
the company provides inclisiran according to the commercial arrangement
The Accelerated Access Collaborative and Academic Health Science Networks will work with system leaders to support the implementation of inclisiran within a primary care setting.
The updated National Guidance for Lipid Management for Primary and Secondary Prevention of CVD endorsed by NICE in December 2021 can be found at: https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2020/04/Lipid-Management-Pathway-NEW-version-4.pdf
61 mg soft capsules
Not approved in accordance with the following NICE TAs:
Commissioner: NHS England