netFormulary NHS
Cambridgeshire and Peterborough
Formulary
 Search
 Formulary Chapter 2: Cardiovascular system - Full Chapter
Chapter Links...
 Details...
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
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 to top
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
 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 to top
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
    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 to top
    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.

     
       
     ....
     Non Formulary Items
    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. 

     

     
    Burinex K®

    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
     
    Diumide-K Continus®

    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
     
    Neo-NaClex-K®

    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