netFormulary NHS
Isle of Wight
Formulary
 Search
 Formulary Chapter 2: Cardiovascular system - Full Chapter
Chapter Links...
 Details...
02.01  Positive inotropic drugs
 note 

Drugs which increase the force of contraction of the myocardium

Sympathomimetics with inotropic activity are in section 02.07

02.01.01  Cardiac glycosides
 note 

Digoxin is most useful for controlling ventricular response in persistant and permanent atrial fibrillation and atrial flutter.

It also has a role in heart failure.

Digoxin has a long half life and only needs to be given once daily (although high doses may be divided to avoid nausea)

Renal function should be monitored.

Any signs of toxicity and digoxin therapy should be withdrawn. 

Digoxin
View adult BNF View SPC online View childrens BNF
First Choice
Green

 

Hypokalaemia predisposes to digoxin toxicity

For chronic management check serum electrolytes at least every 12 months

 

 
02.01.01  Digoxin-specific antibody
Digoxin specific antibody fragments
(Digifab®)
(Cardiac glycoside (digoxin) toxicity)
View adult BNF View SPC online View childrens BNF
First Choice
Red
High Cost Medicine

FOR LIFE THREATENING DIGOXIN OVERDOSE

Use with caution in the elderly

Hypokalaemia predisposes to digoxin toxicity

For chronic management check serum electrolytes at least every 12 months

Signs of toxicity:

Anorexia Nausea and vomiting Diarrhoea
Abdominal pain Headache Fatigue
Drowsiness Confusion Dizzeness
Delirium Hallucinations Depression
Arrhythmias Heart block  

 

 
02.02  Diuretics
 note 

Diuretic mode of action varies between the different groups.

02.02.01  Thiazides and related diuretics to top
 note 

Thiazides are third line choice in the management of hypertension after ACE inhibitors and calcium channel blockers

Thiazides and related diuretics are considered ineffective if eGFR <30ml/min/1.73m2 and should be avoided. Metolazone remains effective but there is a risk of excessive diuresis

Bendroflumethiazide
View adult BNF View SPC online View childrens BNF
First Choice
Green

First line choice for Thiazides

Monitor U&E's

 
Indapamide
View adult BNF View SPC online View childrens BNF
Second Choice
Green

 

Indapamide is claimed to lower blood pressure with less metabolic disturbance, particularly less aggrevation of diabetes. Can be used in stroke patients with perindopril.

 
Metolazone
View adult BNF View SPC online View childrens BNF
Third Choice
Green

 

Only in patients who are symptomatic despite being prescribed the maximum tolerated dose of bendroflumethiazide.

 
02.02.02  Loop diuretics
 note 

Loop diuretics are used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure. They may be added to hypertensive treatments in those with resistant hypertension.

Furosemide
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Bumetanide
View adult BNF View SPC online View childrens BNF
Second Choice
Green
 
02.02.03  Potassium-sparing diuretics and aldosterone antagonists
 note 

Monitor serum potassium levels regulary

Amiloride Hydrochloride
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
02.02.03  Aldosterone antagonists
 note 

Potassium supplements should not be prescribed with aldosterone antagonists and serum potassium should be monitored

Spironolactone potentiates thiazide or loop diuretics.

Eplerenone is licensed as an adjunct in left ventricular dysfunction with evidence of heart failure after myocardial infarction and as an adjunct in chronic mild heart failure with left ventricular systolic dysfunction.

 

Spironolactone
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Eplerenone
View adult BNF View SPC online View childrens BNF
Second Choice
Green plus

Licensed as:

An adjunct in stable patients with left ventricular ejection fraction<40% with evidence of heart failure, following a myocardial infarction (start treatment within 3-14 days)

An adjunct in chronic mild heart failure with left ventricular ejection fraction<30%

 
Link  NICE NG106: Chronic heart failure in adults: diagnosis and management
02.02.04  Potassium-sparing diuretics with other diuretics
 note 

Prescribing of thiazides and potassium sparing diuretics separately is preferable.

Fixed combination products may be justified if compliance is an issue, or to reduce pill burden.

Potassium sparing diuretics are not usually necessary in routine treatment of hypertension unless hypokalaemia develops

Co-amilofruse (furosemide and amiloride)
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Co-amilozide
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
02.02.05  Osmotic diuretics to top
Mannitol
View adult BNF View SPC online View childrens BNF
Formulary
Red

Hospital ONLY

 
02.03  Anti-arrhythmic drugs
Magnesium Sulphate 50% soultion for Injection
((2mmol/ml))
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
02.03.01  Management of arrhythmias
02.03.02  Drugs for arrhythmias
Sotalol
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
02.03.02  Supraventricular arrhythmias
Adenosine (Adenocor®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Hospital ONLY

CCU/ITU/Emergency only

 

 
Dronedarone (Multaq®)
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Licensed for:

Maintenance of sinus rhythm after cardioversion in clinically stable patients with paroxysmal or persistent atrial fibrillation, when alternative treatments are unsuitable

Should be initiated and monitored under specialist supervision.

 
Link  NICE TA197: Dronedarone for the treatment of non-permanent atrial fibrillation
02.03.02  Supraventricular and ventricular arrhythmias to top
Amiodarone
View adult BNF View SPC online View childrens BNF
First Choice
Yellow

Monitoring of patients taking amiodarone

System Reason Monitoring
Thyroid and endocrine Amiodarone is known to affect thyroid function due to iodine content. All patients taking amiodarone must have TFTs checked on a 6 monthly basis, and after discontinuation due to long half life- See SPC for details
Eyes

Most patients develop corneal micro-deposits, which are reversible on stopping treatment. These rarely interfere with vision but can affect night time driving.

If optic neuritis or neuropathy develops treatment must be stopped.

Complete ophthalmic examination is recommended immediately if blurred vision is reported. Otherwise patients will require annual ophthalmic assessments
Electrolyte

Potassium levels

Should be checked before initiating treatment
Chest

Known pulmonary toxicity resulting in dyspnoea and non-productive cough

Chest X ray is required before treatment

Any toxicity is reversed on discontinuation

Liver

Associated with hepatotoxicity

LFTs before treatment and every 6 months whilst taking.

ECG and resuscitation facilities need to be available before administering IV amiodarone

 

 

 
Disopyramide
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Antimuscarinic effects can limit use in patients diagnosed with angle-closure glaucoma or prostatic hyperplasia

Monitor for:

Hypotension, hypoglycaemia, ventricular tachycardia or fibrillation or torsades de pointes (discontinue if occurs) and serum potassium

 
Flecainide
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Use with caution as may precipitate serious arrhythmias in a small number of patients.

 

 
02.03.02  Ventricular arrhythmias
Lidocaine
(Cardiac)
View adult BNF View SPC online View childrens BNF
Formulary
Red
 
02.04  Beta-adrenoceptor blocking drugs
 note 

Beta-blockers are considered generally equally effective. However there are differences between them and choice will depend on particular diseases and indvidual patient need.

NICE hypertension pathway

NICE NG106: Chronic heart failure in adults: diagnosis and management

Bisoprolol
View adult BNF View SPC online View childrens BNF
First Choice
Green

First Line for Heart failure

 

 
Labetalol
View adult BNF View SPC online View childrens BNF
First Choice
Yellow

First line for hypertension in pregnancy

Click on below link for NICE gudiance

 
Atenolol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets / Liquid

Fourth line choice for hypertension

First line choice for patients with co-morbidities

 
Atenolol Injection
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOPSITAL ONLY

 
Carvedilol
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Co-tenidone (atenolol and chlortalidone)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Option if combination therapy required

 
Labetalol Injection
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Metoprolol
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Nebivolol
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
Propranolol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets / Liquid / MR capsules

 
02.05  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
02.05.01  Vasodilator antihypertensive drugs
Hydralazine
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
Sodium nitroprusside
Formulary
Red
 
02.05.02  Centrally acting antihypertensive drugs to top
Clonidine (Catapres®)
View adult BNF View SPC online View childrens BNF
Formulary
Red
 
Methyldopa
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
Moxonidine
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
02.05.03  Adrenergic neurone blocking drugs
02.05.04  Alpha-adrenoceptor blocking drugs
Doxazosin
View adult BNF View SPC online View childrens BNF
Formulary
Green

Fourth choice for hypertension

Non-MR preparations are preferred option.

No clinical benefit to normal release tablets. Normal release tablets offer 24 hour effect

Doxazosin may be useful in patients with co-existing BPH

 

 
02.05.04  Phaeochromocytoma
02.05.05  Drugs affecting the renin-angiotensin system
02.05.05  Heart Failure to top
02.05.05.01  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
 note 

ACE inhibitors are first choice for hypertension in individuals aged under 55 years and patient with diabetes.

Monitor blood pressure and electrolytes 7-14 days after starting treatment and dose changes, then annually when stable

Monitor eGFR

ACE inhibitors in pregnancy should be avoided and should be stopped if pregnancy is confirmed.

Ramipril
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Enalapril
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Lisinopril
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Perindopril erbumine or tert-butylamine
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
02.05.05.02  Angiotensin-II receptor antagonists
Losartan
View adult BNF View SPC online View childrens BNF
First Choice
Green

First choice for hypertension.

 
Candesartan
View adult BNF View SPC online View childrens BNF
Formulary
Green

First choice in Heart Failure.

 
Irbesartan
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Sacubitril valsartan
(Entresto®)
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
Link  NICE TA388: Sacubitril valsartan for heart failure (updated 16/7/16 to include adoption resources)
02.05.05.03  Renin inhibitors
02.06  Nitrates, calcium-channel blockers, and potassium-channel activators
02.06  Angina to top
02.06.01  Nitrates
Glyceryl Trinitrate
(AEROSOL spray)
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Isosorbide Mononitrate
View adult BNF View SPC online View childrens BNF
Formulary
Green

Monitor GTN spray use

Modified release preparations are good for maintenence

 
02.06.02  Calcium-channel blockers
Amlodipine
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Lercanidipine
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Less ankle oedema experienced

 
Diltiazem
View adult BNF View SPC online View childrens BNF
Formulary
Green

Prescribe by brand

 
Lacidipine
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
Nifedipine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Prescribe by brand name

Modified release preparations

 
Nimodipine (Nimotop®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

Subarachnoid Bleed

 
Verapamil
View adult BNF View SPC online View childrens BNF
Formulary
Yellow
 
02.06.03  Other anitanginal drugs
Nicorandil
View adult BNF View SPC online View childrens BNF
Third Choice
Green

Third line after failure to stabilise angina with beta-blocker or calcium channel blocker

Monitor for Nicorandil induced ulceration

Nicorandil can cause serious skin, mucosal and eye ulceration including gastrointestinal ulcers which may progress to perforation, haemorrhage, fistula or abscess. STOP treatment if ulceration occurs and consider alternative treatment.

 
Ranolazine (Ranexa®)
View adult BNF View SPC online View SMC online View childrens BNF
Fourth Choice
Yellow

Limited role in stable angina where beta blockers and/or calcium channel blockers are contraindicated, not tolerated or ineffective

SMC decided ranolazine should NOT be recommended for use within NHS Scotland

SMC decision 2012

 
Link  NICE CG126: Guidance on Stable Angina (2011)
Ivabradine
(Heart failure)
View adult BNF View SPC online View SMC online View childrens BNF
Formulary
Yellow

Approved for use in combination with standard therapy of beta blocker (unless contraindicated) ACE inhibitor or aldosterone antagonist as a treament option for mild to severe stablechronic heart failure in patients who:

have left ventricular ejection fraction <35%

AND

are in sinus rhythm with heart rate of >75bpm

 

 
Link  NICE TA267: Ivabradine for treating chronic heart failure
02.06.04  Peripheral vasodilators and related drugs
Naftidrofuryl
View adult BNF View SPC online View childrens BNF
Formulary
Green

Option for treatment of intermittent claudication in patients with peripheral vascular disease when exercise has not led to satisfactory improvement.

Supervised exercise programme should be offered to all patients with intermittent claudication (NICE) - [2hrs/week for 3 months]

Patients should be assessed after 3-6 months to evaluate any improvement. Treatment should be stopped if no benefit.   

 
Link  NICE CG147: Lower limb peripheral arterial disease management
Link  NICE TA223: Intermittent claudication drugs
02.06.04  Other preparations used in peripheral vascular disease to top
02.07  Sympathomimetics
02.07.01  Inotropic sympathomimetics
Dobutamine
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Dopamine
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Isoprenaline
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
02.07.02  Vasoconstrictor sympathomimetics
Midodrine (Bramox ®)
Formulary
Yellow

In adults for the treatment of severe orthostatic hypotension due to autonomic dysfunction when corrective factors have been ruled out and other forms of treatment are inadequate.

 
Ephedrine
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Noradrenaline / Norepinephrine
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
02.07.03  Cardiopulmonary resuscitation
Adrenaline / Epinephrine 1 in 10,000 (dilute)
(CPR)
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
02.08  Anticoagulants and protamine to top
02.08.01  Parenteral anticoagulants
02.08.01  Heparin
Heparin
View adult BNF View SPC online View childrens BNF
Formulary
Green Hospital

HOSPITAL ONLY

Any hospital doctor may prescribe.

Primary care prescribing unlikely and would need appropriate support and services established prior to discharge 

 
02.08.01  Low molecular weight heparins
Enoxaparin
(Inhixa® Clexane®)
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Enoxaparin is now available as Clexane and Inhixa. These are biosimilar medicines and must therefore be prescribed and maintained by brand as they have slightly different administration techniques. Where a switch is required (e.g. with supply problems) please counsel patients as there is a difference in syringe design.

Inhixa is now the brand of choice for new patients however; Clexane is still available for existing patients.

 
Link  Inhixa Patient Information Leaflet - How to inject
02.08.01  Heparin flushes
02.08.01  Fondaparinux to top
Fondaparinux (Arixtra®)
View adult BNF View SPC online View childrens BNF
Formulary
Green Hospital

HOSPITAL ONLY

ACS only

Fondaparinux treatment should start as soon as possible after diagnosis of an ACS, and continue for 8 days or until discharge. In general, fondaparinux offers similar clinical benefit to enoxaparin, with less bleeding risk (see NICE CG94 for full list of references).

 
02.08.02  Oral anticoagulants
Warfarin
View adult BNF View SPC online View childrens BNF
First Choice
Green

Ensure patient has been appropriately counselled and has a copy of the yellow card for their records

First line choice based on a shared decision with patient

 
Edoxaban (Lixiana®)
View adult BNF View SPC online View childrens BNF
First Choice
Green

First line DOAC for non-valvular AF, please see the attached algorithm

Ensure patient has been properly counselled and received alert card and advice leaflet.

First line choice based on a shared decision with patient

DOACs not to be used in patients with mechanical heart valves

Ensure counselling repeated at every opportunity

 
Apixaban (Eliquis®)
View adult BNF View SPC online View childrens BNF
Second Choice
Green

First line DOAC in poor renal function

Ensure patient has been properly counselled and received alert card and advice leaflet

DOACs not to be used in patients with mechanical heart valves

Ensure counselling repeated at every opportunity

 
Link  NICE TA275: Apixaban for AF
Rivaroxaban (Xarelto®)
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Ensure patient has been properly counselled and received alert card and advice leaflet.

NICE TA607 sets out a dose of 2.5mg twice daily, combined with 75–100mg aspirin once daily, as an option for preventing atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral arterial disease (PAD) who are at high risk of ischaemic events.

DOACs not to be used in patients with mechanical heart valves

Ensure counselling repeated at every opportunity

 
Link  NICE TA607 - Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease
Dabigatran (Pradaxa®)
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Ensure patient has been properly counselled and received alert card and advice leaflet.

DOACs not to be used in patients with mechanical heart valves

Ensure counselling repeated at every opportunity

 
Link  NICE TA249: Dabigatran for Stroke prevention in AF
Idarucizumab
(Praxbind®) Black Triangle
View adult BNF View SPC online View childrens BNF
Formulary
Red

Hospital Only

For emergency reversal of dabigatran

 
02.08.02  Stroke prevention in AF
02.08.02  VTE treatment
02.08.02  VTE prophylaxis in hip/knee surgery
02.08.03  Protamine sulphate to top
Protamine Sulphate
View adult BNF View SPC online View childrens BNF
Formulary
Green Hospital

HOSPITAL ONLY

Any hospital doctor may prescribe - Unlikely to be administered in primary care

 
02.09  Antiplatelet drugs
Aspirin (antiplatelet)
View adult BNF View SPC online View childrens BNF
First Choice
Green
 
Clopidogrel
View adult BNF View SPC online View childrens BNF
First Choice
Green

Choice ranking - dependent on indication

 
Prasugrel (Efient®)
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Use within NICE guidance

 
Link  NICE TA317 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes
Ticagrelor (Brilique®)
View adult BNF View SPC online View childrens BNF
Formulary
Yellow

Use within NICE guidance

 
Link  NICE TA236: Ticagrelor for the treatment of acute coronary syndromes
Link  NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
Dipyridamole
View adult BNF View SPC online View childrens BNF
Formulary
Green plus

If other antiplatelets are not appropriate

 
Dipyridamole and Aspirin
View adult BNF View SPC online View childrens BNF
Formulary
Green plus

If compliance is a concern - NOTE only contains 25mg of aspirin

 
02.10  Stable angina, acute coronary syndromes, and fibrinolysis
02.10.01  Management of stable angina and acute coronary syndromes
02.10.02  Fibrinolytic drugs
Alteplase (Actilyse®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Link  NICE TA264: Ischaemic stroke (acute) - alteplase
Streptokinase
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Tenecteplase (Metalyse®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
Urokinase
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

 
02.11  Antifibrinolytic drugs and haemostatics to top
Etamsylate (Dicynene®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

Licensed for short term blood loss in menorrhagia 

 
Tranexamic Acid
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
02.11  Blood-related products
02.12  Lipid-regulating drugs
02.12  Bile acid sequestrants
 note 

Do not offer a bile acid sequestrant (anion exchange resin) for the prevention of CVD to any of the following:

  • people who are being treated for primary prevention

  • people who are being treated for secondary prevention

  • people with CKD

  • people with type 1 diabetes

  • people with type 2 diabetes. [new 2014]

  • DO NOT OFFER combination of a bile sequestrant with a statin for the primary or secondary prevention of cardiovascular disease 

There are currently supply issues with this class of medications and if one product is unavailable it can be changed to one that is. Refer to the SPS memo for guidance on this shortage and switching between products https://www.sps.nhs.uk/articles/shortage-of-bile-acid-sequestrants/

Colesevelam
View adult BNF View SPC online View childrens BNF
First Choice
Green plus
 
Colestyramine
View adult BNF View SPC online View childrens BNF
First Choice
Green plus
 
Colestipol (Colestid®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Green plus

Third choice option after colesevelam or cholestyramine in the event that the other products are unavailable due to the ongoing supply shortage.

 
02.12  Ezetimibe
 note 

NICE STATES:

Ezetimibe monotherapy is recommended as an option for treating primary (heterozygous‑familial or non‑familial) hypercholesterolaemia in adults in whom initial statin therapy is contraindicated or who cannot tolerate statin therapy.

Intolerance to initial statin therapy is defined as the presence of clinically significant adverse effects that represent an unacceptable risk to the patient or that may reduce compliance with therapy. (NICE)

Ezetimibe, co‑administered with initial statin therapy, is recommended as an option for treating primary (heterozygous‑familial or non‑familial) hypercholesterolaemia in adults who have started statin therapy when:

  • serum total or low‑density lipoprotein (LDL) cholesterol concentration is not appropriately controlled (as defined in section 1.7) either after appropriate dose titration of initial statin therapy or because dose titration is limited by intolerance to the initial statin therapy (as defined in section 1.6) and
  • a change from initial statin therapy to an alternative statin is being considered.

Ezetimibe NICE TA385

This guidance should be used in conjunction with NICE's guidelines on

cardiovascular disease: risk assessment and reduction, including lipid modification

and familial hypercholesterolaemia: identification and management.

Treatment should be reviewed every 3 months. If no benefit is observed then treatment can be discontinued

 

Ezetimibe (Ezetrol®)
View adult BNF View SPC online View childrens BNF
Fourth Choice
Green plus
 
02.12  Fibrates to top
 note 
NICE STATES:
 
Do not routinely offer fibrates for the prevention of cardiovascular disease to any of the following:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with chronic kidney disease
  • people with type 1 diabetes
  • people with type 2 diabetes.
Do not offer the combination of a fibrate with a statin for the primary or secondary prevention of cardiovascular disease.
Bezafibrate
View adult BNF View SPC online View childrens BNF
Fourth Choice
Green plus
 
Fenofibrate
View adult BNF View SPC online View childrens BNF
Fourth Choice
Green plus
 
02.12  Statins
 note 

Statins are an effective treatment for lowering LDL cholesterol and ofer primary and secondary cardiovascular protection.

Following failure or side effects with one statin a different statin should be tried.

People on low intensity statins or low doses of other statins should have doses and options optimised before trying other options.

Statins are contraindicated in pregnancy. Women planning a pregnancy taking a statin should be advised to stop statin 3 months before conceiving and not to restart until they finished breast feeding.

 

Atorvastatin
View adult BNF View SPC online View childrens BNF
First Choice
Green

HIGH INTENSITY STATIN at doses 20mg, 40mg & 80mg

Medium intensity statin at dose of 10mg

First line choice

Aim for >40% reduction in non-HDL cholesterol after 3 months

Primary prevention starting dose for individuals who have 10% or higher QRISK2 score. 20mg

Secondary prevention in people with cardiovascular disease

Exceptions apply for this dose

80mg

Measure LFT's within 3 months of starting and at 12months.

Creatine kinase should be checked if complaints of unexplainable muscle pains and weakness. This does not need to be measured routinely in people who are asymptomatic and on a statin

 
Rosuvastatin
(Prescribe generically)
View adult BNF View SPC online View childrens BNF
Second Choice
Green

HIGH INTENSITY STATIN - At doses 10mg, 20mg or 40mg

Medium intensity statin at 5mg dose

Second line choice

Aim for >40% reduction in non-HDL cholesterol after 3 months

Primary prevention starting dose for individuals who have 10% or higher QRISK2 score. 10mg

Secondary prevention in people with cardiovascular disease

Exceptions apply for this dose

40mg

Measure LFT's within 3 months of starting and at 12months.

Creatine kinase should be checked if complaints of unexplainable muscle pains and weakness. This does not need to be measured routinely in people who are asymptomatic and on a statin

 
Simvastatin
View adult BNF View SPC online View childrens BNF
Second Choice
Green

High intensity statin at dose of 80mg

( MHRA - 80mg dose is associated with increased risk of myopathy.)

Medium intensity statin at doses of 20mg and 40mg

Low intensity at dose of 10mg

Patients who are stable on low/medium intensity statins should be encouraged to switch to a high intensity statin or dose for optimal prevention.

 

 
Fluvastatin
View adult BNF View SPC online View childrens BNF
Third Choice
Green

Medium intensity statin at 80mg dose

Low intensity statin at dose of 20mg and 40mg.

Lower intensity statins may be preferred in patients with intolerance or side effects

Individuals should be encouraged to try a higher intensity statin after discussion of risk and benefits.

 

 

 
Pravastatin
View adult BNF View SPC online View childrens BNF
Fourth Choice
Green

LOW INTENSITY STATIN:

Use of higher intensity statins are advised for optimal outcomes. Low intensity statin may be preferred in patients who have intolerance or side effects.

Change to higher intensity statin should be encourage at medication reviews following discussion of potential risks and benefits.

 
02.12  Nicotinic acid group
 note 

NICE STATES:

Nicotinic acid (niacin) should not be offered for the prevention of cardiovascular disease to any of the following:

  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with chronic kidney disease
  • people with type 1 diabetes
  • people with type 2 diabetes.
Do not offer the combination of nicotinic acid with a statin for the primary or secondary prevention of cardiovascular disease.
02.12  Omega-3 fatty acid compounds
 note 

Please note Omega 3 supplements are considered NON-FORMULARY and should not be prescribed.

There is no evidence to support the use of these on the NHS.

Individuals wishing to supplement their diet may do so and products can be easily purchased from variuos sources for a reasonable price.

Please see CCG position supported by Dr Al-Bahrani

02.12  PCSK9 inhibitors
 note 

PCSK9 inhibitors use is restricted and should be used in line with NICE guidance

Alirocumab (Praluent®) Black Triangle
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

Use in line with NICE guidance

GP needs to be informed of use and record as 'Drugs from elsewhere'

 
Link  NICE TA393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
Evolocumab (Repatha® ) Black Triangle
View adult BNF View SPC online View childrens BNF
Formulary
Red

HOSPITAL ONLY

Use in line with NICE guidance

GP need to be informed of use and record as 'Drugs from elsewhere'

 
Link  NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
02.13  Local sclerosants to top
Sodium Tetradecyl Sulphate
(Fibro-Vein®)
Restricted Drug Restricted
Red
 
 ....
 Non Formulary Items
Mexiletine Black Triangle

Restricted Drug Restricted
High Cost Medicine

Tertiary Care Patients:

To be supplied by the prescribing trust.

Not to be supplied in primary care

  
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

Green

Drugs that may be initiated, stabilised and maintained by primary, secondary or tertiary care Secondary and tertiary care prescribing may be continued by primary care. [this does not indicate first/second line choice]  

Green Hospital

Items used by the Hospital but would not normally be continued into primary care. Primary care prescribers can change to GREEN first or second.   

Green plus

Initiation of drugs by primary care following written advice from secondary/ tertiary care advice.  

Yellow

Drugs that may be continued in primary care following initiation and stabilisation in secondary/tertiary care  

Amber

Items requiring a shared care agreement. These items should be initiated and stabilised by secondary or tertiary care. The GP should only be asked to take over prescribing through a formal shared care agreement. Secondary care will be expected to continue prescribing until the agreement is made.  

Red

Hospital/ Trust ONLY. These are items the secondary and tertiary care are responsible for prescribing and will need to continue to prescribe for long term maintenance. These items will NOT be prescribed in primary care. But primary care should be informed the patient is receiving these items. This will include NHSE funded items requiring repatriation.  

GP - Black

Items covered by NHSE ‘Should not prescribe in primary care list’ – See CCG policy on Drugs of limited clinical value  

GP - Grey

Grey List: Items covered by NHSE ‘Should not prescribe in primary care list’ that are not to be routinely prescribed but may be suitable in a defined population – See CCG policy on Drugs of limited clinical value  

netFormulary