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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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02.01  Expand sub section  Positive inotropic drugs
02.01.01  Expand sub section  Cardiac glycosides
Digoxin
(Tablets, Elixir, Injection)
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Formulary
Green

 

  • Injection is Hospital only. (NWAFT: unlicensed unlicensed paediatric injection)
  • Digoxin doses in the BNF may differ from those in product literature.
  • For Elixir digoxin 50 micrograms/mL: Do not dilute, measure with pipette. Special Container. 
  • Bioavailabilites are approximately: Injection 100%, Liquid 80%, Tablets 70%.
  • Caution when switching between formulations as dose adjustment will be needed. Digoxin 125 micrograms tablet is approximately equivalent to 100 micrograms liquid and to 90 micrograms IV injection.
  • NICE Do not Do Recommendation: Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8–12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence.

 

 
Link  CUHFT: Therapeutic drug monitoring
Link  UKMI: Suggestions for Drug Monitoring in Adults in Primary Care
   
02.01.01  Expand sub section  Digoxin-specific antibody
Digoxin specific antibody fragments (Digifab®)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • Very rarely needed and extremely expensive. Discuss with the National Poisons Centre (0344 892 0111) first

 
Link  DigiFab: Summary of Product Characteristics
Link  Toxbase: National Poisons Information Service
   
02.01.02  Expand sub section  Phosphodiesterase type-3 inhibitors
Enoximone (Perfan®)
(Injection. )
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Restricted Drug Restricted
Red Hospital

  • CUHFT: Restricted to intensive care units (see local IV guide with respect to administration)

  • RPH: Formulary

  • NWAFT: Non formulary


 

 
   
02.02.01  Expand sub section  Thiazides and related diuretics to top
Bendroflumethiazide
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First Choice
Green
 
Indapamide
(2.5mg tablets)
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Formulary
Green

  • 2.5 mg tablets only. MR prep is non formulary.

  • For use in patients with renal failure or those who are intolerant of bendroflumethiazide or co-amilozide.

 
   
Metolazone
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Restricted Drug Restricted
Amber No SCG

 

  • Metolazone has been withdrawn from the UK market on commercial grounds and is available on a NAMED PATIENT BASIS only. unlicensed unlicensed. It should only be prescribed when there is no suitable licensed alternative.
  • For most patients a switch to bendroflumethiazide (in combination with a loop diuretic) would be suitable and is supported by the British Society for Heart Failure.
  • Metolazone may be prescribed for renal patients when a high dose of a loop diuretic +/- another thiazide has failed to control fluid retention adequately.
  • Ongoing management and provision of the medicine will need to be discussed with the GP before initiation.
  • Please note - this medication is not commonly prescribed as a daily dose.
 
   
Chlorothiazide
(Suspension 250mg/5ml )
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Restricted Drug Restricted
Red Hospital

  • CUHFT: Suspension 250mg/5ml for paediatric use only. Available as an unlicensed import.unlicensed unlicensed

  • Non formulary at all other Trusts and in Primary Care

 
   
Chlortalidone
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Restricted Drug Restricted
Red Hospital

  • CUHFT: Formulary (may be difficult to obtain)

  • Non-formulary at all other Trusts and in Primary Care

 
Link  Chlortalidone availability- UKMI Q & A
   
Cyclopenthiazide
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Restricted Drug Restricted
Red Hospital

  • CUHFT: Restricted to Clinical pharmacologists only for exceptional circumstances. (May be difficult to obtain)

  • Non formulary at all other Trusts and in Primary Care


 

 
   
02.02.02  Expand sub section  Loop diuretics
Furosemide
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First Choice
Green

  • Licensed liquids may contain alcohol. For further advice contact Pharmacy, Medicines Information or Medicines Optimisation Team

  • Injection: Hospital only

 
Bumetanide
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Second Choice
Green

 

  • Injection: Hospital only.
  • NWAFT: Only tablets on formulary.
 
   
02.02.03  Expand sub section  Potassium-sparing diuretics and aldosterone antagonists
Amiloride Hydrochloride
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First Choice
Green

March 2020 - Shortage of amiloride 5mg tablets

  • Accord are out of stock until August 2020.
  • Wockhardt stock should be available to support during this time. 
 
Triamterene (Dytac®)
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Restricted Drug Restricted
Amber No SCG

  • Amiloride is the first line choice potassium-sparing diuretic.

  • CUHFT: Formulary

  • Non formulary at all other Trusts

 
   
02.02.03  Expand sub section  Aldosterone antagonists
Spironolactone
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Formulary
Green
  • Where a liquid preparation is clinically required in paediatric patients, Spironolactone 50mg/5mL is the standardised liquid strength which should be prescribed in children (unlicensed unlicensed):
    • Using standardised strengths of unlicensed liquid medicines in children, will reduce the risk of errors being made in the doses given to children and prevent hospitalisation from accidental under and overdoses.
    • See link below for further information.
 
Link  MHRA Drug Safety Update: Spironolactone and Renin Angiotensin Drugs Feb 2016
Link  RCPCH and NPPG Position Statement 18-01: Using Standardised Strengths of Unlicensed Liquid Medicines in Children
   
Eplerenone
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Restricted Drug Restricted
Amber No SCG

  • Second line aldosterone antagonist for controlling blood pressure when spironolactone is indicated but cannot be tolerated.

 
Link  NICE CG 108: Chronic heart failure
   
02.02.04  Expand sub section  Potassium-sparing diuretics with other diuretics
Co-amilofruse
(furosemide / amiloride)
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Formulary
Green

October 2020 - Supply Issues with Co-amilofruse 5/40 tablets 

  • Milpharm and Sanofi (Frumil) are out of stock until week commencing 19 October and late December 2020, respectively.
  • Supplies remain available from Wockhardt.
 
   
Co-amilozide
(amiloride/ hydrochlorothiazide)
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Restricted Drug Restricted
Advice

  • CUHFT: formulary

  • Non formulary at all other Trusts

 
Link  MHRA Drug Safety update: Hydrochlorothiazide - risk of non-melanoma skin cancer, particularly in long-term use
   
Co-triamterzide
(triamterene / hydrochlorothiazide)
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Restricted Drug Restricted
Advice

  • CUHFT: formulary

  • Non formulary at all other Trusts


 

 
Link  MHRA Drug Safety Update: Hydrochlorothiazide - risk of non-melanoma skin cancer, particularly in long-term use
   
02.02.05  Expand sub section  Osmotic diuretics to top
Mannitol
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Formulary
Red Hospital

  • IV Infusion- due to the risk of crystallization use an administration set with an in- line filter

  • 10% infusion 500ml

  • 20% infusion 500ml

 
   
02.02.06  Expand sub section  Mercurial diuretics
02.02.07  Expand sub section  Carbonic anhydrase inhibitors
02.02.08  Expand sub section  Diuretics with potassium
02.03  Expand sub section  Anti-arrhythmic drugs
02.03.01  Expand sub section  Management of arrhythmias to top
02.03.02  Expand sub section  Drugs for arrhythmias
Vernakalant (Brinavess®)
(concentrate for solution for infusion)
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Restricted Drug Restricted
Red Hospital
  • NWAFT: Approved for rapid conversion of recent onset atrial fibrillation to sinus rhythm in adults. 
 
   
02.03.02  Expand sub section  Supraventricular arrhythmias
Adenosine
(Injection)
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Restricted Drug Restricted
Red Hospital
 
   
Dronedarone
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Restricted Drug Restricted
Red Hospital

 

  • Approved as per NICE TA197.
  • Prescribers in Primary Care should not initiate dronedarone for any new patient.

  • Patients currently prescribed should be reviewed by their specialist/initiating trust and dronedarone deprescribed.

  • Prescribing should only continue under exceptional circumstances after multi-disciplinary team recommendation but a shared care arrangement would be required.

     

 

 
Link  NICE TA197: Dronedarone for the treatment of non-permanent atrial fibrillation
Link  MHRA Oct 2011: Cardiovascular, hepatic and pulmonary adverse effects - restrictions and monitoring requirements
   
02.03.02  Expand sub section  Supraventricular and ventricular arrhythmias
Amiodarone
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Formulary
Advice
  • Treatment should be initiated only under hospital or specialist supervision. Clear information must be provided by the hospital specialist to the GP
  • UNDER REVIEW: In line with NHS England guidance the place in therapy of amiodarone is under review locally.
  • Guidance is currently being developed to support the place in therapy for new patients and support primary care with the review of existing patients.

 

 
Link  Amiodarone Prescribing Support
Link  Items which should not routinely be prescribed in primary care_Guidance for CCGs: Amiodarone
   
Disopyramide
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Restricted Drug Restricted
Amber No SCG

 

  • NWAFT: Only capsules are on formulary 

 

 
   
Flecainide
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Formulary
Amber No SCG
 
   
Procainamide
(Injection (unlicensed))
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Restricted Drug Restricted
Red Hospital

  • CUHFT and RPH: Available from "Special order" manufacturers or specialist importing companies.unlicensed unlicensed

  • ECG monitoring required

  • Non formulary at all other Trusts

 
   
Propafenone (Arthmol®)
(Tablet)
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Restricted Drug Restricted
Red Hospital

  • NWAFT and RPH: Formulary (specialist use only)

  • ECG monitoring required

  • Non formulary at all other Trusts

 
   
02.03.02  Expand sub section  Ventricular arrhythmias
Lidocaine
(Prefilled Minijet® syringes, Ampoules, Infusion bags)
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Formulary
Red Hospital

  • ECG monitoring required

 
   
02.04  Expand sub section  Beta-adrenoceptor blocking drugs to top
Bisoprolol
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First Choice
Green

  • First line choice of beta blocker in hypertension.

 
Atenolol
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Formulary
Green
 
   
Metoprolol
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Formulary
Green

June 2020 - Intermittent supply issues with Metoprolol 50mg and 100mg tablets

  • Aurobindo-Milpharm, the sole supplier in the UK, have a long-term shortage affecting metoprolol 50mg and 100mg tablets; caused by some manufacturers discontinuing the products and others having supply difficulties.
  • They currently have limited stock available; supply is likely to be intermittent for several months.
  • See link to shortage memo below for further information. 
 
Link  June 2020: Shortage of metoprolol 50mg and 100mg tablets (published 27th April)
   
Propranolol
(Tablet, Capsule MR, Liquid, Injection)
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Formulary
Green

  • NWAFT, CPFT and Primary Care: Injection non formulary

 
   
Carvedilol
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Restricted Drug Restricted
Green

  • Management of Heart Failure

  • When initiated in secondary care- Restricted to Consultant Cardiologist only

 
   
Labetalol
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Restricted Drug Restricted
Advice
  •  RPH: Restricted to use in Donor Care.
  • Formulary at all other Trusts and in Primary Care when 1st line formulary choices are unsuitable.
  • Labetalol tablets are licensed for use in pregnancy for the treatment of hypertension. Please see link below for further information. 

 

 
Link  UKTIS - Use of labetalol in pregnancy
   
Nebivolol
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Restricted Drug Restricted
Advice

  • CUHFT and RPH: Restricted those patients intolerant of other beta blockers (e.g. due to Raynauld's disease) as is highly specific.

  • Non formulary at all other Trusts


 

 
   
Sotalol
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Restricted Drug Restricted
Amber No SCG
  • For treatment of ARRHYTHMIAS ONLY (including ventricular tachyarrhythmias and symptomatic non-sustained ventricular tachyarrhythmias).  
  •    
    Esmolol
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    Restricted Drug Restricted
    Red Hospital

    • NWAFT and RPH: Formulary

    • CUHFT: Restricted to intensive care and resuscitation areas following European Resuscitation Guidelines.

     
       
    02.05  Expand sub section  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
    02.05.01  Expand sub section  Vasodilator antihypertensive drugs
    Hydralazine
    (Tablets, injections)
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    Formulary
    Green

    • Injection: Hospital only

     
       
    Minoxidil
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    Restricted Drug Restricted
    Amber No SCG

    • CUHFT: Must be prescribed in addition to a diuretic and a beta blocker

    • Non formulary at all other Trusts

     
       
    Tadalafil (Adcirca®)
    (Pulmonary hypertension)
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    Restricted Drug Restricted
    Red Hospital

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare 

    • Non formulary at all other Trusts

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
       
    Ambrisentan
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    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare

    • Non formulary at all other Trusts

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
    Link  Letters sent to healthcare professionals October 2019: Volibris (ambrisentan) - new patient alert card and removal of the controlled distribution system
       
    Iloprost
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    unlicensedunlicensed - Supplied on a named patient basis only



    • RPH: Restricted to Critical Care

    • NWAFT: Formulary.

    • CUHFT: Restricted to:

      • Vasculitis (limb ischaemia)

      • Rheumatology (peripheral vascular disease)



     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
    Link  Group Prior Approval Forms for CCG Commissioned Indications
    Link  NICE Evidence Review ESUOM24: Critical limb ischaemia in peripheral vascular disease (intravenous iloprost)
       
    Iloprost nebules (Vantavis®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare 

    • Non Formulary at all other Trusts


     

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
       
    Macitentan (Opsumit® View adult BNF View SPC online View childrens BNF  Track Changes Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare 

    • Non formulary at all other Trusts

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
       
    Riociguat (Adempas®)
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    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare

    • Non formulary at all other Trusts

     
    Link  NHS England: Targeted Therapies for use in Pulmonary Hypertension in Adults Superseded
       
    Sildenafil (Revatio®, Granpidam®)
    (Pulmonary hypertension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare.



    • CUHFT: Intravenous sildenafil is clinically approved for acute pulmonary hypertension in neonates (off-label use) as second line additional agent when nitrous oxide alone ineffective, and patient is NBM so cannot have oral sildenafil. 



    • Non formulary at all other Trusts. 


     

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
    Link  MHRA Drug Safety Update: 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
       
    Sodium Nitroprusside
    View adult BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to hypertensive crisis unlicensedunlicensed 

    • Non Formulary at all other Trusts


     


     

     
       
    Tolazoline
    (Injection)
    View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to neonatal use only. Named patient use only. unlicensed unlicensed

    • Non formulary at all other Trusts 

     
       
    Bosentan
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare 

    • CUHFT: Restricted to the treatment of digit ulceration in systemic sclerosis. Prior approval required (NHSE)

    • Non formulary at all other Trusts and in Primary Care


     

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
    Link  Clinical Commissioning Policy: Treatment of Digital Ulceration in Systemic Sclerosis
       
    Sildenafil (Generic)
    (Digital ulcers)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     



     




      • Prescribe generically as 25mg or 50mg tablets. (DO NOT PRESCRIBE 20mg tablets for this indication)



     




      • Non-formulary at all other Trusts for this indication



     




      • For other indications see seperate entry



     

     
    Link  Clinical Commissioning Policy: Sildenafil and bosentan for the treatment of digital ulceration in systemic sclerosis
    Link  NICE Evidence summary: Sildenafil for digital ulcers
    Link  MHRA Drug Safety update: 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
       
    02.05.02  Expand sub section  Centrally acting antihypertensive drugs
    Methyldopa
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • Should only be used for hypertension where other agents have failed or are not suitable.
    • Methyldopa use in pregnancy:
      • Methyldopa may be indicated in the treatment of hypertension or gestational hypertension.
      • Methyldopa is not specifically licensed for the treatment of hypertension in pregnancy. However, the manufacturer states that methyldopa can be used during pregnancy if there is no safer alternative available.
      • NICE guidelines identify labetalol as the preferred antihypertensive for use during pregnancy. 
      • See links below for further information. 
     
    Link  NICE CKS - Hypertension in Pregnancy (Updated October 2019)
    Link  UKTIS - Use of methyldopa in pregnancy
       
    Clonidine
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted for the maintenance of sedation in ICU. unlicensed unlicensed

    • NWAFT: Specialist use only

    • RPH: Restricted to

      • Hypertensive crisis.

      • Restlessness and agitation in critically ill patients. unlicensed unlicensed




    See Section 4 for prophylaxis of migraine, attention deficit-hyperactivity disorder (unlicensed unlicensed) and Tourette’s syndrome (unlicensed unlicensed).

     
       
    02.05.03  Expand sub section  Adrenergic neurone blocking drugs
    02.05.04  Expand sub section  Alpha-adrenoceptor blocking drugs to top
    Doxazosin
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Immediate release only. Modified release tablets are non formulary.

    • Dose should be started low and titrated up.

     
    Prazosin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Doxazosin is the 1st line choice of alpha blocker.
    • CUHFT: Formulary.
    • Non formulary at all other Trusts.

    October 2020 - Shortage of Prazosin (Hypovase) 1mg tablets

    • Hypovase 1mg tablets are out of stock with resupply date to be confirmed. 
    • Hypovase 500mcg tablets are currently available.
     
       
    02.05.04  Expand sub section  Phaeochromocytoma
    Phenoxybenzamine
    (Capsules)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and NWAFT: Restricted to hypertension in phaeochromocytoma only.

    • Non formulary at all other Trusts


    Owing to risk of contact sensitisation healthcare professionals should avoid contamination of hands.

     
       
    Phentolamine
    (antihypertensive)
    View adult BNF View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     




      • CUHFT and NWAFT: Formulary



     




      • Non formulary at all other Trusts



     

     
    Link  Summary of Product Characteristics (SPC): Phentolamine mesilate solution for injection
       
    02.05.05  Expand sub section  Drugs affecting the renin-angiotensin system
    02.05.05.01  Expand sub section  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
    Lisinopril
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
     
    Ramipril
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

     

    • Primary Care: prescribe as capsules. 

     

     
    Enalapril
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • NWAFT: Restricted to existing patients and paediatric use.
    • Formulary at all other Trusts where 1st line choices are unsuitable.

    October 2020 - Supply Difficulties with Enalapril 20mg tablets

    • Supplies are currently available from Aurobindo.
    • Dexcel and Noumed are currently out of stock with resupply expected by w/c 9 November 2020 and early 2021, respectively.
    • There will be ongoing constraints with supplies of enalapril 20mg tablets until November 2020 when more manufacturers are back in stock.
    • Specialist importers can source unlicensed products. Lead times may vary.
    • See Medicine Supply Notification below (issued 24/07/2020) for further actions to be taken in relation to this shortage. 

     

     
    Link  Medicine Supply Notification July 2020: Enalapril 20mg tablets (published 24/07/2020)
       
    Perindopril erbumine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Please prescribe generic.

    • NWAFT: non formulary


    Perindopril arginine is non formulary in all Trust and Primary Care 

     
    Link  Items which should not routinely be prescribed in primary care: Perindopril Arginine
    Link  PrescQIPP: Switching from Coversyl® Arginine products (perindopril arginine) to perindopril erbumine tablets
       
    Captopril
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT: Accepted on Formulary for use by cardiologists for ACEI test dose; not for treatment. (Hospital only)

    • RPH: Restricted to the treatment of refractory autonomic dysreflexia

    • NWAFT: formulary

     
       
    02.05.05.02  Expand sub section  Angiotensin-II receptor antagonists
    Losartan
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
     
    Candesartan
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green
     
       
    Sacubitril / valsartan ( Entresto ®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Specialist initiation by Heart Failure Specialist with access to MDT as per NICE TA388

     
    Link  NICE TA388: Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
    Link  Prescribing Support: Sacubitril/valsartan (Entresto)
       
    Valsartan
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Advice

     

    • NWAFT: Formulary (capsules).
    • RPH: Formulary (capsules).
    • Non formulary at all other Trusts.
    • Prescribe as capsules in Primary Care.

     

     
       
    Irbesartan
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • CUHFT: Formulary

    • Non formulary at all other Trusts

     
       
    02.05.05.03  Expand sub section  Renin inhibitors to top
    02.06.01  Expand sub section  Nitrates
    Isosorbide Mononitrate MR
    (Modified Release)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Long acting once daily tablet or capsule

    • Acute Trusts: MR tablets are preferred. 60mg MR tablets are scored for easy administration of 30mg dose if needed.

    • Primary Care: prescribers are asked to prescribe ISMN MR as one of the preferred low cost brands detailed below:


      • 25mg and 50mg MR formulations - Elantan LA25 or LA50 modified-release capsules

      • 40mg MR formulation - Nyzamac SR 40mg modified-release capsules 

      • 60mg MR formulation - Chemydur XL or Monomil XL 60mg modified-release tablets Do not crush MR formulations.


    • Do not crush MR formulations

     
    Glyceryl Trinitrate
    (Sublingual tablets , Spray, Patches.)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Sublingual tablets: Discard tablets 8 weeks after opening bottle

    • Primary Care:


      • Prescribe spray as Glyceryl trinitrate 400micrograms/ dose pump sublingual spray

      • Prescribing of patches in Primary Care should be on the advice of a specialist


     
    Isosorbide Mononitrate
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Short acting preparations should be administered twice a day with the last dose of the day in the early afternoon (asymmetric dosing) to allow an adequate nitrate-free period and prevent development of tolerance.

    • Prescribe generically

     
       
    Isosorbide Dinitrate
    (Tablet, MR Tablet, 0.05% Solution for infusion, 0.1% Concentrate for dilution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • Injection: Hospital only (Glass or polyethylene infusion apparatus is preferable; loss of potency if PVC used)

      • RPH: 0.05% Solution for infusion and 0.1% Concentrate for dilution (For administration by IV infusion only except when administered by an intra-coronary injection during percutaneous coronary intervention) 

      • NWAFT: 0.05% Solution for infusion

      • CUHFT: 0.05% Solution for infusion



    • Oral formulations: Formulary (Specialist advice)


    Isosorbide mononitrate is preferred over isosorbide dinitrate as mononitrate preparations are more widely available and isosorbide dinitrate requires more frequent dosing. 

     
       
    Glyceryl Trinitrate (Nitrocine®)
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     




      • Injection: Glass or polyethylene apparatus is preferable; loss of potency will occur if PVC is used.



     


     

     
       
    02.06.02  Expand sub section  Calcium-channel blockers
    Amlodipine
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
     
    Felodipine
    (MR Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • RPH and CUHFT: non formulary

    • Formulary at all other Trusts and in Primary Care

     
       
    Nifedipine
    (modified release formulations)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Different versions of modified- release preparations may not have the same clinical effect.
    • Prescribers should specify the brand to be dispensed.
    • In Primary Care (February 2020) due to stock availability issues the current formulary choices are:  
      • NIFEDIPRESS MR - Available as a 10mg or 20mg modified release tablet. 
      • ADIPINE XL - Available as a 30mg or 60mg prolonged release tablet.
      • For further information see link below. 
    • Brand in acute trusts as purchased . Please check with Pharmacy.
    • Patients receiving nifedipine for the management of Raynaud's phenomenon should be prescribed a modified-release formulation (off-label) vs. immediate release (licensed). This is due to the increased risk of cardiac complications and mortality with the immediate capsule release profile - see LINK
    • Nifedipine use in pregnancy:
      • NICE guidelines state that where labetalol is not an appropriate first-line treatment, nifedipine may be used to treat hypertension in pregnancy. 
      • However, nifedipine is not specifically licensed for the treatment of hypertension in pregnancy.
      • See links below for further information. 
     
    Link  February 2020: Shortages/Discontinuations of Nifedipine products
    Link  NICE CKS - Hypertension in Pregnancy (Updated October 2019)
    Link  UKTIS - Use of calcium channel blockers in pregnancy
       
    Diltiazem
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • Standard strength formulations (60mg) are licensed as 'generics' and there is no requirement for brand name dispensing. (In Primary Care prescribe as Tildiem 60mg MR tablets).
    • Diltiazem MR preparations above 60mg strength should be prescribed by brand name because different brands may not have the same clinical effect.
    • 60mg MR preparations have a different release profile to other modified release diltiazem products. Multiples of 60mg tablets/capsules given once or twice daily should not be used to substitute higher strength products.
    • In Primary Care: Prescribe the preferred low cost brand Zemtard XL (ONCE daily).
    • Acute Trusts:  All prescriptions for other brands will be changed to those brands kept by pharmacy, if patients own medication cannot be used on admission. Current brands:

      • Extended release (ONCE daily) - SLOZEM

      • Modified release (TWICE daily) DILZEM SR (non- formulary at NWAFT)

      • Modified release (THREE times daily) generic 60mg diltiazem.


     

     
       
    Nifedipine
    (Immediate release capsules)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • Short acting capsules Restricted Item Information on restriction :
      • RPH: Restricted for the treatment of refractory autonomic dysreflexia (Hospital only)

     

     

     
    Link  February 2020: Shortages/Discontinuations of Nifedipine products
       
    Verapamil
    (Tablets, MR Tablets, Oral Solution, MR Capsules, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Do not crush MR formulations.

    • Injection (Hospital Only): ECG monitoring required if given as an IV injection

     
    Link  What is the evidence for verapamil for prevention of cluster headache?
       
    Lercanidipine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • RPH: Non formulary

    • CUHFT: May be prescribed by Clinical Pharmacologists for patients who suffer from ankle oedema with other calcium channel blockers.

    • Formulary at all other Trusts and in Primary Care

     
       
    Nimodipine
    (Tablet, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and NWAFT: Formulary

      • Injection:Polyethylene, polypropylene, or glass apparatus should be used. PVC should be avoided

      • Tablets: May be crushed or halved but are light sensitive—administer immediately.



    • RPH: Non formulary

     
       
    02.06.03  Expand sub section  Other anitanginal drugs
     note 

     

    Nicorandil (Ikorel®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Restricted to patients whose angina is inadequately controlled by first line anti-anginal therapies, or who have a contraindication or intolerance to first line anti-anginal therapies

     
    Link  MHRA Advice: Nicorandil (Ikorel) - now second-line treatment for angina - risk of ulcer complications
    Link  MHRA Advice: Nicorandil - risk of gastrointestinal ulceration
    Link  NICE CG126: Stable angina management
       
    Ivabradine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Ivabradine should be initiated by a heart failure specialist with access to a multidisciplinary heart failure team as per NICE TA267

    • Ivabradine is also recommended for stable angina as per NICE CG126

    • A prescribing support document is available.

     
    Link  Prescribing Support Document: Ivabradine for Chronic Heart Failure
    Link  Prescribing Support Document: Ivabradine for Stable Angina
    Link  NICE CG126: Stable angina management
    Link  NICE TA267: Ivabradine for chronic heart failure
       
    Ranolazine
    (MR Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Restricted to adjunctive therapy in the treatment of stable angina in patients inadequately controlled or intolerant of first-line antianginal therapies as per NICE CG126

    • A prescribing support document is available.

     
    Link  Prescribing Support Document: Ranolazine for Stable Angina
    Link  NICE GC126: Stable angina management
       
    02.06.04  Expand sub section  Peripheral vasodilators and related drugs
    Naftidrofuryl
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Restriced to the treatment of intermittent claudication in people with peripheral arterial disease for whom vasodilator therapy is considered appropriate after taking into account other treatment options as per NICE TA223

     
    Link  NICE TA223: Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease
    Link  NICE CG147: Peripheral arterial disease - diagnosis and management
    Link  Bandolier review of drug treatment of peripheral arterial disease
       
    Pentoxifylline (Trental®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Pentoxifylline is not recommended for the treatment of intermittent claudication in people with peripheral arterial disease as per NICE TA233

    • NWAFT: Restricted for the treatment of osteonecrosis of the jaw. unlicensed unlicensed

    • Non formulary at all other Trusts and in Primary Care

     
       
    02.07  Expand sub section  Sympathomimetics to top
    02.07.01  Expand sub section  Inotropic sympathomimetics
    Dobutamine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Do NOT give as a bolus.

     
       
    Dopamine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Do NOT give as a bolus.

     
       
    Dopexamine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Intensive care units only

    • Non formulary at all other Trusts

     
       
    Isoprenaline
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH and NWAFT: unlicensedunlicensed - named patient use

    • CUHFT: Non Formulary


    Isoprenaline hydrochloride 1mg is equivalent to isoprenaline sulphate 1.125mg (from UCL guide).


     

     
       
    02.07.02  Expand sub section  Vasoconstrictor sympathomimetics
    Ephedrine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and NWAFT: Formulary

    • RPH: Non formulary

     
       
    Midodrine
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber SCG


    •  For the management of orthostatic hypotension and neurocardiogenic syncope as per shared care guideline



     
    Link  Shared Care Guideline: Midodrine for orthostatic hypotension and neurocardiogenic syncope
       
    Noradrenaline / Norepinephrine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    April 2020 - Medicine Supply Notification Noradrenaline 4mg in 4ml ampoule

    • See link below for further information. 
     
    Link  Letters sent to healthcare professionals April 2020: Noradrenaline (Norepinephrine) 4mg/4ml concentrate for solution for infusion - temporary supply of a different presentation in market and changes to the instructions
    Link  Medicine Supply Notification April 2020: Noradrenaline 4mg in 4ml ampoule
       
    Phenylephrine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

     




      • CUHFT and NWAFT: Formulary



     




      • Non formulary at all other Trusts



     

     
       
    Metaraminol
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    unlicensedunlicensed. Use is restricted.



    • RPH: Formulary

    • CUHFT: Restricted to use in:

      • Theatres - for hypotension

      • Priapism



    • NWAFT: Restricted to use in:

      • Critical Care

      • Supervision of Critical Care Outreach Team.



     
       
    02.07.03  Expand sub section  Cardiopulmonary resuscitation
    Adrenaline / Epinephrine
    (1 in 10,000, dilute)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Cardiopulmonary resuscitation

     
       
    02.08  Expand sub section  Anticoagulants and protamine
    Idarucizumab  (Praxbind ®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine

     

    • A specific reversal agent for dabigatran and is indicated in adult patients treated with Pradaxa (dabigatran etexilate) when rapid reversal of its anticoagulant effects is required.

    • CUHFT: HIGHLY RESTRICTED - on Haematologist advice only. Two compassionate use doses (5g) are currently held in each ED department.
    • RPH and NWAFT: RESTRICTED USE - Contact Pharmacy for advice. 



     
       
    02.08.01  Expand sub section  Parenteral anticoagulants to top
    Argatroban (Exembol®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and RPH: Anticoagulation in adult patients with heparin-induced thrombocytopenia type II who require parenteral antithrombotic therapy, where fondparinux is not suitable.

    • NWAFT: Non formulary

     
    Link  
       
    02.08.01  Expand sub section  Heparin
    Heparin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

      • CUHFT and NWAFT: For further advice on formulations please contact your Ward or Lead Pharmacist

     

      • RPH only:

     



    Heparinised saline flush



    10 units/mL



    5mL amp



    Heparin flush for maintaining patency of ports



    100 units/mL



    2mL amp



    Heparin preservative-free for theatres only



    1,000 units/mL



    5mL amp



    Heparin for clinical perfusionists only



    1,000 units/mL



    20mL amp



    Heparin:




    Prophylaxis and treatment of deep vein thrombosis and pulmonary embolism.




    Treatment of unstable angina pectoris and prophylaxis of mural thrombosis following myocardial infarction.




    In haemofiltration and extracorporeal circulation (bypass and ecmo).



    5,000 units/mL



    5mL amp



    Heparin for cath labs only



    1,000 units in NaCl 0.9%



    500mL bag

     

     

     

     

     
       
    02.08.01  Expand sub section  Low molecular weight heparins
    Dalteparin
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Advice

     

    • Dalteparin is the LMWH of choice (excluding RPH where Tinzaparin is 1st line).
    • See Trusts guidelines for further information on dosing and duration of treatment.
    • Traffic light status for initiation and continuation of treatment is indication specific. Please see LMWH Prescribing Guideline (THIS GUIDELINE IS CURRENYLY UNDER REVIEW). 
    • For paediatric patients under the age of 16 years, both the prescribing and monitoring of dalteparin should remain - HOSPITAL ONLY. 
    • Patients, irrespective of age, requiring administration of dalteparin from vials, both the prescribing and monitoring should remain - HOSPITAL ONLY.
    • Dalteparin is indicated for VTE prophylaxis where high risk pregnancy is confirmed:
      • High risk pregnancy may be confirmed either by the hospital or within general practice.
      • Presribing and monitoring to be continued by the patient's GP.
      • Very few women will need prescriptions from the beginning of pregnancy. Women will be risk assessed by the community midwives at booking.
      • More women will have a prescription initiated from their specialist from 28 weeks of gestation. 

     

     
    Tinzaparin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH: Tinzaparin is the LMWH of choice

    • CUHFT and NWAFT: for use ONLY in the Dialysis Unit to replace unfractionated heparin. ALL other locations/indications: use dalteparin.

    • Non formulary in Primary Care


     

     
       
    Enoxaparin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

     

    • RPH (HOSPITAL ONLY): VTE prophylaxis in patients with renal impairment when creatinine clearance <20ml/min.
    • RPH and Primary Care Shared Care Guideline: For patients undergoing invasive procedures to establish a diagnosis of pulmonary hypertension, assess treatment response or in preparation for surgery. See link below. 
    • Non formulary at all other Trusts and in Primary Care. 
    • Biosimilars available - brand prescribing recommended. 
    • Patients, irrespective of age, requiring administration of enoxaparin from vials, both the prescribing and monitoring should remain -HOSPITAL ONLY
    • For paediatric patients under the age of 16 years, both the prescribing and monitoring of enoxaparin should remain - HOSPITAL ONLY

     

     
    Link  RPH: Shared Care Guideline - Enoxaparin for patients undergoing invasive procedures to establish a diagnosis of pulmonary hypertension, assess treatment response or in preparation for surgery
       
    02.08.01  Expand sub section  Heparinoids
    Danaparoid (Orgaran®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Haematologist approval required only if heparin causes thrombocytopenia.

    • NWAFT: Restricted to use in thromboembolic disease in patients with history of heparin-induced thrombocytopenia.

    • RPH: Non formulary.

     
       
    02.08.01  Expand sub section  Hirudins
     note  RESTRICTED to Dr. Baglin for approximately 3 patients per year for Heparin induced thrombocytopenia and thrombosis (HIT).
    Bivalirudin (Angiox®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH: Formulary

    • Non formulary at all other Trusts

     
    Link  NICE TA230: Bivalirudin for the treatment of ST-segment-elevation myocardial infarction
    Link  MHRA Drug Safety Update: Risks associated with incorrect dose
    Link  NICE CG 94:Unstable angina and NSTEMI
       
    02.08.01  Expand sub section  Heparin flushes to top
     note  Restricted to Dr. Baglin for approximately 3 patients per year for Heparin induced thrombocytopenia and thrombosis (HIT).
    http://connect/utilities/action/act_download.cfm?mediaid=17481
    Heparin
    (Flush)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH and NWAFT: Formulary

    • CUHFT: Restricted to heamatologist recommendation only for Heparin induced thrombocytopenia and thrombosis (HIT). 

     
    Link  NPSA Alert: Intravenous Heparin Flush solutions (2008)
    Link  SPS: Should heparin based flushing solutions be used in preference to saline to maintain the patency of indwelling intravascular catheters and cannulae?
       
    02.08.01  Expand sub section  Epoprostenol
    Epoprostenol (Flolan®, Veletri®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to all ICUs.

    • RPH: Restricted to use in pulmonary hypertension only, available via homecare.

    • NWAFT: Non formulary

     
    Link  Clinical Commissioning Policy: National policy for targeted therapies for the treatment of pulmonary hypertension in adults (May 2014)
    Link  MHRA Advice: Veletri (epoprostenol) powder for solution for infusion - incompatibilities with some models of administration devices
       
    02.08.01  Expand sub section  Fondaparinux
    Fondaparinux ( Arixtra®)
    ( 5mg, 7.5mg, 10mg solution for injection pre-filled syringe)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    • CUHFT, NWAFT and RPH: Formulary for ACS as per NICE guidelines on unstable angina and NSTEMI. (NWAFT: Where eGFR is less than 30ml/min use dalteparin)

    • CUHFT: Also accepted for use in line with Trust guideline for HIT.

     
    Link  NICE Guideline CG94: Unstable angina and NSTEMI - early management
       
    02.08.02  Expand sub section  Oral anticoagulants
    Warfarin
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
  • Only 1mg and 3mg tablets are routinely used at acute trusts
  • 500 microgram strength should not be prescribed in primary or secondary care.

  • If needed tablets can be crushed and dispersed in water. 
  • Rivaroxaban (Xarelto®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     Warfarin remains a suitable first-line option for most patients.

    • Where warfarin is not clinically appropriate, edoxaban is the lowest acquisition cost DOAC in primary care for Non-Valvular Atrial Fibrillation
    • Prescribing is restricted to:
      • Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (TA256) (Can be initiated in Primary Care)
      • Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (TA287)
      • Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (TA261)
      • Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults (TA170) (Hospital Only)
      • Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome (TA335)
      • Current local agreement in place at CUHFT only for 12 weeks care and supply of treatment for DVT patients. All other Trusts specialist initiation with continuation of prescribing in Primary Care (unless specified hospital only)
    •  CUHFT only: Prescribing also approved for:
      • Thromboembolism prophylaxis in lower limb injury requiring immobilisation started in ED only. (off label use)
      • VTE prophylaxis in acetabular and pelvic fracture for 3 months by Orthopaedic team. Full 12 weeks to be supplied from Lloyds (off label use).
      • THR/TKR: Trust product of choice as an alternative to dalteparin is rivaroxaban.
      • Superficial thrombophlebitis via Lloyds OP (off-label use) 10mg daily for 6 - 12 weeks.  
    • HOSPITAL ONLY - Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease in line with NICE TA607 is currently HOSPITAL only. Pathway for use and prescribing classification for this NICE TA is currently in development and under review (March 2020).  
     
    Link  MHRA drug safety update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
    Link  MHRA Drug Safety Update July 2019: Rivaroxaban (Xarelto▼) - Reminder that 15 mg and 20 mg tablets should be taken with food
    Link  MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs) - increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Letters sent to healthcare professionals in May 2019: Apixaban (Eliquis), dabigatran etexilate (Pradaxa), edoxaban (Lixiana▼) and rivaroxaban (Xarelto▼) are not recommended in patients with antiphospholipid syndrome
    Link  NICE TA170: Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults
    Link  NICE TA256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation
    Link  NICE TA261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
    Link  NICE TA287: Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
    Link  NICE TA335: Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome
    Link  Rivaroxaban Risk Minimisation Materials
    Link  Xarelto patient information leafelet: AF
    Link  Xarelto patient information leaflet: DVT
    Link  Xarelto patient information leaflet: PE
    Link  MHRA Drug Safety Update December 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼) - Risk of serious haemorrhage and clarified contraindications apply to all 3 medicines.
       
    Apixaban (Eliquis®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Warfarin remains a suitable first-line option for most patients.

    • Where warfarin is not clinically appropriate, edoxaban is the lowest acquisition cost DOAC in primary care for Non-Valvular Atrial Fibrillation

    • Prescribing is restricted to:

      • Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation (TA275) (Can be initiated in Primary Care)

      • Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (TA341)

      • Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (TA245) (Hospital only)



     
    Link  MHRA drug safety update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
    Link  MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs) - increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Letters sent to healthcare professionals in May 2019: Apixaban (Eliquis), dabigatran etexilate (Pradaxa), edoxaban (Lixiana▼) and rivaroxaban (Xarelto▼) are not recommended in patients with antiphospholipid syndrome
    Link  NICE TA245: Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults
    Link  NICE TA275: Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation
    Link  NICE TA341: Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
    Link  Patient Alert Card
    Link  MHRA Drug Safety Update December 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼) - Risk of serious haemorrhage and clarified contraindications apply to all 3 medicines.
       
    Phenindione
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

      • CUHFT and NWAFT: Restricted to patients intolerant of warfarin.

     

      • RPH: Non formulary

    October 2020: phenindione stock availability

    • Phenindione 10mg and 25mg tablets:
      Advanz, sole supplier of phenindione tablets, only have supplies of short dated stock available (expiry 30/11/2020).
    • Further resupply is expected during November 2020.
     
       
    Dabigatran (Pradaxa®)
    (Capsules)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Warfarin remains a suitable first-line option for most patients.

    • Where warfarin is not clinically appropriate, edoxaban is the lowest acquisition cost DOAC in primary care for Non-Valvular Atrial Fibrillation

    • Prescribing is restricted to:


      • Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (TA249) (Can be initiated in Primary Care)

      • Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (TA327) (5 days of parenteral heparin is recommended prior to switching to dabigatran for DVT and PE treatment.)

      • Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults (TA157) (Hospital only


    • Do not crush or open capsules as this increases bioavailability by 75%.

     
    Link  MHRA drug safety update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
    Link  MHRA Drug Safety Update December 2014: Dabigatran (Pradaxa▼) risk of serious haemorrhage - contraindications clarified and reminder to monitor renal function.
    Link  MHRA Drug Safety Update December 2014: Dabigatran (Pradaxa) - contraindicated in patients with prosthetic heart valve(s) requiring anti-coagulant treatment
    Link  MHRA Drug Safety Update December 2014: New oral anticoagulants apixaban (Eliquis▼), dabigatran (Pradaxa) and rivaroxaban (Xarelto▼) - Risk of serious haemorrhage and clarified contraindications apply to all 3 medicines.
    Link  MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs) - increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Letters sent to healthcare professionals in May 2019: Apixaban (Eliquis), dabigatran etexilate (Pradaxa), edoxaban (Lixiana▼) and rivaroxaban (Xarelto▼) are not recommended in patients with antiphospholipid syndrome
    Link  NICE TA157: Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults
    Link  NICE TA249: Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation
    Link  NICE TA327: Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
       
    Edoxaban (Lixiana®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Warfarin remains a suitable first-line option for most patients.

    • Where warfarin is not clinically appropriate, edoxaban is the lowest acquisition cost DOAC in primary care for Non-Valvular Atrial Fibrillation

    • Prescribing is restricted to:


      • Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (TA355) (Can be initiated in Primary Care)

      • Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (TA354) (5 days of parenteral heparin is recommended before switching to Edoxaban in the treatment of DVT and PE)



     



    • CUHFT only: Cancer associated thrombosis (Specialist Initiation) unlicensed unlicensed

     
    Link  MHRA drug safety update June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
    Link  Edoxaban: Risk minimisation resources
    Link  MHRA Drug Safety Update June 2019: Direct-acting oral anticoagulants (DOACs) - increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Letters sent to healthcare professionals in May 2019: Apixaban (Eliquis), dabigatran etexilate (Pradaxa), edoxaban (Lixiana▼) and rivaroxaban (Xarelto▼) are not recommended in patients with antiphospholipid syndrome
    Link  NICE TA354: Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism
    Link  NICE TA355:Edoxaban for preventing stroke/systemic embolism in non‑valvular atrial fibrillation
       
    Acenocoumarol (Sinthrome®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT: Specialist Initiation- for patients intolerant of warfarin.

    • Non formulary at all other Trusts


     

     
       
    02.08.02  Expand sub section  Atrial Fibrillation
    02.08.02  Expand sub section  VTE treatment to top
    02.08.02  Expand sub section  VTE prophylaxis in hip/knee surgery
    02.08.02  Expand sub section  VTE Prophylaxis
    02.08.03  Expand sub section  Protamine sulphate
    Protamine Sulphate
    (Injection )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    • No more than 50mg of protamine sulfate should be given in any one dose.

    • To be given by slow intravenous injection over 10 minutes.

     
       
    02.09  Expand sub section  Antiplatelet drugs
    Aspirin (antiplatelet)
    (Dispersible Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    OTC

     

    • Aspirin dispersible and EC tablets (75mg) can be purchased from a Community Pharmacist. 
    • Pregnant women at an increased risk of preeclampsia at their booking appointment should be offered a prescription of 150mg aspirin (in some circumstances this may not be appropriate and lower doses (60-75mg) may be used (for example, women with hepatic or renal disease)) to be taken each night from 12 weeks of pregnancy until birth (off-label use):
      • Please note Community pharmacies cannot legally sell aspirin as a Pharmacy Only Medicine for prevention of pre-eclampsia in pregnancy in England.
      • Aspirin for this indication must be prescribed.
      • Please see links below for further information. 

     

     
    Clopidogrel
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • GI risks very similar to aspirin.
    • Prescribe generically
    • Use in the following circumstances:

      • People who have had an ischaemic stroke or who have peripheral arterial disease or multivascular disease (as per NICE TA210)

      • Following MI only if aspirin is contra-indicated or not tolerated

      • Proven gastro-intestinal haemorrhage with low dose aspirin.

      • For cardiologists to treat patients who have had an acute coronary syndrome (ACS).


    • Where a liquid preparation is clinically required in paediatric patients, Clopidogrel 25mg/5mL* is the standardised liquid strength which should be prescribed in children (unlicensed unlicensed):
      • *Clopidogrel strength is agreed, but as no monograph for this medication exists yet in the BNFC it is not yet published there. 
      • Using standardised strengths of unlicensed liquid medicines in children, will reduce the risk of errors being made in the doses given to children and prevent hospitalisation from accidental under and overdoses.
      • See link below for further information.

     

     
    Link  MHRA: Clopidogrel - risk of acquired haemophilia
    Link  MHRA: Clopidogrel and proton pump inhibitors - interaction, updated advice
    Link  NICE Evidence Summary ESUOM23: Clopidogrel for transient ischaemic attack
    Link  NICE TA210: Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
    Link  RCPCH and NPPG Position Statement 18-01: Using Standardised Strengths of Unlicensed Liquid Medicines in Children (April 2020)
    Link  CUH Prescribing of antiplatelets in non-ST elevation acute coronary syndrome (ACS)
       
    Dipyridamole (Modified Release Capsules)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • Recommended as per NICE TA210 (modified-release dipyridamole)

    • Only if alternatives are not appropriate for the individual patient.

     
    Link  NICE TA210 Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
       
    Prasugrel
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG
     
    Link  NICE TA317: Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes
    Link  MHRA Advice: Prasugrel (Efient) - increased risk of bleeding
    Link  MHRA Advice: Prasugrel (Efient) - rare but serious hypersensitivity reactions
       
    Ticagrelor
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Specialist Initiation only as per:

      • NICE TA236 for the treatment of acute coronary syndromes

      • NICE TA420 for preventing atherothrombotic events after myocardial infarction.



    • A Prescribing Support Document is available.


     

     
    Link  NICE TA236: Ticagrelor for the treatment of acute coronary syndromes
    Link  NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
    Link  Prescribing Support Document: Ticagrelor for the treatment of acute coronary syndromes
       
    Tirofiban
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RESTRICTED to Cardiologists only - for the management of Acute Coronary Syndrome as per NICE TA47


     

     
    Link  NICE TA47: Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes
       
    Abciximab
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH: Formulary

    • CUHFT: Approved only for Dr. Higgins to treat FOUR patients annually for thrombo-embolic complications of neuro-surgery. All other uses at CUHFT non formulary.

    • NWAFT: Non Formulary

     
    Link  NICE TA47: Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes
       
    02.10  Expand sub section  Stable angina, acute coronary syndromes, and fibrinolysis to top
    02.10.01  Expand sub section  Management of stable angina and acute coronary syndromes
    02.10.02  Expand sub section  Fibrinolytic drugs
    Streptokinase
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital
     
       
    Alteplase
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

    • CUHFT, NWAFT and RPH: Recommended as per NICE TA264 for stroke patients presenting within 4.5 hours of the stroke and intracranial haemorrhage has been excluded by appropriate imaging techniques.
    • RPH: Also in combinations with Dornase alfa for pleurodesis. 

    June 2020 - Shortage of Urokinase

    • CUHFT -  Due to a nationwide shortage of Urokinase, we are sourcing Alteplase as a temporary replacement. Internal guidance has been circulated. For further information contact pharmacy.

     





     

     

     
    Link  NICE TA264: Alteplase for treating acute ischaemic stroke
    Link  CUHFT Administration of alteplase (rtPA) during cardiopulmonary resuscitation (CPR) caused by pulmonary embolism (PE)
    Link  CUHFT Patient Management Guide
       
    Reteplase
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to use by cardiologists 2nd line in acute myocardial infarction.

    • Non formulary at all other Trusts


     

     
       
    Urokinase
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

    • NWAFT and RPH: Formulary

     

    • CUHFT: Restricted for unblocking Hickmann lines and in dialysis. Only 10,000 unit vial on Formulary.

    June 2020 - Shortage of Urokinase

    • CUHFT -  Due to a nationwide shortage of Urokinase, we are sourcing Alteplase as a temporary replacement. Internal guidance has been circulated. For further information contact pharmacy.



     

     
       
    Tenecteplase
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to use by ambulance crew for mycardial infartion patients.

    • NWAFT and RPH: Non formulary

     
       
    02.11  Expand sub section  Antifibrinolytic drugs and haemostatics
     note  Tranexamic acid is the 1st line formulary choice of anti-fibrinolytic drug
    Tranexamic Acid
    (Injection, Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Injection is Hospital Only

    • For use as a mouthwash see Section 12.03.04

     
    Lusutrombopag (Mulpleo®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • Approved for use in accordance with NICE TA617 - Lusutrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure. 
     
    Link  NICE TA617: Lusutrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure
       
    Emicizumab (Hemlibra®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    NHS England
    Homecare
    BlueTeq

     

    • CUHFT - Approved as per NHSE CCP:
      • Prophylaxis in patients with congenital haemophilia with factor VIII inhibitors (all ages).
      • Prophylaxis in severe congenital haemophilia A without factor VIII inhibitors (all ages) - dosing as per UKHCDO tables here.
    • Non-formulary at all other Trusts and in Primary Care. 

     

     
    Link  NHS England Clinical Commissioning Policy: Emicizumab as prophylaxis in people with congenital haemophilia A with factor VIII inhibitors (all ages)
    Link  NHS England Commissioning Policy: Emicizumab as prophylaxis in people with severe congenital haemophilia A without factor VIII inhibitors (all ages)
       
    Aprotinin (Trasylol®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

      • CUHFT: Formulary - see major haemorrhage protocol

     

      • RPH: Formulary

     

      • Non-formulary at all other Trusts and in Primary Care

     

     
       
    02.11  Expand sub section  Blood-related products
     note 

    Not supplied by pharmacy. Please contact Trust blood service with enquiries

    02.12  Expand sub section  Lipid-regulating drugs to top
    02.12  Expand sub section  Statins
    Atorvastatin
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Primary prevention: 20mg daily.

    • Secondary prevention: 80mg daily.

     
    Simvastatin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
     
    Link  MHRA: Simvastatin - updated advice on drug interactions
    Link  MHRA: Simvastatin - dose limitations with concomitant amlodipine or diltiazem
    Link  MHRA: Simvastatin - increased risk of myopathy at high dose (80 mg)
       
    Pravastatin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • First choice for HIV patients and transplant patients, low risk of interactions.

     
       
    Rosuvastatin
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • Restricted to:

      • Patients without Familial Hypercholesterolaemia last line before the patient is considered for one of the PCSK9 inhibitors; alirocumab or evolocumab.

      • Patients with Familial Hypercholesterolemia second line to atorvastatin prescribed at the maximum tolerated dose (titrated to a 80mg).



     
       
    02.12  Expand sub section  Bile acid sequestrants
    02.12  Expand sub section  Ezetimibe
    Ezetimibe
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • Recommended for treating primary heterozygous-familial and non-familial hypercholesterolaemia in line with NICE TA385

     
    Link  NICE TA385: Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia
       
    02.12  Expand sub section  Fibrates
    Fenofibrate
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
     
    Bezafibrate
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green
     
       
    02.12  Expand sub section  Nicotinic acid group to top
    Nicotinic Acid
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Formulary

    • Non formulary at all other Trusts and in Primary Care

     
       
    02.12  Expand sub section  Omega-3 fatty acid compounds
    02.12  Expand sub section  PCSK9 inhibitors
    Alirocumab
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    BlueTeq

    • Approved for treating primary hypercholesterolaemia and mixed dyslipidaemia in line with NICE TA393.

     
    Link  NICE TA393 Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    Evolocumab
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    BlueTeq

    • Approved for treating primary hypercholesterolaemia and mixed dyslipidaemia in line with NICE TA394.

     
    Link  NICE TA394 Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    02.12  Expand sub section  Other lipid modifying agents
    02.13  Expand sub section  Local sclerosants
    Sodium Tetradecyl Sulphate
     Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to vascular surgeon use only for varicose vein treatment as per NICE guidance.

    • Non formulary at all other Trusts and in Primary Care


     

     
       
     ....
     Non Formulary Items
    Acebutolol  (Sectral®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey

     




      • For existing patients already stabilised on acebutolol only.



     




      • Do not use for new patients.



     

     
    Acipimox

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Aliskiren

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

     

    • Not included in NICE hypertension guideline as insufficient evidence of its effectiveness.
    • See also safety concerns (see links below).
    • Prescribers in Primary Care should not initiate aliskiren for any new patient.

    • Patients currently prescribed aliskiren should be reviewed by their specialist/initiating trust and aliskiren deprescribed.

    • CUHFT have withdrawn their current shared care guideline.

       

     

     

    Link  EMA advise clinicians to review Aliskiren prescribing following termination of ALTITUDE study
    Link  MHRA: Aliskiren (Rasilez): risk of angioedema and renal dysfunction
    Link  MHRA: Aliskiren (Rasilez): risk of cardiovascular and renal adverse reactions—new contraindications and warnings
     
    Amlodipine and Valsartan  (Exforge®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    • Prescribe as individual constituents if required. Combination products are not recommended

     
    Andexanet alfa Black Triangle  (Ondexxya®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    High Cost Medicine

    Not recommended for prescribing in Cambridgeshire and Peterborough until a positive NICE TA is published or until further evidence relating to clinical and patient outcomes compared with current treatment is made available - CUHFT will not be accepting chairmans action requests until then. 

    Licensed for adult patients treated with a direct factor Xa inhibitor (apixaban or rivaroxaban) when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding. 

     

     
    Atorvastatin and Ezetemibe  (Atozet®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    • Prescribe as individual constituents if required. Combination products are not recommended

     
    Azilsartan

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Burinex K®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Cangrelor

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    • NICE TA351: Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti‑platelet therapy (terminated appraisal). No evidence submission was received from The Medicines Company.

    Link  NICE TA351: Reducing Artherothrombotic Events
     
    Captopril and Hydrochlorothiazide  (Capozide®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide- risk of non-melanoma skin cancer, particularly in long-term use
     
    Captopril and Hydrochlorothiazide  (Co-zidocapt®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
     
    Catridecacog  (NovoThirteen®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    High Cost Medicine
    No formal submission
     
    Celiprolol Hydrochloride

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Centyl K®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Cilostazol  (Pletal®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    • Cilostazol, pentoxifylline and inositol nicotinate are not recommended for the treatment of intermittent claudication in people with peripheral arterial disease as per NICE TA233

    Link  MHRA: Cilostazol (Pletal) - Risks of cardiovascular and bleeding events
     
    Ciprofibrate

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Clonidine
    (Tablets)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    • See Section 4 for prophylaxis of migraine, attention deficit-hyperactivity disorder (unlicensed unlicensed) and Tourette’s syndrome (unlicensed unlicensed).

    June 2020 - Shortage of Clonidine 25microgram tablets

    • Accord are out of stock and unable to advise a resupply date.
    • Sandoz have stock available which is being sent to wholesalers - Ethigen, Lexon and AAH. 
    • See link below for further information.
    Link  June 2020: Shortage of Clonidine 25microgram tablets
     
    Co-flumactone

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Colesevelam  (Cholestagel®)
    (Tablets)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    • Bile acid sequestrants are NOT RECOMMENDED for primary and secondary prevention of cardiovascular disease alone or in combination with a statin.
     
    Colestipol  (Colestid®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    • Bile acid sequestrants are NOT RECOMMENDED for primary and secondary prevention of cardiovascular disease alone or in combination with a statin.
     
    Colestyramine  (Questran®, Questran® Light)
    (Sachets (powder for oral suspension))

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    • Bile acid sequestrants are NOT RECOMMENDED for primary and secondary prevention of cardiovascular disease alone or in combination with a statin.
     
    Co-tenidone
    (atenolol / chlortalidone)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Cozaar- Comp®
    (Losartan & hydrochlorothiazide)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Digitoxin

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Digoxin  (Lanoxin®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Diumide-K Continus®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Dyazide®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Enalapril and Hydrochlorothiazide  (Innozide®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
     
    Eprosartan

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Eptifibatide

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Etamsylate

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Factor IX, recombinant  (Rixubis®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    No formal submission
     
    Flecainide Acetate  (Tambocor®, Tambocor XL ®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Fluvastatin

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Fosinopril

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Frusene®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Furosemide  (Lasix®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Gemfibrozil

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Glyceryl Trinitrate  (GTN® 300 mcg)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Guanethidine Monosulphate

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey

    • Non formulary at all Trusts

    • BNF recommends guanethidine monosulfate is less suitable for prescribing.

     
    Iloprost  (Colonis)
    (100mcg/ml concentrate for solution for infusion)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    • RPH: New Product Assessment taking place by RPH. Existing unlicensed product will continue to be issued in the interim.
    • Iloprost 100 micrograms/ml Concentrate for solution for infusion is NOT ready to use and requires dilution before administration. 

     

     
    Imidapril  (Tanatril®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Indapamide MR

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey

    • Modified release formulation is non formulary.

     
    Indoramin

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Indoramin  (Doralese®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Inositol Nicotinate  (Hexopal®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    • Cilostazol, pentoxifylline and inositol nicotinate are not recommended for the treatment of intermittent claudication in people with peripheral arterial disease as per NICE TA233

     
    Isosorbide Dinitrate
    (Oral)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey

    Prodrug of isosorbide mononitrate - use that instead.

     
    Kalspare®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Lacidipine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Lasikal®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Lasilactone®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Lisinopril and Hydrochlorothiazide  (Carace® Plus)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide - risk of non-melanoma skin cancer, particularly in long-term use
     
    Lisinopril and Hydrochlorothiazide  (Lisicostad®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
     
    Lisinopril and Hydrochlorothiazide  (Zestoretic®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
     
    Lomitapide  (Lojuxta®▼)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    High Cost Medicine
     
    Metoprolol Tartrate  (Lopresor® SR)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Mexiletine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    • Mexiletine unlicensed (unlicensed) is NON-FORMULARY at all trusts and in Primary Care.



     

     
    Milrinone  (Primacor®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Moexipril

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    Non Formulary
    Grey
     
    Moxisylyte  (Opilon®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Moxonidine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Nadolol  (Corgard®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Neo-NaClex-K®

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Nicardipine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Nifedipine
    (Immediate release capsules)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    • For the treatment of refractory autonomic dysreflexia (Hospital only) see monograph above (LINK). 
    • Patients receiving nifedipine for the management of Raynaud's phenomenon should be prescribed a modified-release formulation (off-label) vs. immediate release (licensed). This is due to the increased risk of cardiac complications and mortality with the immediate capsule release profile. 

     

     

    Link  February 2020: Shortages/Discontinuations of Nifedipine products
     
    Nisoldipine  (Syscor® MR)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Olmesartan

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Omega-3-Acid Ethyl Esters
    (All brands including Omacor®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

     




      • Not recommended for prescribing



     

    Link  Items which should not routinely be prescribed in primary care
     
    Oxprenolol Hydrochloride

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Oxprenolol Hydrochloride  (Trasicor®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Oxprenolol Hydrochloride and Cyclopenthiazide  (Trasidrex®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Perindopril Arginine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Pindolol

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Pindolol  (Visken®)

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    Non Formulary
    Grey
     
    Pindolol and Clopamide  (Viskaldix®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Quinapril

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Quinapril and Hydrochlorothiazide

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide - risk of non-melanoma skin cancer, particularly in long-term use
     
    Ramipril and Felodipine  (Triapin®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Rasitro®
    (Aliskeren / amlodipine / hydrochlorothiazide )

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety Update: Hydrochlorothiazide- risk of non-melanoma skin cancer, particularly in long-term use
     
    Sevikar HCT®
    (Olmesartan / amlodipine / hydrochlorothiazide )

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
    Link  MHRA Drug Safety update: Hydrochlorothiazide - risk of non-melanoma skin cancer, particularly in long-term use
     
    Simoctocog alfa  (Nuwiq)
    (®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Telmisartan

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Terazosin

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Timolol

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Timolol Maleate and Bendroflumethiazide  (Prestim®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Timolol Maleate and Co-amilozide  (Moducren®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Torasemide

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Trandolapril

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Trandolapril and Verapamil  (Tarka®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
    Xipamide  (Diurexan®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Grey
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    OTC

    Available Over the Counter. Consider Self Care   

    Green

    Formulary - Can be prescribed in both secondary and primary care.   

    Advice

    Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

    Amber No SCG

    Formulary - Specialist initiation without shared care guidance.  

    Amber SCG

    Formulary - Specialist initiation with shared care guidance.  

    Red Hospital

    Restricted - Hospital only, not to be prescribed in primary care.  

    Switch

    Not recommended for prescribing. Switch to alternative cost-effective option.   

    Black

    Not recommended for prescribing in primary or secondary care.  

    Grey

    Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

    Non Formulary

    Non-Formulary (category under review).  

    netFormulary