| Formulary Chapter 2: Cardiovascular system - Full Chapter
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 Academic Health Science Network (North East and North Cumbria) - Atrial Fibrilation |
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| 02.06 |
Nitrates, calcium-channel blockers, and potassium-channel activators |
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| 02.06 |
Angina |
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| 02.06.01 |
Nitrates |
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Glyceryl Trinitrate
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Formulary
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- 400 microgram/metered dose spray .
5mg & 10mg/day patches - for use in cardiothoracic critical care unit. .
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Glyceryl Trinitrate Injection
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Formulary
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- 5mg in 5ml , 50mg in 10ml & 50mg in 50ml injections
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Isosorbide Dinitrate 10mg in 10ml injection
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Formulary
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Isosorbide Mononitrate
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Formulary
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- 10mg, 20mg and 40mg tablets
- 60mg MR capsules
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| 02.06.02 |
Calcium-channel blockers |
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Amlodipine
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First Choice
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- Preferred calcium channel blocker for treating hypertension.
- 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.
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MHRA Drug Safety Update (Dec 2014): Simvastatin: dose limitations with concomitant amlodipine or diltiazem
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Diltiazem
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First Choice
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- Preferred calcium channel blocker for angina.
- Zemtard® is the formulary brand of choice for starting new patients on long acting diltiazem.
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MHRA Drug Safety Update (Dec 2014): Simvastatin: dose limitations with concomitant amlodipine or diltiazem
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Felodipine
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Formulary
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- M/R tablets: 2.5mg, 5mg, 10mg
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Nimodipine Injection
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Formulary
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- 10mg in 50ml for IV infusion
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Verapamil Injection
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Formulary
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- Injection: 5mg/2ml (2.5mg/1ml)
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Lercanidipine
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Alternatives
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- For use as a second line calcium channel blocker where amlodipine is not tolerated.
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Nifedipine
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Alternatives
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- Once daily formualtions are preferred
- 20mg controlled release tablets (Adalat LA), 30mg & 60mg m/r capsules (Coracten XL)
- 5mg & 10mg capsules
- 10mg & 20mg retard tablets
- 20mg in 1ml (1mg/drop) nifedipine oral solution is also approved for use
 unlicensed.
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Verapamil
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Alternatives
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- Tablets - 40mg, 80mg, 120mg, 160mg
- MR Tablets - 240mg
- Oral Solution - 40mg/5ml
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Nimodipine
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Alternatives
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- 30mg tablets - treatment should be on the advice of the stroke team or a cardiologist.
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Nicardipine 1mg in 1ml injection
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Alternatives
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- Approved as a second line agent for the treatment of aortic dissection and pre-eclampsia.
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| 02.06.03 |
Other anitanginal drugs |
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Nicorandil
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Formulary
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MHRA Drug Safety Update (Jan 2016): Nicorandil (Ikorel): now second-line treatment for angina - risk of ulcer complications
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Ivabradine
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Formulary
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- Angina - for intiation on advice from a consultant cardiologist in patients with contra-indications to or intolerance of beta-blockers.
- Heart failure - approved for use in accordance with NICE guidelines.
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NICE CG126: Guidance on Stable Angina (2011)
MHRA Drug Safety Update (Dec 2014): Ivabradine (Procoralan) in the symptomatic treatment of angina: risk of cardiac side effects
NICE TA267: Ivabradine for treating chronic heart failure
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Ranolazine
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Formulary
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- For use in the treatment of angina in those patients for whom other treatments have been unsuccesful.
- Initial prescribing should be by a consultant cardiologist only.
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NICE CG126: Guidance on Stable Angina (2011)
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| 02.06.04 |
Peripheral vasodilators and related drugs |
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Naftidrofuryl
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Formulary
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- Approved for the treatment of intermittent claudication in people with peripheral arterial disease.
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NICE CG147: Lower limb peripheral arterial disease management
NICE TA223: Intermittent claudication drugs
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| 02.06.04 |
Other preparations used in peripheral vascular disease |
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic.
The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible.
SCGs are available or are being developed for most of the drugs listed as AMBER. |
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Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria.
These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary.
In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary.
If the drug requires urgent initiation, it is expected that the specialist provides the first prescription from the inpatient/outpatient setting, of sufficient supply for a patient’s immediate needs. The quantity provided should cover at least up to the point where the discharge/clinic letter has reached the GP, plus reasonable time for the practice to manage the document and issue further supplies. A GREEN+ drug can only be recommended to primary care for initiation if it does not need to be initiated urgently, taking into account clinical need. |
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Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible. |
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Self-care – available OTC, can be purchased as part of self-care for self-limiting conditions as per NHSE policy guidance |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care. |
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