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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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02.08.02  Expand sub section  Oral anticoagulants
Warfarin
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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)
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    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 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)
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    • 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 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 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
       
    Phenindione
    (Tablet)
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    Restricted Drug Restricted
    Amber No SCG

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

    • RPH: Non formulary

     
       
    Dabigatran (Pradaxa)
    (Capsules)
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    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 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)
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    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  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)
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    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 to top
     ....
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    Scottish Medicines Consortium
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    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).  

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