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

50mg tablets scored
(12.5–25mg once daily, recommended by NICE)

2.5mg, 5mg 
 

2.5mg, 5mg
For oedema

250mg in 5ml suspension

Unlicensed special Paediatrics only

2.5mg, 5mg

Unlicensed special

 Wirral

1mg, 5mg
 

1mg/5ml
 

20mg, 40mg
 

20mg/5mL, 40mg/5mL, 50mg/5mL
(50mg/5ml is standard strength used at Alder Hey)

500mg

5mg

5mg/5ml

25mg, 50mg, 100mg 

5mg/5ml, 10mg/5ml, 25mg/5ml,50mg/5ml, 100mg/5ml
(50mg/5ml is standard strength used at Alder Hey)

25mg, 50mg

Paediatrics: no BNFc entry - seek specialist advice

100mg

Paediatrics: no BNFc entry - seek specialist advice

150mg, 300mg

Paediatrics: no BNFc entry - seek specialist advice

1% (2mL, 5mL, 10mL, 20mL)

25mg, 50mg, 100mg 

Tenormin® syrup 25mg/5ml

1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg

May be prescribed in paediatrics under specialist advice. Dosage information from specialist centre. 

 paediatrics

3.125mg, 6.25mg, 12.5mg, 25mg

Liquid 1mg/ml Extemp. preparation Alder Hey for paediatric use.

100mg, 200mg 

50mg, 100mg 

2.5mg, 5mg

10mg, 40mg, 80mg, 160mg 

80mg licensed (40mg import- unlicensed in the UK)

80mg, 160mg 

5mg/5ml, 10mg/5ml, 40mg/5ml, 50mg/5ml
(50mg/5ml standard strength used at Alder Hey)

40mg, 80mg, 160mg

25mg, 50mg

 paediatrics

2.5mg, 5mg, 10mg

For renal use only.

Paediatrics: no BNFc entry - seek specialist advice

Injection 10mg/mL

125mg, 250mg, 500mg

25micrograms,100micrograms scored

200micrograms, 300micrograms, 400micrograms

Paediatrics: no BNFc entry - seek specialist advice

1mg, 2mg, 4mg 

1mg, 2mg, 5mg

Restricted to nephrology patients.

500micrograms/5ml unlicensed special

10mg

For phaeochromcytoma only

  for heart failure with reduced ejection fraction.

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.

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.

2.5mg, 5mg, 10mg, 20mg

No longer routinely recommended in new adult patients. Patients currently stable may remain on treatment.

2.5mg, 5mg, 10mg, 20mg 

2mg, 4mg, 8mg 
 

1.25mg, 2.5mg, 5mg, 10mg 

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.

Unlicensed special various strengths available from special–order manufacturers.
5mg/5ml is standard strength used at Alder Hey.

2mg, 4mg, 8mg, 16mg, 32mg 

75mg, 150mg, 300mg 
 
 paediatrics

12.5mg, 25mg, 50mg, 100mg 

12.5mg/5ml when reconstituted 

40mg, 80mg, 160mg, 320mg

5mg/24 hours, 10mg/24 hours

5mg, 10mg

1mg/ml and 2mg/ml

60mg 
 
 paediatrics only for Raynaud’s syndrome

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

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.

5mg, 10mg 

120mg, 180mg, 240mg

40mg, 80mg 

40mg/5ml
Not used at Alder Hey

Unlicensed special oral drops 20mg/ml

Tablets 5 mg, 7.5 mg

 Angina

 Heart failure

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

Concentrate for infusion 100micrograms/ml

Paediatrics: only for Raynaud’s syndrome.

Injection 100mg/mL

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

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

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

Flush 10units/mL, 100units/mL

2.5mg/0.5mL prefilled syringe


Paediatrics: no BNFc entry - seek specialist advice

1mg

Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.

10mg, 25mg, 50mg

Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.

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

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

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

Paediatrics Only warfarin is used in paediatrics. Seek specialist advice.

Drug Safety UpdateRivaroxaban (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

75mg
 
 paediatrics

75mg
 
 
 paediatrics

50mg/5ml, 200mg/5ml

25mg, 100mg

For paediatrics

5mg, 10mg

Paediatrics: no BNFc entry - seek specialist advice

Tablets 90mg, 60mg

Unlicensed special 

75mg/mL; 150mg/mL pre-filled syringe (Praluent^®)

 for cardiovascular risk reduction in adults with atherosclerotic cardiovascular disease

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

10mg, 20mg, 40mg

10mg, 20mg, 40mg

 paediatrics

Inegy^® ezetimibe/simvastatin 10mg/20mg, 10mg/40mg, 10mg/80mg

20mg/5ml, 40mg/5ml

5mg, 10mg, 20mg, 40mg

N.B. restricted use ONLY where no other statin is suitable(see link below). 

4g/sachet

625mg

Lipid specialist only

Paediatrics: no BNFc entry - seek specialist advice

10mg 
 
 paediatrics

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.

160mg

Second choice if statin contraindicated or not tolerated.

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