Formulary Chapter 2: Cardiovascular system - Full Chapter
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Notes: |
Coronavirus guidance
Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.
The list of resources will be updated as new material becomes available so please check back regularly for updates.
The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.
Cardiovascular system
Review date: July 2021
Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.
Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.
Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol ) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.
NHS England Specialised Commissioning Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.
NHS England Specialised Commissioning: Key documents
NHS England Specialised Commissioning: National programmes of care and clinical reference groups
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Chapter Links... |
National Institutes of Health, US Dept of Health and Human Services: Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents |
NHSE Drug, NHS England Specialised Commissioning: Key documents |
NHSE Drug, NHS England Specialised Commissioning: National programmes of care and clinical reference groups |
NICE CG126: Management of stable angina |
NICE CG172: MI - secondary prevention |
NICE CG180: Atrial fibrillation |
NICE CG187: Acute heart failure: diagnosis and management |
NICE CG94: Unstable MI and NSTEMI |
NICE CG95: Chest pain of recent onset |
NICE NG 136: Hypertension |
NICE NG106: Chronic heart failure in adults |
NICE NG158 (2020): Venous thromboembolic diseases: diagnosis, management and thrombophilia testing |
NICE Patient Decision Aid: Atrial fibrillation: medicines to help reduce your risk of a stroke – what are the options? |
Details... |
02.01 |
Positive inotropic drugs |
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02.01.01 |
Cardiac glycosides |
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Digoxin
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Formulary
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Take care when prescribing and dispensing Digoxin has a low therapeutic index so cautious dose determination is essential and individual patient factors must be considered during formulation changes. Patient levels should be monitored appropriately. The bioavailability of orally administered digoxin is approximately 63% in tablet form and 75% as the oral solution. This equates to ONE 62.5 microgram tablet being approximately equivalent to 50 micrograms (1 ml) elixir. However, the manufacturer is aware of one study showing no clinically relevant difference in bioavailability of digoxin tablets and elixir and suggests that these dosage forms can usually be used interchangeably.[SPS (2018)] |
Tablets |
62.5 micrograms, 125 micrograms, 250 micrograms |
Oral solution |
50 micrograms/ml |
Congestive heart failure
Paediatrics
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02.01.01 |
Digoxin-specific antibody |
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Digoxin specific antibody fragments
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Formulary
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02.01.02 |
Phosphodiesterase type-3 inhibitors |
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Enoximone injection
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Formulary
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5mg/mL
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Milrinone injection
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Formulary
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1 mg/mL, 10-mL amp
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02.02 |
Diuretics |
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02.02.01 |
Thiazides and related diuretics |
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Chlortalidone tablets
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Formulary
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50mg tablets scored (12.5–25mg once daily, recommended by NICE) paediatrics
Not used at Alder Hey
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Indapamide standard release tablets
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Formulary
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2.5mg
N.B. the modified release preparation is not recommended
Paediatrics: no BNFc entry - seek specialist advice
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Bendroflumethiazide tablets
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Formulary
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2.5mg, 5mg paediatrics
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NICE NG 136 Hypertension
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Bendroflumethiazide tablets
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Formulary
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2.5mg, 5mg For oedema
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Chlorothiazide suspension
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Unlicensed
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250mg in 5ml suspension Unlicensed special Paediatrics only
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Metolazone tablets
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Unlicensed
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2.5mg, 5mg Unlicensed special
Wirral
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Bumetanide tablets
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Formulary
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1mg, 5mg paediatrics
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Bumetanide oral liquid
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Formulary
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1mg/5ml paediatrics
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Furosemide tablets
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Formulary
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20mg, 40mg paediatrics
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Furosemide oral solution sugar free
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Formulary
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20mg/5mL, 40mg/5mL, 50mg/5mL (50mg/5ml is standard strength used at Alder Hey) paediatrics
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Furosemide tablets
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Formulary
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500mg
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Furosemide injection
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Formulary
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10mg/mL
May be used in the community as part of a specific service
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02.02.03 |
Potassium-sparing diuretics and aldosterone antagonists |
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Amiloride tablets
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Formulary
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5mg paediatrics
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Amiloride oral solution sugar free
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Formulary
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5mg/5ml paediatrics
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02.02.03 |
Aldosterone antagonists |
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Spironolactone tablets
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Formulary
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25mg, 50mg, 100mg paediatrics
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Spironolactone oral suspension
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Formulary
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5mg/5ml, 10mg/5ml, 25mg/5ml,50mg/5ml, 100mg/5ml (50mg/5ml is standard strength used at Alder Hey) paediatrics
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Eplerenone tablets
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Formulary
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25mg, 50mg Paediatrics: no BNFc entry - seek specialist advice
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02.02.04 |
Potassium-sparing diuretics with other diuretics |
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Combination preparations are considered to be less suitable for prescribing than the separate components. |
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02.02.05 |
Osmotic diuretics |
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Mannitol intavenous infusion
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Formulary
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500mL infusion 10%, 20%
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02.02.06 |
Mercurial diuretics |
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02.02.07 |
Carbonic anhydrase inhibitors |
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02.02.08 |
Diuretics with potassium |
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02.03 |
Anti-arrhythmic drugs |
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02.03.01 |
Management of arrhythmias |
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02.03.02 |
Drugs for arrhythmias |
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02.03.02 |
Supraventricular arrhythmias |
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Adenosine injection
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Formulary
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6mg/2mL
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Dronedarone tablets
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Formulary
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400mg
Paediatrics: no BNFc entry - seek specialist advice
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NICE TA197: Atrial fibrillation - dronedarone
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02.03.02 |
Supraventricular and ventricular arrhythmias |
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Amiodarone
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Formulary
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Tablets |
100 mg , 200 mg |
Suspension  |
10 mg/ml (unlicensed special) |
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Pan Mersey APC (2019). Amiodarone prescribing support information
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Disopyramide capsules
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Formulary
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100mg Paediatrics: no BNFc entry - seek specialist advice
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Flecainide
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Formulary
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Tablets |
50 mg, 100 mg |
Liquid  |
5 mg/ml (unlicensed special; this is the standard strength used at Alder Hey) |
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Propafenone hydrochloride tablets
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Formulary
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150mg, 300mg Paediatrics: no BNFc entry - seek specialist advice
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02.03.02 |
Ventricular arrhythmias |
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Mexiletine
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Second Choice
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Capsules 150mg, 200mg, 250mg
Unlicensed "Special"
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Lidocaine hydrochloride injection
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Formulary
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1% (2mL, 5mL, 10mL, 20mL) 2% (2mL, 5mL, 10mL, 20mL)
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02.04 |
Beta-adrenoceptor blocking drugs |
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Atenolol tablets
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Formulary
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25mg, 50mg, 100mg paediatrics
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Atenolol syrup sugar free
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Formulary
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Tenormin® syrup 25mg/5ml paediatrics
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Bisoprolol tablets
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Formulary
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1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg May be prescribed in paediatrics under specialist advice. Dosage information from specialist centre.
paediatrics
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Carvedilol tablets
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Formulary
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3.125mg, 6.25mg, 12.5mg, 25mg Liquid 1mg/ml Extemp. preparation Alder Hey for paediatric use. paediatrics
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Labetalol tablets
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Formulary
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100mg, 200mg paediatrics
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Metoprolol tablets
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Formulary
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50mg, 100mg paediatrics
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Nebivolol tablets
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Formulary
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2.5mg, 5mg Paediatrics: no BNFc entry - seek specialist advice
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Propranolol tablets
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Formulary
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10mg, 40mg, 80mg, 160mg paediatrics
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Nadolol tablets
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Formulary
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80mg licensed (40mg import- unlicensed in the UK) paediatrics
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Propranolol m/r capsules
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Formulary
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80mg, 160mg paediatrics
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Propranolol oral solution
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Formulary
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5mg/5ml, 10mg/5ml, 40mg/5ml, 50mg/5ml (50mg/5ml standard strength used at Alder Hey) paediatrics
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Sotalol tablets
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Formulary
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40mg, 80mg, 160mg
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Atenolol injection
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Formulary
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500micrograms/mL
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Esmolol injection
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Formulary
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10mg/ml
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Labetalol injection
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Formulary
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5mg/mL
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Metoprolol injection
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Formulary
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1mg/mL
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02.05 |
Drugs affecting the renin-angiotensin system and some other antihypertensive drugs |
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02.05.01 |
Vasodilator antihypertensive drugs |
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Hydralazine tablets
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Formulary
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25mg, 50mg
paediatrics
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Minoxidil tablets
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Formulary
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2.5mg, 5mg, 10mg For renal use only. Paediatrics: no BNFc entry - seek specialist advice
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Ambrisentan tablets
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Formulary
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5mg, 10mg
NHSE commissioned drug - see Specialised Commissioning: Key documents
Pulmonary Arterial Hypertension
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Bosentan tablets
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Formulary
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62.5mg, 125mg
NHSE commissioned drug - see Specialised Commissioning: Key documents
Pulmonary hypertension, digital ulceration in systemic sclerosis only by NHSE designated specialist centres
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Epoprostenol injection
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Formulary
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500microgram vial
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Iloprost nebules
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Formulary
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10mcg/ml 1ml vials.
NHSE commissioned drug - see Specialised Commissioning: Key documents
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Macitentan tablets
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Formulary
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10mg
NHSE commissioned drug - see Specialised Commissioning: Key documents
Pulmonary Hypertension
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Riociguat tablets
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Formulary
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NHSE commissioned drug - see Specialised Commissioning: Key documents
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Sildenafil
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Formulary
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tablets 20mg
oral suspension - 10mg/mL
NHSE commissioned drug - see Specialised Commissioning: Key documents
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Tadalafil
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Formulary
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tablets 20mg
NHSE commissioned drug - see Specialised Commissioning: Key documents
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Iloprost injection
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Unlicensed
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Unlicensed special
NHSE commissioned drug - see Specialised Commissioning: Key documents
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Sodium Nitroprusside
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Unlicensed
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Injection 10mg/mL
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02.05.02 |
Centrally acting antihypertensive drugs |
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Methyldopa tablets
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Second Choice
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125mg, 250mg, 500mg paediatrics
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NICE NG133 Hypertension in pregnancy: diagnosis and management
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Clonidine tablets
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Formulary
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25micrograms,100micrograms scored paediatrics
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Moxonidine tablets
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Formulary
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200micrograms, 300micrograms, 400micrograms Paediatrics: no BNFc entry - seek specialist advice
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02.05.03 |
Adrenergic neurone blocking drugs |
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02.05.04 |
Alpha-adrenoceptor blocking drugs |
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Doxazosin
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Formulary
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1mg, 2mg, 4mg paediatrics
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Doxazosin M/R
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Formulary
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4mg, 8mg
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Pan Mersey APC (2018). DOXAZOSIN modified release (M/R) tablets
UKMI Q&A: How should conversion between doxazosin formulations be carried out in patients with hypertension? (2016)
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Prazosin tablets
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Formulary
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1mg, 2mg, 5mg
Restricted to nephrology patients.
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Prazosin suspension
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Unlicensed
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500micrograms/5ml unlicensed special
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02.05.04 |
Phaeochromocytoma |
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Phenoxybenzamine capsules
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Formulary
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10mg For phaeochromcytoma only
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Phentolamine injection
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Unlicensed
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10mg/mL
For phaeochromcytoma only
Paediatrics: no BNFc entry - seek specialist advice
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02.05.05 |
Drugs affecting the renin-angiotensin system |
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Sacubitril/Valsartan tablets (Entresto®)
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Formulary
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24mg/26mg, 49mg/51mg, 97mg/103mg
Prescribing and monitoring of sacubitril/valsartan must be retained by the heart failure team during dose titration and until the patient is stabilised on the maximum tolerated dose, this is expected to be a minimum of 3 months of prescribing by the heart failure team to allow dose titration and review of the patient once they are stable on optimum dose.
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Pan Mersey APC (2020): Sacubitril/Valsartan film-coated tablets (Entresto®▼)
NICE TA388: Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
North West Strategic Clinical Network: Position statement
North West Strategic Clinical Network: Treatment algorithm
North West Strategic Clinical Network: GP communication letter
North West Strategic Clinical Network: Patient information leaflet
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Dapagliflozin tablets
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Formulary
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for heart failure with reduced ejection fraction.
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Pan Mersey APC (2020) DAPAGLIFLOZIN tablets (Forxiga®) for heart failure with reduced ejection fraction
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02.05.05.01 |
Angiotensin-converting enzyme inhibitors (ACE inhibitors) |
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Captopril liquid
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Formulary
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5mg/5ml, 25mg/5ml First line in children until stabilised. No longer routinely recommended in new adult patients. Patients currently stable may remain on treatment. paediatrics
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Captopril tablets
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Formulary
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12.5mg, 25mg, 50mg First line in children until stabilised. No longer routinely recommended in new adult patients. Patients currently stable may remain on treatment. paediatrics
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Enalapril tablets
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Formulary
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2.5mg, 5mg, 10mg, 20mg No longer routinely recommended in new adult patients. Patients currently stable may remain on treatment. paediatrics
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Lisinopril tablets
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Formulary
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2.5mg, 5mg, 10mg, 20mg paediatrics
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Perindopril erbumine tablets
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Formulary
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2mg, 4mg, 8mg paediatricsPaediatrics: no BNFc entry - seek specialist advice
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Ramipril capsules
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Formulary
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1.25mg, 2.5mg, 5mg, 10mg paediatricsPaediatrics: no BNFc entry - seek specialist advice
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Enalapril liquid
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Unlicensed
|
Unlicensed special various strengths available from special–order manufacturers. 5mg/5ml is standard strength used at Alder Hey. No longer routinely recommended in new adult patients. Patients currently stable may remain on treatment. paediatrics
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Lisinopril liquid
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Unlicensed
|
Unlicensed special various strengths available from special–order manufacturers. 5mg/5ml is standard strength used at Alder Hey. paediatrics
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02.05.05.02 |
Angiotensin-II receptor antagonists |
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Candesartan tablets
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Formulary
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2mg, 4mg, 8mg, 16mg, 32mg paediatrics
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Irbesartan tablets
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Formulary
|
75mg, 150mg, 300mg paediatrics Paediatrics: no BNFc entry - seek specialist advice
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Losartan tablets
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Formulary
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12.5mg, 25mg, 50mg, 100mg paediatrics
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Losartan oral suspension
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Formulary
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12.5mg/5ml when reconstituted paediatrics
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Valsartan tablets and capsules
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Formulary
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40mg, 80mg, 160mg, 320mg paediatrics
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ARB + ACEI combination
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Formulary
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Combination use of medicines from different classes of renin-angiotensin system blocking agents: MHRA Medicines and Healthcare Products Regulatory Agency
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02.05.05.03 |
Renin inhibitors |
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Aliskiren tablets
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Formulary
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150mg, 300mg
|
Pan Mersey APC (2020): ALISKIREN tablets (Rasilez®) for Hypertension
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02.06 |
Nitrates, calcium-channel blockers, and potassium-channel activators |
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02.06.01 |
Nitrates |
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Glyceryl Trinitrate sublingual tablets
|
Formulary
|
300micrograms, 500micrograms, 600micrograms
Paediatrics: no BNFc entry - seek specialist advice
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Glyceryl Trinitrate patches
|
Formulary
|
5mg/24 hours, 10mg/24 hours paediatricsPaediatrics: no BNFc entry - seek specialist advice
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Glyceryl trinitrate patch: Pan Mersey Prescribing Support Information for Children
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Glyceryl Trinitrate spray
|
Formulary
|
400micrograms/metered dose
Paediatrics: no BNFc entry - seek specialist advice
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Isosorbide Mononitrate tablets
|
Formulary
|
10mg, 20mg, 40mg M/R 25mg, 40mg, 50mg, 60mg
Paediatrics: no BNFc entry - seek specialist advice
|
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Isosorbide Dinitrate injection
|
Formulary
|
0.1% injection (1mg/mL) 10mL amps
Paediatrics: no BNFc entry - seek specialist advice
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|
02.06.02 |
Calcium-channel blockers |
|
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Amlodipine tablets
|
Formulary
|
5mg, 10mg paediatrics
|
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Amlodipine liquid
|
Formulary
|
1mg/ml and 2mg/ml paediatrics
|
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Diltiazem tablets
|
Formulary
|
60mg
paediatrics only for Raynaud’s syndrome
|
|
Diltiazem modified release
|
Formulary
|
Different versions of modified release containing more than 60mg may not have the same clinical effect so should be prescribed by brand. Modified release available as 60mg, 90mg, 120mg, 180mg, 200mg, 240mg, 300mg and 360mg formulations suitable for either once or twice daily administration depending on brand.
paediatrics : only for Raynaud’s syndrome Paediatrics: no BNFc entry - seek specialist advice
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|
Felodipine m/r tablets
|
Formulary
|
2.5mg, 5mg, 10mg
Paediatrics: no BNFc entry - seek specialist advice
|
|
Nifedipine m/r tablets and capsules
|
Formulary
|
All modified release preparations of nifedipine must be prescribed by brand. Modified release available as 10mg, 20mg, 30mg, 40mg and 60mg formulations suitable for either once or twice daily administration depending on brand. paediatrics
|
|
Nifedipine capsules
|
Formulary
|
5mg, 10mg paediatrics
|
|
Verapamil modified release
|
Formulary
|
120mg, 180mg, 240mg paediatrics
|
|
Verapamil tablets
|
Formulary
|
40mg, 80mg paediatrics
|
|
Verapamil oral solution
|
Formulary
|
40mg/5ml Not used at Alder Hey paediatrics
|
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Nimodipine tablets
|
Formulary
|
30mg
|
|
Nimodipine intravenous infusion
|
Formulary
|
200microgram/ml 50ml vial
|
|
Nifedipine oral liquid
|
Unlicensed
|
Unlicensed special oral drops 20mg/ml paediatrics
|
|
02.06.03 |
Other anitanginal drugs |
|
|
Ivabradine
|
Formulary
|
Tablets 5 mg, 7.5 mg
Angina
Heart failure
|
MHRA (2014). Ivabradine (Procoralan) in the symptomatic treatment of angina: risk of cardiac side effects
NICE (2012). Ivabradine for treating chronic heart failure
Pan Mersey APC (2018). IVABRADINE (Procoralan®) for the treatment of chronic heart failure
|
Nicorandil tablets
|
Formulary
|
10mg, 20mg
Paediatrics: no BNFc entry - seek specialist advice
Due to risk of ulcer complications use nicorandil for treatment of stable angina only in patients whose angina is inadequately controlled by other anti-anginal therapies, or who have a contraindication or intolerance to other anti-anginal therapies such as beta-blockers or calcium antagonists.
|
Drug Safety Update Jan 2016 Nicorandil (Ikorel): now second-line treatment for angina - risk of ulcer complications
|
Ranolazine m/r tablets
|
Formulary
|
375mg, 500mg, 750mg
As adjunctive therapy in line with licence after calcium channel blockers and beta blockers
Dose titration necessary: The recommended initial dose is 375 mg twice daily. After 2–4 weeks, the dose should be titrated to 500 mg twice daily and, according to the patient's response, further titrated to a recommended maximum dose of 750 mg twice daily. If patient experiences treatment-related adverse events (e.g. dizziness, nausea, or vomiting), down-titration to 500 mg or 375 mg twice daily may be required.
Paediatrics: no BNFc entry - seek specialist advice
|
|
02.06.04 |
Peripheral vasodilators and related drugs |
|
|
Naftidrofuryl oxalate capsules
|
Formulary
|
100mg
Paediatrics: no BNFc entry - seek specialist advice
|
|
Iloprost infusion
|
Formulary
|
Concentrate for infusion 100micrograms/ml
Paediatrics: only for Raynaud’s syndrome.
|
|
Cilostazol tablets
|
Formulary
|
50mg, 100mg
|
|
Inositol nicotinate tablets
|
Formulary
|
500mg, 750mg
|
|
Pentoxifylline tablets
|
Formulary
|
400mg
|
|
|
02.06.04 |
Other preparations used in peripheral vascular disease |
|
|
02.07 |
Sympathomimetics |
|
|
02.07.01 |
Inotropic sympathomimetics |
|
|
Dobutamine hydrochloride infusion
|
Formulary
|
12.5mg/mL concentrate for IV infusion 20mL amps
|
|
Dopamine hydrochloride infusion
|
Formulary
|
40mg/mL concentrate for IV infusion 5mL amps
|
|
02.07.02 |
Vasoconstrictor sympathomimetics |
|
|
Midodrine tablets
|
Formulary
|
2.5mg, 5mg Oral alpha agonist treatment for severe orthostatic hypotension due to autonomic dysfunction when corrective factors have been ruled out and other forms of treatment are inadequate.
Paediatrics: no BNFc entry - seek specialist advice
|
|
Ephedrine hydrochloride injection
|
Formulary
|
30mg/mL injection 1mL amps 3mg/mL injection 10mL amps
|
|
Noradrenaline / Norepinephrine injection
|
Formulary
|
Noradrenaline base 1mg/mL 4ml amps
|
|
Phenylephrine hydrochloride injection
|
Formulary
|
10mg/mL 1ml amps
|
|
Metaraminol injection
|
Unlicensed
|
10mg/mL injection Unlicensed special
|
|
02.07.03 |
Cardiopulmonary resuscitation |
|
|
Adrenaline / Epinephrine Intravenous injection
|
Formulary
|
1 in 10,000 (100microgram/mL) injection
|
|
02.08 |
Anticoagulants and protamine |
|
|
|
|
02.08.01 |
Parenteral anticoagulants |
|
|
Argatroban
|
Formulary
|
Injection 100mg/mL
|
|
|
Heparin sodium injection (unfractionated)
|
Formulary
|
1,000 units/mL (1mL, 5mL, 20mL amps) 5,000 units/mL (1mL amp) restricted use
|
|
02.08.01 |
Low molecular weight heparins |
|
|
|
Dalteparin sodium injection
|
Formulary
|
12 500 units/mL, 2500-unit (0.2-mL) syringe
25 000 units/mL, 5000-unit (0.2-mL) syringe , 7500-unit (0.3-mL) syringe, 10 000-unit (0.4-mL) syringe, 12 500-unit (0.5-mL) syringe, 15 000-unit (0.6-mL) syringe, 18 000-unit (0.72-mL) syringe2,500 units/mL, 4mL (10,000-unit) amps10,000 units/mL, 1mL (10,000-unit) amps25,000 units/mL, 4-mL (100,000-unit) amps10,000 units/mL, 1-mL (10,000-unit) graduated syringe when used as surgical or medical VTE prophylaxis or treatment in hospital, or for prevention of miscarriage in women with history of recurrent miscarriage for the duration of treatment during pregnancy. paediatrics
|
|
Enoxaparin sodium injection
|
Formulary
|
100 mg/mL: 20-mg (0.2-mL, 2,000-units) syringe 40-mg (0.4-mL, 4,000-units) syringe 60-mg (0.6-mL, 6,000-units) syringe 80-mg (0.8-mL, 8,000-units) syringe 100-mg (1-mL, 10,000-units) syringe 300 mg (3-mL, 30,000-units) vial 150 mg/mL: 120-mg (0.8-mL, 12,000-units) syringe 150-mg (1-mL, 15,000-units) syringe
Enoxaparin is now available as the originator brand (Clexane®) and biosimilar brand (Inhixa®). Prescribing should be by brand to ensure that the correct product is selected for prescribing, dispensing and administration due to differences in syringe design. when used as surgical or medical VTE prophylaxis or treatment in hospital, or for prevention of miscarriage in women with history of recurrent miscarriage for the duration of treatment during pregnancy. paediatrics
|
|
Tinzaparin sodium injection
|
Formulary
|
10,000 units/mL: 2,500-unit (0.25-mL) syringe 3,500-unit (0.35-mL) syringe 4,500-unit (0.45-mL) syringe 20,000-unit (2-mL) vial 20,000 units/mL: 0.5mL (10,000-unit) syringe 0.7-mL (14,000-unit) syringe 0.9-mL (18,000-unit) syringe 2-mL (40,000-unit) vial
when used as surgical or medical VTE prophylaxis or treatment in hospital, or for prevention of miscarriage in women with history of recurrent miscarriage for the duration of treatment during pregnancy. paediatrics
|
|
|
|
|
Danaparoid sodium injection
|
Formulary
|
1,250 units/mL, 0.6-mL amp (750 units)
|
|
|
Bivalirudin injection
|
Formulary
|
powder for reconstitution 250mg vial
Paediatrics: no BNFc entry - seek specialist advice
|
NICE TA230 : Bivalirudin for the treatment of STEMI, 2011
|
02.08.01 |
Heparin flushes |
|
|
Heparin
|
Formulary
|
Flush 10units/mL, 100units/mL The use of heparin flushes should be kept to a minimum. For maintaining patency of peripheral venous catheters, sodium chloride injection 0.9% is as effective as heparin flushes. The role of heparin flushes in maintaining patency of arterial and central venous catheters is unclear.
|
|
|
Epoprostenol
|
Formulary
|
500micogram and 1.5mg vials for reconstitution
NHSE commissioned drug - see Specialised Commissioning: Key documents
|
|
|
Fondaparinux sodium injection
|
Formulary
|
2.5mg/0.5mL prefilled syringe
Paediatrics: no BNFc entry - seek specialist advice
|
|
02.08.02 |
Oral anticoagulants |
|
|
|
Oral anticoagulants
Paediatric use: in paediatrics only warfarin is used as an anticoagulant.
|
|
Warfarin
|
Formulary
|
Tablets |
500 micrograms, 1 mg, 3 mg, 5 mg
Treatment and secondary prevention of DVT/PE. Includes initiation by specialist warfarin service.
Paediatrics.
|
Oral suspension |
5 mg per 5 ml
paediatrics
Specialist centre usually tries to get patients onto 1 mg tablets before discharge.
|
|
|
Acenocoumarol tablets
|
Formulary
|
1mg
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
|
|
Phenindione tablets
|
Formulary
|
10mg, 25mg, 50mg
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
|
|
Apixaban
|
Formulary
|
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
Prevention of stroke and systemic embolism in atrial fibrillation
2.5 mg, 5 mg tablets
In the absence of a specific clinical reason to select a particular DOAC, choose the least costly DOAC first for patients with non-valvular AF. Currently this is edoxaban.
Pan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
NICE (2013). Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation
Treatment and prevention of PE and DVT
2.5 mg, 5 mg tablets Note: 2.5 mg, 5 mg tablets are in Wirral for this indication.
For suspected VTE where an agreed local treatment pathway includes managing the initial diagnosis of VTE in Primary Care (off-label use in line with NICE CG 158). Where management is initiated in secondary care or a specialist service the RAG designation is Amber initiated.
NICE (2015). Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
VTE prophylaxis in patients who are having elective hip and knee replacement surgery
2.5 mg, 5 mg tablets
Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults
|
|
Dabigatran
|
Formulary
|
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
Prevention of stroke and systemic embolism in atrial fibrillation
75 mg, 110 mg, 150 mg capsules
In the absence of a specific clinical reason to select a particular DOAC, choose the least costly DOAC first for patients with non-valvular AF. Currently this is edoxaban.
Pan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
NICE (2012). Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation
Treatment and prevention of PE and DVT
75 mg, 110 mg, 150 mg capsules Note: 75 mg, 110 mg, 150 mg capsules are in Wirral for this indication.
For suspected VTE where an agreed local treatment pathway includes managing the initial diagnosis of VTE in Primary Care (off-label use in line with NICE CG 158). Where management is initiated in secondary care or a specialist service the RAG designation is Amber initiated.
NICE (2014). Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
VTE prophylaxis in patients who are having elective hip and knee replacement surgery
75 mg, 110 mg, 150 mg capsules
NICE (2008). Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults
|
|
Edoxaban
|
Formulary
|
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
Prevention of stroke and systemic embolism in atrial fibrillation
15 mg, 30 mg, 60 mg tablets
In the absence of a specific clinical reason to select a particular DOAC, choose the least costly DOAC first for patients with non-valvular AF. Currently this is edoxaban.
Pan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
NICE (2015). Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation
Treatment and prevention of PE and DVT
15 mg, 30 mg, 60 mg tablets Note: 15 mg, 30 mg, 60 mg tablets are in Wirral for this indication.
For suspected VTE where an agreed local treatment pathway Includes managing the initial diagnosis of VTE in Primary Care (off-label use in line with NICE CG 158). Where management is initiated in secondary care or a specialist service the RAG designation is Amber initiated.
Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism
|
|
Rivaroxaban
|
Formulary
|
Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.
Drug Safety Update Rivaroxaban (Xarelto▼): reminder that 15 mg and 20 mg tablets should be taken with food
Prevention of stroke and systemic embolism in atrial fibrillation
10 mg, 15 mg, 20 mg tablets
In the absence of a specific clinical reason to select a particular DOAC, choose the least costly DOAC first for patients with non-valvular AF. Currently this is edoxaban.
Pan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
NICE (2012). Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation
Prevention of atherothrombotic events in adult patients with coronary artery disease or symptomatic peripheral artery disease at high risk of ischaemic events - in combination with aspirin.
2.5 mg tablets
Pan Mersey APC (2019) RIVAROXABAN 2.5mg tablets (Xarelto®▼) for the prevention of atherothrombotic events
NICE (2019). Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease
Treatment and prevention of PE and DVT
10 mg, 15 mg, 20 mg tablets Note: 10 mg, 15 mg, 20 mg tablets are in Wirral for this indication.
For suspected VTE where an agreed local treatment pathway includes managing the initial diagnosis of VTE in Primary Care (off-label use in line with NICE CG 158). Where management is initiated in secondary care or a specialist service the RAG designation is Amber initiated.
NICE (2012). Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
NICE (2013). Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
Acute coronary syndrome (ACS)
2.5mg tablets
Pan Mersey APC (2017) RIVAROXABAN tablets (Xarelto®▼) in Acute Coronary Syndrome
NICE (2015) Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome
VTE prophylaxis in patients who are having elective hip and knee replacement surgery
10 mg, 15 mg, 20 mg tablets
NICE (2009). Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults
|
|
Idarucizumab
|
Formulary
|
Praxbind® 2.5g/50mL solution for injection/infusion
|
|
|
|
|
02.08.03 |
Protamine sulphate |
|
|
Protamine Sulphate injection
|
Formulary
|
10mg/mL, 5mL amps
|
|
02.09 |
Antiplatelet drugs |
|
|
Aspirin tablets (antiplatelet)
|
Formulary
|
75mg paediatrics Unlicensed in children
|
UKMI Q&A: Is there evidence to support the use of EC aspirin to reduce GI side effects in cardiovascular patients? (2017)
|
Clopidogrel tablets
|
Formulary
|
75mg paediatrics Paediatrics: no BNFc entry - seek specialist advice. Dosage information from initiating centre.
|
NICE TA80: Acute coronary syndromes - clopidogrel
|
Dipyridamole MR capsules
|
Formulary
|
200mg
Paediatrics: no BNFc entry - seek specialist advice
|
|
Dipyridamole oral suspension
|
Formulary
|
50mg/5ml, 200mg/5ml paediatrics
|
|
Dipyridamole tablets
|
Formulary
|
25mg, 100mg For paediatrics
|
|
Prasugrel tablets
|
Formulary
|
5mg, 10mg Paediatrics: no BNFc entry - seek specialist advice
|
NICE TA317: Acute coronary syndrome - prasugrel
|
Ticagrelor
|
Formulary
|
Tablets 90mg, 60mg Orodispersible tablets 90mgMaximum treatment duration of 1 year at 90mg bd; extended treatment with 60mg bd up to a maximum of 3 years. Paediatrics: no BNFc entry - seek specialist advice
|
Pan Mersey APC (2019): Ticagrelor tablets (Brilique®)
NICE TA236: Acute coronary syndromes - ticagrelor
NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
|
Abciximab
|
Formulary
|
2mg/mL, 5mL vial
Paediatrics: no BNFc entry - seek specialist advice
|
|
Eptifibatide
|
Formulary
|
2mg/mL 10mL vial 750micrograms/mL 100mL vial
Paediatrics: no BNFc entry - seek specialist advice
|
|
Tirofiban
|
Formulary
|
Concentrate for intravenous infusion, 250micrograms/mL. For dilution before use, 50mL (12.5mg) vial Intravenous infusion, 50 micrograms/mL, 250mL bag
Paediatrics: no BNFc entry - seek specialist advice
|
|
Aspirin suppositories
|
Unlicensed
|
Unlicensed special paediatrics
|
|
|
|
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
|
Formulary
|
10mg (5.8 million units)/vial 20mg (11.6 million units)/vial 50mg (29 million units)/vial
|
NICE TA264: Ischaemic stroke (acute) - alteplase
|
Streptokinase
|
Formulary
|
1.5 million unit vial
|
|
Tenecteplase
|
Formulary
|
10,000 units (50mg) vial 8,000 units (40mg) vial
Paediatrics: no BNFc entry - seek specialist advice
|
|
Urokinase
|
Formulary
|
10,000 unit vial 25,000 unit vial
|
|
|
02.11 |
Antifibrinolytic drugs and haemostatics |
|
|
Tranexamic acid tablets
|
Formulary
|
500mg
|
|
Tranexamic acid injection
|
Formulary
|
100mg/mL 5mL amp
|
|
Tranexamic acid liquid
|
Unlicensed
|
500mg/ml unlicensed special
|
|
02.11 |
Blood-related products |
|
|
|
NHSE commissioned service- see Specialised Commissioning: Key documents for further information. |
|
02.12 |
Lipid-regulating drugs |
|
|
Alirocumab
|
Formulary
|
75mg/mL; 150mg/mL pre-filled syringe (Praluent®)
for cardiovascular risk reduction in adults with atherosclerotic cardiovascular disease
|
Pan Mersey APC (2019): ALIROCUMAB solution for injection (Praluent®▼) for reduction of cardiovascular risk in adults with established atherosclerotic cardiovascular disease
ALIROCUMAB injection (Praluent®▼) Pan Mersey Area Prescribing Committee policy statement
NICETA 393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
|
Evolocumab
|
Formulary
|
140mg solution for injection in pre-filled pen (Repatha®)
NHSE commissioned drug for treatment of homozymgous familial hypercholesterolaemia only. All other licensed indications are CCG commissioned.
for cardiovascular risk reduction in adults with atherosclerotic cardiovascular disease
|
NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
Pan Mersey APC (2019). EVOLOCUMAB injection (Repatha SureClick®▼) for reduction of cardiovascular risk in adults with established atherosclerotic cardiovascular disease
|
|
|
|
|
|
Atorvastatin tablets
|
First Choice
|
10mg, 20mg, 40mg, 80mg
paediatrics
Atozet® atorvastatin 20mg + ezetimibe 10mg
|
Atozet. Pan Mersey APC (2015). COMBINATION PRODUCTS, ORAL.
|
Pravastatin tablets
|
Formulary
|
10mg, 20mg, 40mg paediatrics
|
|
Simvastatin tablets
|
Formulary
|
10mg, 20mg, 40mg
paediatrics
Inegy® ezetimibe/simvastatin 10mg/20mg, 10mg/40mg, 10mg/80mg
|
Inegy®. Pan Mersey APC (2015). COMBINATION PRODUCTS, ORAL.
|
Simvastatin oral suspension
|
Formulary
|
20mg/5ml, 40mg/5ml paediatrics
|
|
Rosuvastatin tablets
|
Formulary
|
5mg, 10mg, 20mg, 40mg N.B. restricted use ONLY where no other statin is suitable(see link below). paediatrics
|
Pan Mersey APC (2018). ROSUVASTATIN tablets
|
02.12 |
Bile acid sequestrants |
|
|
Colestyramine powder sachets
|
Formulary
|
4g/sachet paediatrics
|
|
Colesevelam tablets
|
Formulary
|
625mg Lipid specialist only Paediatrics: no BNFc entry - seek specialist advice
|
|
|
Ezetimibe
|
Formulary
|
10mg paediatrics Atozet® atorvastatin 20mg + ezetimibe 10mg for prevention of cardiovascular events in patients with CHD and history of ACS where patient choleterol levels are within target range
|
Atozet. Pan Mersey APC (2015). COMBINATION PRODUCTS, ORAL.
EZETIMIBE (Ezetrol®) for the prevention of cardiovascular events; Pan Mersey Area Prescribing Committee Prescribing Policy Statement
NICE TA385: Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia
|
02.12 |
Fibrates |
|
|
Fenofibrate capsules
|
Second Choice
|
67mg, 200mg, 267mg Second choice if statin contraindicated or not tolerated. 67mg can be used in renal impairment but check dose. 200mg and 267mg NOT to be used in renal impairment. paediatrics
|
|
Fenofibrate tablets
|
Second Choice
|
160mg Second choice if statin contraindicated or not tolerated. paediatricsPaediatrics: no BNFc entry - seek specialist advice
|
|
02.12 |
Nicotinic acid group |
|
|
02.12 |
Omega-3 fatty acid compounds |
|
|
Omega-3-Acid Ethyl Esters capsules
|
Formulary
|
Hypertriglyceridaemia
For prevention of pancreatitis, as an additional / alternative option after fibrates and statin therapy where these are insufficiently effective at maximally tolerated doses or where they are contraindicated, where serum triglycerides >10mml/L. 1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
|
|
Omega-3-Acid Ethyl Esters capsules
|
Formulary
|
Primary or secondary prevention of CVD
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
|
|
Omega-3-Acid Ethyl Esters capsules
|
Formulary
|
Multiple sclerosis
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
|
NICE guidelines CG186: Multiple sclerosis
|
Omega-3-Acid Ethyl Esters capsules
|
Formulary
|
Management of patients with primary IgA nephropathy
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
|
|
|
Sodium Tetradecyl Sulphate injection (Fibrovein®)
|
Formulary
|
1% (2mL) 3% (2mL, 5mL)
Paediatrics: no BNFc entry - seek specialist advice
|
|
.... |
Key |
|
|
Cytotoxic Drug
|
|
Controlled Drug
|
|
High Cost Medicine
|
|
Cancer Drugs Fund
|
|
NHS England |
|
Homecare |
|
CCG |
|
Traffic Light Status Information
Status |
Description |

|
Medicines considered suitable for non-specialist prescribing in primary or secondary care. |

|
Requires specialist assessment to enable patient selection. Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care. |

|
Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria:
(1) Requires specialist assessment to enable patient selection
(2) Medicine is suitable for on-going prescribing in Primary Care
(3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable
|

|
Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria:
(1)Requires specialist assessment to enable patient selection
(2)Medicine is suitable for on-going prescribing in Primary Care
(3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable
(4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care
|

|
Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained. |

|
Shared Care.
Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care.
Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber.
A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients.
A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care.
All drugs to be included in this category must meet Shared Care criteria 1 to 3:
SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition.
SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care.
SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year).
Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.
|

|
Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care. |

|
Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. |

|
Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available. |
|
|
|