| 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... |
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Lipid-regulating drugs |
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Alirocumab
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Formulary
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75mg/mL; 150mg/mL pre-filled syringe (Praluent®)
 for cardiovascular risk reduction in adults with atherosclerotic cardiovascular disease
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 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
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Evolocumab
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Formulary
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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
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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
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Statins |
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Atorvastatin tablets
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First Choice
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10mg, 20mg, 40mg, 80mg
 paediatrics
 Atozet® atorvastatin 20mg + ezetimibe 10mg
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Atozet. Pan Mersey APC (2015). COMBINATION PRODUCTS, ORAL.
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Pravastatin tablets
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Formulary
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10mg, 20mg, 40mg paediatrics
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Simvastatin tablets
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Formulary
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10mg, 20mg, 40mg
paediatrics
Inegy® ezetimibe/simvastatin 10mg/20mg, 10mg/40mg, 10mg/80mg
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Inegy®. Pan Mersey APC (2015). COMBINATION PRODUCTS, ORAL.
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Simvastatin oral suspension
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Formulary
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20mg/5ml, 40mg/5ml paediatrics
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Rosuvastatin tablets
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Formulary
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5mg, 10mg, 20mg, 40mg
N.B. restricted use ONLY where no other statin is suitable(see link below). paediatrics
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Pan Mersey APC (2018). ROSUVASTATIN tablets
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Bile acid sequestrants |
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Colestyramine powder sachets
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Formulary
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4g/sachet paediatrics
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Colesevelam tablets
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Formulary
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625mg
Lipid specialist only
Paediatrics: no BNFc entry - seek specialist advice
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Ezetimibe |
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Ezetimibe
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Formulary
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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
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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
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Fibrates |
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Fenofibrate capsules
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Second Choice
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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
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Fenofibrate tablets
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Second Choice
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160mg
Second choice if statin contraindicated or not tolerated. paediatricsPaediatrics: no BNFc entry - seek specialist advice
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Nicotinic acid group |
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Omega-3 fatty acid compounds |
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Omega-3-Acid Ethyl Esters capsules
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Formulary
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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
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Omega-3-Acid Ethyl Esters capsules
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Formulary
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Primary or secondary prevention of CVD
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
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Omega-3-Acid Ethyl Esters capsules
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Formulary
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Multiple sclerosis
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
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NICE guidelines CG186: Multiple sclerosis
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Omega-3-Acid Ethyl Esters capsules
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Formulary
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Management of patients with primary IgA nephropathy
1g of omega-3-acid ethyl esters 90 containing eicosapentaenoic acid 460mg and docosahexaenoic acid 380mg
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
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Description |
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Medicines considered suitable for non-specialist prescribing in primary or secondary care. |
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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. |
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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
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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
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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. |
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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.
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Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care. |
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Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. |
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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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