| Formulary Chapter 2: Cardiovascular system - Full Chapter
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| Chapter Links... |
 Academic Health Science Network (North East and North Cumbria) - Atrial Fibrilation |
| County Durham and Darlington DVT Pathway Information |
| NICE NG148: Acute kidney injury: prevention, detection and management |
| NICE NG191: COVID-19 rapid guideline: managing COVID-19 |
| South Tees Hospitals Cardiology drug prescribing guidelines & formulary |
| Details... |
| 02.08 |
Anticoagulants and protamine |
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Defibrotide
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Formulary
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- Approved for use in severe veno-occlusive disease following stem cell transplant - in accordance with NHS England commissioning policy.
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 Use of defibrotide in severe venoocclusive disease following stem cell transplant
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Idarucizumab
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Formulary
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- Approved for use as a rapid reversal agent for dabigatran.
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| 02.08.01 |
Parenteral anticoagulants |
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Argatroban
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Formulary
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- For use on advice of haematologists in patients with heparin induced thrombocytopenia.
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| 02.08.01 |
Heparin |
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Heparin
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Formulary
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| 02.08.01 |
Low molecular weight heparins |
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Enoxaparin (Inhixa®)
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Formulary
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- Use during pregnancy and for pre-operative bridging therapy .
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Venous thromboembolic diseases: diagnosis, management and thrombophilia testing
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism
Shared Care Guideline (CUMBRIA ONLY) - Low Molecular Weight Heparin (LMWH) - Enoxaparin
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Tinzaparin
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Formulary
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- Use during pregnancy and for pre-operative bridging therapy
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Venous thromboembolic diseases: diagnosis, management and thrombophilia testing
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism
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| 02.08.01 |
Heparinoids |
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Danaparoid
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Formulary
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- For use on advice from haematologists in patients who develop thrombocytopenia with heparins - cross reactivity with heparin antibodies is thiought to be <10%.
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| 02.08.01 |
Hirudins |
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Bivalirudin
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Formulary
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- Approved for preventing thrombosis in patients undergoing percutaneous coronary artery interventions.
- For use instead of abciximab in some low risk patients.
- Approved in combination with aspirin and clopidogrel for the treatment of adults with ST segment elevation MI undergoing percutaneous coronary intervention, in accordance with NICE guidance.
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NICE NG185: Acute coronary syndromes
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| 02.08.01 |
Heparin flushes |
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Heparin
(Flush)
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Formulary
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- 50 units in 5ml & 200 units in 2ml – for flushing cannulae
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TauroHep®
(Taurolidine and citrate catheter lock solution with heparin)
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Formulary
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- Approved for use in the prevention of central intravenous line infections
in; haemodialysis patients, adult parenteral nutrition patients, patients with recurrent line infections, and immune deficiency unit patients.
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TauroLock®
(Taurolidone and citrate catheter lock solution)
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Formulary
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- Approved for use in the prevention of central intravenous line infections in; haemodialysis patients, adult parenteral nutrition patients, patients with recurrent line infections, and immune deficiency unit patients.
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| 02.08.01 |
Epoprostenol |
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Epoprostenol
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Formulary
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- For pulmonary hypertension see section 2.5.1
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Iloprost
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Formulary
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- Mainly for use in treating pulmonary hypertension - see secton 2.5.1
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| 02.08.01 |
Fondaparinux |
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Fondaparinux
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Formulary
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- Approved for high risk orthopaedic surgery pateints and as an alternative to enoxaparin in accordance with NICE guidance.
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Venous thromboembolic diseases: diagnosis, management and thrombophilia testing
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| 02.08.02 |
Oral anticoagulants |
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Warfarin
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Formulary
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- 500 microgram, 1mg, 3mg & 5mg tablets
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- 1mg/1ml oral suspension - - for use in paediatric patients on mechanical support using ventricular assistance devices, and for patients with mechanical heart valves or irregular heart rythms who have not been weaned
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MHRA Drug Safety Update (July 2016): Warfarin: reports of calciphylaxis
MHRA Drug Safety Update (June 2024): Warfarin: be alert to the risk of drug interactions with tramadol
MHRA Drug Safety Update (Oct 2020): Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic
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Phenindione
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Formulary
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Acenocoumarol (Sinthrome®)
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Formulary
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Andexanet alfa (Ondexxya®)
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Formulary
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- 200mg powder for solution for infusion
- Approved for reversing anticoagulation from apixaban and rivaroxaban in adults with life-threatening or uncontrolled bleeding in line with NICE
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NICE TA697: Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban
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Apixaban
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Formulary
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- Only approved for use in accordance with NICE guidance.
- In the absence of a specific clinical reason to select a particular DOAC, choose the most cost effective DOAC first. Rivaroxaban 'cost effective once daily choice for non-valvular AF' and Apixaban 'cost effective twice daily choice for non-valvular AF
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NICE TA245: Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults
NICE TA275: Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation
NICE TA341: Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
MHRA Drug Safety Update Dec 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼)
MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
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Dabigatran
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Formulary
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MHRA Drug Safety Update Dec 2014: Dabigatran (Pradaxa): contraindicated in patients with prosthetic heart valve(s) requiring anti-coagulant treatment
MHRA Drug Safety Update Dec 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼)
MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
MHRA Drug Safety update May 2023: Direct-acting oral anticoagulants (DOACs): paediatric formulations; reminder of dose adjustments in patients with renal impairment
NICE TA157: Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults
NICE TA249: Dabigatran for Stroke prevention in AF
NICE TA327: Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
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Edoxaban
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Formulary
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MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
NICE TA354: Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism
NICE TA355:Edoxaban for preventing stroke/systemic embolism in non‑valvular atrial fibrillation
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Rivaroxaban
(For CAD/PAD)
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Formulary
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- 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 NICE TA607
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MHRA Drug Safety Alert June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
MHRA Drug Safety Update Dec 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼)
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 June 2019: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety update May 2023: Direct-acting oral anticoagulants (DOACs): paediatric formulations; reminder of dose adjustments in patients with renal impairment
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
NICE TA607: Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease
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Rivaroxaban
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Formulary
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- 2.5mg, 10mg, 15mg & 20mg tablets
- 1mg/1ml granules for oral suspension
- approved for the treatment of VTE in children
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MHRA Drug Safety Update Dec 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼)
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 June 2019: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
MHRA Drug Safety Update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
MHRA Drug Safety update May 2023: Direct-acting oral anticoagulants (DOACs): paediatric formulations; reminder of dose adjustments in patients with renal impairment
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
NICE TA170: Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults
NICE TA256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation
NICE TA261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
NICE TA287: Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
NICE TA335: Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome
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| 02.08.02 |
Stroke prevention in AF |
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| 02.08.02 |
VTE treatment |
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| 02.08.02 |
VTE prophylaxis in hip/knee surgery |
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| 02.08.02 |
Antidotes |
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| 02.08.03 |
Protamine sulphate |
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Protamine Sulphate
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Formulary
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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 undertakes the initial prescribing responsibility for an appropriate period of time, usually a minimum of 28 days. A GREEN+ drug can only be recommended to primary care for initiation if does not need to be initiated within 28 days. |
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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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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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