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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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: Currently under review.

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 View childrens BNF) 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.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
02.08.02  Expand sub section  Oral anticoagulants
 note 

Oral anticoagulants

Paediatric use: in paediatrics only warfarin is used as an anticoagulant.

Warfarin
View adult BNF View SPC online View childrens BNF
Formulary
Tablets Green 500 micrograms, 1 mg, 3 mg, 5 mg

Amber Initiated Treatment and secondary prevention of DVT/PE. Includes initiation by specialist warfarin service.

Amber Initiated Paediatrics.

Oral suspension Green 5 mg per 5 ml

Amber Initiated paediatrics

Specialist centre usually tries to get patients onto 1 mg tablets before discharge.

 
   
Acenocoumarol tablets
View adult BNF View SPC online
Formulary
Green

1mg

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

 
   
Phenindione tablets
View adult BNF View SPC online
Formulary
Green

10mg, 25mg, 50mg

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

 
   
Apixaban
View adult BNF View SPC online
Formulary

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


Prevention of stroke and systemic embolism in atrial fibrillation

Green 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.

LinkPan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
LinkNICE (2013). Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation


Treatment and prevention of PE and DVT

Amber Initiated 2.5 mg, 5 mg tablets
Note: 2.5 mg, 5 mg tablets are Green in Wirral for this indication.

Green 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.

 
LinkNICE (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

Red 2.5 mg, 5 mg tablets

LinkApixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults

 
   
Dabigatran
View adult BNF View SPC online
Formulary

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


Prevention of stroke and systemic embolism in atrial fibrillation

Green 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.

LinkPan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
LinkNICE (2012). Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation


Treatment and prevention of PE and DVT

Amber Initiated 75 mg, 110 mg, 150 mg capsules
Note: 75 mg, 110 mg, 150 mg capsules are Green in Wirral for this indication.

Green 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.


LinkNICE (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

Red 75 mg, 110 mg, 150 mg capsules

LinkNICE (2008). Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults

 
   
Edoxaban
View adult BNF View SPC online View childrens BNF
Formulary

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


Prevention of stroke and systemic embolism in atrial fibrillation

Green 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.

LinkPan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
LinkNICE (2015). Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation


Treatment and prevention of PE and DVT

Amber Initiated 15 mg, 30 mg, 60 mg tablets
Note: 15 mg, 30 mg, 60 mg tablets are Green in Wirral for this indication.

Green 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.


LinkEdoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism

 
   
Rivaroxaban
View adult BNF View SPC online
Formulary

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

Drug Safety UpdateLinkRivaroxaban (Xarelto▼): reminder that 15 mg and 20 mg tablets should be taken with food


Prevention of stroke and systemic embolism in atrial fibrillation

Green 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.

LinkPan Mersey APC (2018) Direct Oral Anticoagulants (DOACs) in Non-Valvular Atrial Fibrillation
LinkNICE (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.

Green 2.5 mg tablets

LinkPan Mersey APC (2019) RIVAROXABAN 2.5mg tablets (Xarelto®▼) for the prevention of atherothrombotic events
LinkNICE (2019). Rivaroxaban for preventing atherothrombotic events in people with coronary or peripheral artery disease


Treatment and prevention of PE and DVT

Amber Initiated 10 mg, 15 mg, 20 mg tablets
Note: 10 mg, 15 mg, 20 mg tablets are Green in Wirral for this indication.

Green 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.


LinkNICE (2012). Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
LinkNICE (2013). Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism


Acute coronary syndrome (ACS)

Amber Initiated 2.5mg tablets

LinkPan Mersey APC (2017) RIVAROXABAN tablets (Xarelto®▼) in Acute Coronary Syndrome 
LinkNICE (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

Red 10 mg, 15 mg, 20 mg tablets

LinkNICE (2009). Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults

 

 
   
Idarucizumab
View adult BNF View SPC online
Formulary
Red
Praxbind® 2.5g/50mL solution for injection/infusion 
   
 ....
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

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

Amber Recommended

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

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 Retained

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   

Amber

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.  

Purple

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.   

Red

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

Black

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

Grey

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.  

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