netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 2: Cardiovascular system - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

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 Details...
02.01  Positive inotropic drugs
02.01.01  Cardiac glycosides
Digoxin tabs, oral solution, injection
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Formulary

When switching from intravenous to oral route may need to increase dose by 20–33% to maintain the same plasma-digoxin concentration

50 micrograms of oral solution is equivalent to 62.5 micrograms of tablets

 
   
02.01.01  Digoxin-specific antibody
Digoxin specific antibody fragments
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Formulary
High Cost Medicine
 
   
02.01.02  Phosphodiesterase type-3 inhibitors
Enoximone injection
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Restricted Drug Restricted RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY 
   
Milrinone injection
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Restricted Drug Restricted RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY 
   
Levosimendan infusion
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Unlicensed Drug Unlicensed

RESTRICTED USE - ICU AND LFU

Adjunctive short-term treatment of acutely decompensated severe chronic heart failure.

Use according to local guideline

 
   
02.02  Diuretics to top
02.02.01  Thiazides and related diuretics
Bendroflumethiazide tabs
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Formulary  
   
Chlortalidone tabs
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Formulary  
   
Indapamide tabs, MR tabs
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Formulary  
   
Metolazone tabs
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Unlicensed Drug Unlicensed

Resistant oedema in renal impairment.

Dose = 2.5mg on alternate days to 10mg daily

 
   
02.02.02  Loop diuretics
Furosemide tabs, oral solution, injection
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Formulary  
   
Bumetanide tabs
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Formulary  
   
Bumetanide injection
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Unlicensed Drug Unlicensed  
   
02.02.03  Potassium-sparing diuretics and aldosterone antagonists
Amiloride tabs
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Formulary  
   
02.02.03  Aldosterone antagonists
Eplerenone tabs
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Formulary

For signs and symptoms of heart failure after recent myocardial infarction as per NICE CG172.

Reserved for patients unable to tolerate spironolactone when used for the treatment of chronic heart failure with left ventricular dysfunction

 
Link  NICE CG172 Myocardial Infarction: cardiac rehabilitation and secondary prevention
   
Spironolactone tabs
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Formulary

Approved off-label indication:

Treatment of hypertension as per NICE CG127

 
Link  NICE CG127: Hypertension in adults: diagnosis and management
   
Potassium canrenoate injection
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Unlicensed Drug Unlicensed

Aldosterone antagonist.

Alternative to oral spironolactone

 
   
Spironolactone oral suspension
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Unlicensed Drug Unlicensed

Oedema and ascites in liver cirrhosis, malignant ascites, nephrotic syndrome, congestive heart failure, primary hyperaldosteronism.

Dose: As for licensed oral doses for tablet formulation

 
   
02.02.04  Potassium-sparing diuretics with other diuretics to top
Co-amilofruse tabs (amiloride with furosemide)
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Formulary  
   
Co-amilozide tabs (amiloride with hydrochlorothiazide)
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Formulary  
   
Co-triamterzide tabs (triamterine with hydrochlorothiazide)
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Formulary  
   
Amiloride with cyclopenthiazide tabs (Navispare®)
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Formulary  
   
02.02.05  Osmotic diuretics
Mannitol intravenous infusion
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Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY 
   
02.02.06  Mercurial diuretics
02.02.07  Carbonic anhydrase inhibitors
02.02.08  Diuretics with potassium
02.03  Anti-arrhythmic drugs to top
02.03.01  Management of arrhythmias
02.03.02  Drugs for arrhythmias
 note 

In all acute tachycardias with a wide QRS complex, it is advisable to seek expert advice unless the precise nature of the arrhythmia is known. The use of the incorrect drug in these circumstances is dangerous.


Adenosine can be helpful diagnostically in this setting because its shorter action makes it relatively safe. Failure of the tachycardia to respond suggests that it is ventricular rather than supraventricular

02.03.02  Supraventricular arrhythmias
Adenosine injection
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Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
   
Dronedarone tabs
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Formulary
Amber 2
 
Link  NICE TA197: Atrial fibrillation - dronedarone
   
02.03.02  Supraventricular and ventricular arrhythmias
Amiodarone tabs, injection
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Formulary
Amber 1
PARENTERAL USE UNDER SPECIALIST SUPERVISION ONLY 
   
Disopyramide caps, injection
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Restricted Drug Restricted
Amber 2
USE UNDER SPECIALIST SUPERVISION ONLY 
   
Flecainide tabs, injection
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Formulary
Amber 2
USE UNDER SPECIALIST SUPERVISION ONLY 
   
Procainamide injection
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Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
   
Propafenone tablets
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Formulary
Amber 2
USE UNDER SPECIALIST SUPERVISION ONLY 
   
02.03.02  Ventricular arrhythmias to top
Lidocaine injection
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Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY 
   
Mexiletine injection and caps (ventricular tachycardia)
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Unlicensed Drug Unlicensed
Red

USE UNDER SPECIALIST SUPERVISION ONLY Treatment of ventricular tachycardia

 
   
Ajmaline injection
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Unlicensed Drug Unlicensed

Diagnostic test for Brugada syndrome

Dose: 1 mg/kg (actual body weight) up to a maximum dose of 100 mg

 
   
Hydroquinidine slow release caps
Unlicensed Drug Unlicensed
Red

CARDIAC ARRHYTHMIA SPECIALIST USE ONLY For prevention of recurrent vetricular fibrillation (VF) in Brugada syndrome and short-coupled idiopathic VF

Dose: 600 mg to 900 mg daily in divided doses

 
   
Mexiletine caps (congenital myotonia)
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Unlicensed Drug Unlicensed
Red

USE UNDER SPECIALIST SUPERVISION ONLY Treatment of congenital myotonia

Dose: initiate at 1.5mg/kg (usually 2-3 divided doses) and increase to 10mg/kg (maximum daily dose of 600mg)

 
   
02.04  Beta-adrenoceptor blocking drugs
Acebutolol tabs
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Formulary  
   
Atenolol tabs, oral solution, injection
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Formulary  
   
Bisoprolol tabs
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Formulary  
   
Carvedilol tabs
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Restricted Drug Restricted
Amber 1
Treatment of NYHA class IV heart failure 
   
Labetalol tabs, injection
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Formulary Injection = Red Traffic Light (hospital only) 
   
Metoprolol tabs, injection
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Formulary

Injection = Red Traffic Light (hospital only)

Also approved for off-label use as an intravenous infusion:

  • ICU only via local Trust protocol
  • Restricted to use where betablockers licensed for infusion are unavailable
 
   
Propranolol tabs, MR caps, oral solution, injection
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Formulary  
   
Esmolol injection
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Restricted Drug Restricted
Red
USE UNDER SPECIALIST SUPERVISION ONLY 
   
Nadolol tabs
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Formulary
Red
CONGENITAL CARDIOLOGY CLINIC USE ONLY Treatment of catecholaminergic polymorphic ventricular tachycardia (CPVT), Long QT syndrome and refractory ventricular arrhythmias  
   
Nebivolol tabs
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Formulary  
   
Sotalol tabs
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Formulary
Amber 1
INITIATION BY SPECIALIST ONLY 
   
Co-tenidone tabs
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Formulary  
   
Oxprenolol tabs
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Formulary  
   
02.05  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
02.05.01  Vasodilator antihypertensive drugs
Bosentan tabs (digital ulcer disease - off-label)
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Restricted Drug Restricted
Red
High Cost Medicine

INITIATION BY SPECIALIST ONLY

Last-line option, to reduce the number of new digital ulcers in patients with systemic sclerosis and ongoing digital ulcer disease, who:

  • Have a history of multiple digital ulcers
  • Have previously failed treatment with iloprost
  • Use in accordance with local guideline
 
   
Bosentan tabs (Fontan circulation - off-label)
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Restricted Drug Restricted
Red

Approved off-label indication:

Patients with a failing Fontan circulation

Restricted use in patients where there is a suggestion of segmental pulmonary arterial hypertension or failing Fontan only after full discussion and approval from the pulmonary hypertension and congenital heart disease MDT.

Dose = Bosentan 62.5 mg to 125 mg twice a day.

 
   
Hydralazine tabs, injection
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Formulary  
   
Minoxidil tabs
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Restricted Drug Restricted
Amber 2
USE ON SPECIALIST ADVICE ONLY 
   
Sildenafil tabs (as 25mg tablets)
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Restricted Drug Restricted

Approved off-label indication:

Raynaud’s secondary to scleroderma in patients that are contraindicated to or have failed other treatment options

  • Use in accordance with local guideline
  • RESTRICTED USE – CONSULTANT SPECIALISTS ONLY
 
   
Sildenafil tabs - generic (Fontan circulation - off-label)
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Restricted Drug Restricted
Red

Approved off-label indication:

Patients with a failing Fontan circulation

Restricted use in patients where there is a suggestion of segmental pulmonary arterial hypertension or failing Fontan only after full discussion and approval from the pulmonary hypertension and congenital heart disease MDT.

Dose = Sildenafil 12.5mg to 100mg three times a day.

Only generic sildenafil tablets should be supplied for this indication.

 
   
Sildenafil tabs - generic (pulmonary hypertension)
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Restricted Drug Restricted
Red

Approved off-label indication:

Initiation of treatment in pulmonary hypertension following discussion with local specialist centre (Royal Free Hospital)

Dose = 25 mg to 100 mg three times a day

 
   
Diazoxide injection
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Formulary
Red
 
   
Iloprost injection
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Unlicensed Drug Unlicensed
Red

RESTRICTED USE - CONSULTANT SPECIALIST ONLY

Treatment of digital ulcer disease

Use in accordance with local guideline

 
   
Iloprost injection  (severe peripheral artery disease)
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Unlicensed Drug Unlicensed
Red

USE UNDER SPECIALIST SUPERVISION ONLY

  • Treatment of severe peripheral arterial occlusive disease, particularly those at risk of amputation and in whom surgery or angioplasty is not possible
  • Treatment of severe Raynaud’s phenomenon unresponsive to other therapies
  • Treatment of advanced thromboangiitis obliterans (Buerger’s disease) with critical limb ischaemia where revascularisation is not indicated

Use in accordance with local guideline

 
   
Sodium nitroprusside injection
Unlicensed Drug Unlicensed
Red

USE ON SPECIALIST ADVICE ONLY

Approved as 2nd line treatment of life-threatening hypertension in intensive care units. First line treatment is labetalol.

 
   
Papaverine injection
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Unlicensed Drug Unlicensed
Red

RESTRICTED USE – CONSULTANT SPECIALISTS ONLY

As an intrathecally administered adjunct treatment during aortic aneurysm repair

Use in accordance with local guideline

 
   
02.05.02  Centrally acting antihypertensive drugs
Clonidine tabs (hypertension)
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Formulary

For use in hypertension

 
   
Clonidine tabs (vasomotor symptoms in menopause)
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Formulary
Amber 2

Treatment of vasomotor symptoms in the menopause where hormonal treatment is ineffective or inappropriate

Dose = up to 75 micrograms twice a day 

 

 
   
Clonidine tabs (sedative in ICU - off-label)
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Formulary
Red

Approved off label indication:

For use as an opioid sparing co-analgesic and sedative agent when opioid and benzodiazepine requirements are increasing without effect. May also be used as a weaning agent

Use in accordance with Critical Care Guideline for Clonidine

 
   
Methyldopa tabs
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Formulary DRUG OF CHOICE IN PREGNANCY 
   
Moxonidine tabs
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Formulary  
   
Clonidine patches (dyskinesia and dystonia in paediatric patients)
Unlicensed Drug Unlicensed
Red

Specialist paediatric neurology prescribing only

Approved for the treatment of paediatric dystonia/ dyskinesia as an alternative to clonidine liquid (unlicensed special) or clonidine tablets in whom transdermal delivery is more appropriate.

300 microgram per 24 hours patches are available routinely, with 200 microgram per 24 hours and 100 microgram per 24 hours possible for order if required for titration to a specific dose.  All formulations are 7 day patches.

Refer to the paediatric formulary entry and APC recommendation for detailed information

 
Link  SE London APC recommendation: Clonidine patches for dystonia/dyskinesia in paediatrics
   
02.05.03  Adrenergic neurone blocking drugs to top
Guanethidine monosulphate injection
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Formulary  
   
02.05.04  Alpha-adrenoceptor blocking drugs
Doxazosin tabs (hypertension)
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Formulary

MR tabs are non-formulary (see below)

 
   
Indoramin tabs
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Formulary  
   
Prazosin tabs
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Formulary  
   
Midodrine tabs (orthostatic hypotension)
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Restricted Drug Restricted
Amber 3

Orthostatic hypotension

Consultant recommendation only

Initiation and first 3 months supplied by the hospital (see documents below for transfer of care requirements)

 
Link  POTS - IST - orthostatic hypotension: Midodrine Transfer of prescribing responsibility (Jan 2018)
Link  POTS - IST - orthostatic hypotension: Notification of Initiation of midodrine (Jan 2018)
Link  SE London APC: POTS - IST- Orthostatic Hypotension: Midodrine prescribing guidance (2018)
   
Midodrine tabs (POTS/IST - off-label)
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Restricted Drug Restricted
Amber 3

Approved off-label indication:

Postural Orthostatic Tachycardia Syndrome (POTS) and Inappropriate Sinus Tachycardia (IST) where fludrocortisone is considered inappropriate or has failed to control symptoms

Initiation and first 3 months supplied by the specialist cardiology clinic at GSTFT or KCH only (see documents below for transfer of care requirements)

 
Link  POTS - IST - orthostatic hypotension: Midodrine Transfer of prescribing responsibility (Jan 2018)
Link  POTS - IST - orthostatic hypotension: Notification of Initiation of midodrine (Jan 2018)
Link  SE London APC Recommendation: Midodrine for POTS or IST
Link  SE London APC: POTS - IST- Orthostatic Hypotension: Midodrine prescribing guidance (2018)
   
02.05.04  Phaeochromocytoma
Phenoxybenzamine caps, injection
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Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY 
   
Phentolamine injection
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Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY 
   
02.05.05  Drugs affecting the renin-angiotensin system
Sacubitril and valsartan tabs
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Restricted Drug Restricted
Amber 3

Heart failure specialist initiation only

Follow SE London APC prescribing guidance and NICE TA388

 
Link  NICE TA388: Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
Link  SE London APC guidance for prescribing sacubitril valsartan for symptomatic chronic heart failure with reduced ejection fraction
Link  SE London APC: Sacubitril valsartan - notification of initiation
Link  SE London APC: Sacubitril valsartan - transfer of care to GP
   
02.05.05.01  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
Captopril tabs
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Formulary  
   
Enalapril tabs
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Formulary  
   
Fosinopril tabs
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Formulary  
   
Lisinopril tabs
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Formulary  
   
Perindopril erbumine tabs
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Formulary

Approved off-label indication:

Secondary prevention of stroke in combination with indapamide

 
   
Ramipril tabs, caps
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Formulary ACE inhibitor of choice at KCH 
   
Trandolapril caps
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Formulary  
   
02.05.05.02  Angiotensin-II receptor antagonists to top
Candesartan tabs
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Formulary  
   
Irbesartan tabs
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Formulary  
   
Losartan tabs
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Formulary First-line ARB for hypertension 
   
Irbesartan and hydrochlorthiazide tabs
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Formulary Treatment of essential hypertension for patients requiring irbesartan and a thiazide diuretic 
   
Valsartan caps, tabs
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Restricted Drug Restricted

RESTRICTED USE

Heart failure (off-label)

 
   
02.05.05.03  Renin inhibitors
Aliskiren tabs
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Restricted Drug Restricted
Amber 2

CONSULTANT SPECIALISTS ONLY

Treatment of resistant hypertension as a last-line option after all other options stated in the British Hypertension Society guideline that are not contraindicated (including alphablockers, beta-blockers, and potassium-sparing diuretics) have failed or are not tolerated

 
   
02.06  Nitrates, calcium-channel blockers, and potassium-channel activators
02.06.01  Nitrates
 note  Long acting nitrates should only be considered as third line options as per NICE CG126: Stable angina: management
Glyceryl trinitrate spray (diagnosis of cluster headache - off-label)
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Formulary
Red

Approved for the diagnosis of chronic cluster headache (within the headache clinic setting ONLY)

Dose = 3 sprays once only

 
   
Glyceryl trinitrate tabs, spray, injection, patches
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Formulary  
   
Isosorbide dinitrate tabs, injection
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Formulary  
   
Isosorbide mononitrate tabs, m/r tabs
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Formulary  
   
02.06.02  Calcium-channel blockers
 note  For the use of calcium-channel blockers in the management of stable angina, please refer to NICE clinical guideline 126. Calciumchannel blockers and beta-blockers should be considered as first line treatment options for stable angina.
Amlodipine tabs
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First Choice First-line dihydropyridine calcium channel blocker 
Nifedipine caps, m/r tabs, m/r caps
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Formulary  
   
Diltiazem tabs, m/r tabs, m/r caps
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Formulary  
   
Verapamil tabs, m/r tabs
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Formulary  
   
Nimodipine tabs, injection
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Formulary  
   
Felodipine m/r tabs
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Formulary Second line dihydropyridine calcium channel blocker at LGT (after amlodipine) 
   
Lacidipine tabs
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Formulary  
   
Nicardipine injection
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Restricted Drug Restricted
Red
  • Second line option for severe hypertension (after labetalol) in critical care settings only 
  •    
    Nicardipine tabs
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    Formulary  
       
    Flunarizine caps, tabs
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    Unlicensed Drug Unlicensed

    Approved for:

    • Intermittent claudication
    • Raynaud’s syndrome
    • Prophylaxis of migraine
    • Vertigo

    Protocol for prophyaxis of migraine:

    • Starting dose of 10 mg at night (5mg for patients ≥65 years). Treatment should be discontinued if no significant improvement observed after 2 months.
    • Maintenance treatment should continue at the same daily dose but interrupted by two successive drug-free days every week, e.g. Saturday and Sunday.
    • All patients should have treatment stopped after 6 months and it should only be re-initiated if the patient relapses.
     
       
    02.06.03  Other anitanginal drugs to top
     note  These drugs (and long-acting nitrates) should only be considered if  beta-blockers, calcium-channel blockers or a combination of both do not satisfactorily control symptoms or if first line options are contraindicated or not tolerated. Please refer to NICE clinical guideline 126
    Ivabradine tabs (off-label use for POTS and IST)
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    Restricted Drug Restricted
    Amber 3

    Approved off-label indication:

    Postural Orthostatic Tachycardia Syndrome (POTS) and Inappropriate Sinus Tachycardia (IST) where a beta-blocker has failed or is inappropriate

    Initiation and first 3 months supplied by the specialist cardiology clinic at GSTFT or KCH only (see documents below for transfer of care requirements)

     
    Link  POTS - IST: Ivabradine Transfer of prescribing responsibility (2018)
    Link  POTS - IST: Notification of Initiation of ivabradine (Jan 2018)
    Link  SE London APC Recommendation: Ivabradine for POTS or IST
    Link  SE London APC: Ivabradine prescribing guidance for treatment of POTS or IST (2018)
       
    Ivabradine tabs
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    Restricted Drug Restricted
    Amber 2

    INITIATION BY CONSULTANT CARDIOLOGISTS ONLY

    Use as per NICE TA267 and SE London APC guidance for treating chronic heart failure. Use as per NICE CG126 and SE London APC guidance for treating chronic stable angina (links below). 

     
    Link  MHRA Advice for the use of ivabradine in symptomatic angina
    Link  NICE TA267: Ivabradine for treating chronic heart failure
    Link  SE London APC Guidance: Ivabradine for chronic heart failure due to left ventricular dysfunction
    Link  SE London APC Guidance: Ivabradine for ongoing symptoms in patients with chronic stable angina
       
    Ivabradine tabs (off-label use for ECMO ICU patients only)
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    Restricted Drug Restricted
    Red

    SHORT TERM USE IN ICU ONLY Approved off label indication:

    For management of sinus tachycardia in patients undergoing extracorporeal membrane oxygenation (ECMO) and where a beta-blocker is not appropriate.

     
       
    Nicorandil tabs
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    Formulary  
       
    Ranolazine m/r tabs
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    Formulary
    Amber 2
    INITIATION BY CONSULTANT CARDIOLOGISTS ONLY For ongoing symptoms in chronic stable angina despite the use of first-line therapies such as beta-blockers or calcium channel blockers Ranolazine may be particularly useful where the use of other antianginal therapies is limited by bradycardia (heart rate <50 beats per minute) or hypotension (systolic blood pressure <90mmHg), as it has little effect on heart rate or blood pressure. It may also be useful where first-line anti-anginal therapies are contraindicated or not tolerated 
       
    02.06.04  Peripheral vasodilators and related drugs
    Naftidrofuryl caps
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    Formulary  
    Link  NICE TA223: Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease
       
    Pentoxifylline tabs
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    Formulary  
       
    Pentoxifylline tabs (osteonecrosis of the jaw - off-label)
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    Formulary
    Red

    Approved off-label indication:

    Prevention of osteonecrosis of the jaw. Used in combination with vitamin E capsules

     
       
    Pentoxifylline liquid (osteonecrosis of the jaw (unlicensed product))
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    Unlicensed Drug Unlicensed
    Red

    Prevention of osteonecrosis of the jaw. Used in combination with vitamin E capsules

    Restricted to use in patients who cannot take tablets due to swallowing difficulties

     
       
    02.06.04  Other preparations used in peripheral vascular disease
    Oxerutins caps
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    Formulary  
       
    02.07  Sympathomimetics
    02.07.01  Inotropic sympathomimetics
    Dobutamine injection
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    Formulary RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY 
       
    Dopamine injection
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    Formulary RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY 
       
    Dopexamine injection
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    Formulary RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY 
       
    Isoprenaline injection
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    Unlicensed Drug Unlicensed

    Short-term emergency treatment of heart block or severe bradycardia.

    Dose: 0.5 – 10 micrograms/minute

     
       
    02.07.02  Vasoconstrictor sympathomimetics to top
    Ephedrine injection
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    Formulary  
       
    Metaraminol injection
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    Formulary

    Acute hypotension.

    In emergency: 0.5-5 mg by intravenous injection, then 15-100mg by intravenous infusion, adjusted according to response.

     
       
    Noradrenaline / Norepinephrine injection
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    Formulary  
       
    Phenylephrine injection
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    Formulary  
       
    02.07.03  Cardiopulmonary resuscitation
    Adrenaline / Epinephrine injection
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    Formulary  
       
    02.08  Anticoagulants and protamine
    02.08.01  Parenteral anticoagulants
    Argatroban injection
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    Formulary

    For use under the supervision of a Consultant Haematologist

    For anticoagulation in patients with HIT type 2 undergoing cardiac surgery or have renal failure in a HDU/ITU setting who are not suitable for treatment with fondaparinux

     
       
    Defibrotide infusion
    Unlicensed Drug Unlicensed
    Red
    High Cost Medicine
    BlueTeq

    USE UNDER SPECIALIST SUPERVISION ONLY Treatment of patients with severe veno-occlusive disease following stem cell transplant in line with NHS England Clinical Commissioning Policy B04/P/c

     
    Link  NHS England Clinical Commissioning Policy B04/P/c: Defibrotide in severe venoocclusive disease following stem cell transplant
       
    02.08.01  Heparin
    Heparin injection
    View adult BNF View SPC online
    Formulary  
       
    02.08.01  Low molecular weight heparins to top
    Enoxaparin injection
    View adult BNF View SPC online
    Formulary
    Amber 2
     
    Link  South East London Guidance for Prescribing Enoxaparin in primary care
       
    Dalteparin injection
    View adult BNF View SPC online
    Formulary
    Red
    First-line LMWH at GSTFT 
       
    02.08.01  Hirudins
    Bivalirudin injection
    View adult BNF View SPC online
    Formulary
    Red
     
    Link  NICE CG94: Unstable angina and NSTEMI
    Link  NICE TA230 : Bivalirudin for the treatment of STEMI, 2011
       
    02.08.01  Epoprostenol
    Epoprostenol injection
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    USE ON SPECIALIST ADVICE ONLY 
       
    02.08.01  Fondaparinux
    Fondaparinux injection
    View adult BNF View SPC online
    Formulary
    Red

    Use in accordance with NICE CG92: Venousthromboembolism: reducing the risk

     

    Approved off-label indication:

    First-line parenteral anticoagulant in adult patients with HIT and patients with an allergy to heparin

    Use in accordance with local guideline

     
       
    02.08.02  Oral anticoagulants
    Acenocoumarol tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Apixaban tabs
    View adult BNF View SPC online
    Formulary

    Amber Traffic Light For treatment and secondary prevention of DVT and PE, and thromboprophylaxis in AF.

    See links at the end of the section for initiation of treatment and transfer of care documents

    Red Traffic Light (hospital only) For prevention of VTE after hip or knee replacement surgery 

     
    Link  SE London APC prescribing guidance - Apixaban for AF
    Link  SE London APC prescribing guidance - Apixaban for VTE
    Link  NICE TA245: Venous thromboembolism - apixaban (hip and knee surgery
    Link  NICE TA275: Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) - apixaban
    Link  NICE TA341: Apixaban for treatment and secondary prevention of DVT and/or PE
    Link  Apixaban for non-valvular AF - manufacturers patient information booklets (several languages)
    Link  Apixaban for venous thromboembolism - manufaturers patient information booklets (several languages)
       
    Dabigatran caps
    View adult BNF View SPC online
    Formulary

    Amber Traffic Light For treatment and secondary prevention of DVT and PE, and thromboprophylaxis in AF

    See links at the end of the section for initiation of treatment and transfer of care documents

     

    Red Traffic Light (hospital only) For prevention of VTE after hip or knee replacement surgery 

     
    Link  SE London APC prescribing guidance: Dabigatran for AF
    Link  SE London APC prescribing guidance: Dabigatran for VTE
    Link  NICE TA157: Venous thromboembolism - dabigatran
    Link  NICE TA249: Dabigatran for Stroke prevention in AF
    Link  NICE TA327: Dabigatran for treatment and secondary prevention of DVT and/or PE
       
    Edoxaban tabs
    View adult BNF View SPC online
    Formulary
    Amber 3
    See links at the end of the section for initiation of treatment and transfer of care documents 
    Link  SE London APC prescribing guidance: Edoxaban for AF
    Link  SE London APC prescribing guidance: Edoxaban for VTE
    Link  NICE TA354: Edoxaban for treating and for preventing DVT and/or PE
    Link  NICE TA355: Edoxaban for thromboprohylaxis in non-valvular AF
    Link  Edoxaban - manufacturer’s patient support materials (several languages)
       
    Phenindione tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Rivaroxaban tabs (licensed uses)
    View adult BNF View SPC online
    Formulary

    Amber Traffic Light For treatment and secondary prevention of DVT and PE, thromboprophylaxis in AF, and preventing adverse outcomes after acute management of ACS.

    See links at the end of the section and below for initiation of treatment and transfer of care documents

     

    Red Traffic Light (hospital only) For prevention of VTE after elective hip or knee replacement surgery

     
    Link  Rivaroxaban for ACS: Notification of initiation to GP
    Link  Rivaroxaban in ACS: Transfer of care to GP
    Link  SE London prescribing guidance: Rivaroxaban for ACS
    Link  SE London prescribing guidance: Rivaroxaban for AF
    Link  SE London prescribing guidance: Rivaroxaban for VTE
    Link  NICE TA256: Rivaroxaban for thromboprophylaxis in AF
    Link  NICE TA261: Rivaroxaban for the treatment of DVT and prevention of recurrent DVT and/or PE
    Link  NICE TA287: Rivaroxaban for treating PE and preventing recurrent VTE
    Link  NICE TA335: Rivaroxaban for preventing adverse outcomes after acute management of ACS
    Link  Rivaroxaban - manufacturer’s patient brochures (several languages)
       
    Warfarin tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Rivaroxaban tabs (orthopaedic off label use)
    View adult BNF View SPC online
    Formulary
    Red
    Approved off-label indication:
  • Thromboprophylaxis post pelvic ring/acetabular fracture as an alternative to Low Molecular Weight Heparin Full course of up to 90 days to be prescribed and provided by the hospital. Dose as per thromboprophylaxis post elective orthopaedic surgery (10mg daily)  
  • Link  SE London APC Recommendation: Rivaroxaban for thromboprophylaxis post pelvic ring fracture
       
    02.08.03  Protamine sulphate to top
    Protamine sulphate injection
    View adult BNF View SPC online
    Formulary  
       
    02.09  Antiplatelet drugs
    Abciximab injection
    View adult BNF View SPC online
    Formulary
    Red
    USE UNDER SPECIALIST SUPERVISION ONLY Use as per NICE CG94: ACS and NSTEMI (see link below at end of section) 
       
    Aspirin (antiplatelet) tabs
    View adult BNF View SPC online
    Formulary  
       
    Cangrelor injection
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved for use (in combination with aspirin suppositories) for the reduction of thrombotic cardiovascular events in patients with coronary artery disease undergoing PCI.

    Restricted to unconscious patients in whom oral therapy with P2Y12 inhibitors (e.g. clopidogrel) is not feasible.

     

     
       
    Clopidogrel tabs
    View adult BNF View SPC online
    Formulary Use as per NICE CG94: ACS and NSTEMI (see link below at end of section) Use as per NICE TA210: Prevention of occlusive vascular events (see link below at end of section) 
       
    Dipyridamole tabs, m/r caps, oral suspension
    View adult BNF View SPC online
    Formulary Use as per NICE TA210: Prevention of occlusive vascular events (see link below at end of section) 
       
    Eptifibatide injection
    View adult BNF View SPC online
    Formulary
    Red
    USE UNDER SPECIALIST SUPERVISION ONLY Use as per NICE CG94: ACS and NSTEMI (see link below at end of section) 
       
    Prasugrel tabs
    View adult BNF View SPC online
    Formulary  
    Link  NICE TA317: Prasugrel with PCI for ACS (review of TA182)
       
    Ticagrelor tabs, orodispersible tabs
    View adult BNF View SPC online
    Formulary
    Amber 1

    Orodispersible tabs reserved for patients with swallowing difficulties or on enteral feeding

     
    Link  NICE TA236: Acute coronary syndromes - ticagrelor
    Link  NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
       
    Tirofiban injection
    View adult BNF View SPC online
    Formulary
    Red

    USE UNDER SPECIALIST SUPERVISION ONLY

    Use as per NICE CG94: ACS and NSTEMI (see link below at end of section) Use for reduction of cardiovascular events in patients with STEMI intended for primary PCI

     

    Refer to local guidelines for use

     
       
    Aspirin suppositories
    (Unlicensed product)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed Where treatment is imperative and oral treatment is not possible 
       
    Ticlopidine tabs
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed Intolerance to aspirin or clopidogrel. Dose: 250 mg bd 
       
    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
    Urokinase injection
    View adult BNF View SPC online
    Formulary
    Red

    Occluded intravenous catheters and cannulas blocked by fibrin clots

    Follow local guidance for dosage and administration

     
       
    Alteplase 2 mg injection (Actilyse Cathflo®)
    View adult BNF View SPC online
    Formulary
    Red

    Approved for use in for malfunctioning tunnelled Central Venous Haemodialysis Catheters (CVHC)

    Follow local guideline for use at GSTT amd KCH

     
       
    Alteplase injection (catheter directed thrombolysis in DVT - off-label)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Catheter directed thrombolysis in acute subclavian and/or iliofemoral deep vein thrombosis (DVT)

    Follow the "Acute Deep Vein Thrombosis Catheter Directed Thrombolysis Protocol" on GTi for dosing and administration

     
       
    Alteplase injection (catheter directed thrombolysis in pulmonary embolism - off-label)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label use:

    Catheter directed thrombolysis in intermediate or high risk pulmonary embolism

    • Restricted to use where systemic thrombolysis is less appropriate according to patient bleeding and thrombosis risk factors
    • Pulmonary Embolism Team recommendation only

    Refer to local guidelines for use

     
       
    Alteplase injection (licensed use in massive PE and stroke)
    View adult BNF View SPC online
    Formulary
    Red

    USE UNDER SPECIALIST SUPERVISION ONLY

    For use in ischaemic stroke as per NICE TA264 Acute massive pulmonary embolism: Refer to local guidelines

     
    Link  NICE TA264: Ischaemic stroke (acute) - alteplase
       
    Alteplase injection (off-label systemic use in pulmonary embolism)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Intermediate risk pulmonary embolism

    • Dose for patients ≥ 50kg = 50 mg (10 mg in 1 minute followed by 40 mg over 2 hours)
    • Dose for patients < 50 kg = 0.5 mg/kg (10 mg in 1 minute followed by remainder over 2 hours)

    Follow local guidelines for use

     
       
    Alteplase injection (Off-label use in intrapleural fibrinolysis)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    • Intrapleural fibrinolysis for complex pleural infection (together with dornase alpha)
    • UNDER SPECIALIST SUPERVISION ONLY
    • Follow local guidelines at GSTT
    • Regimen: Alteplase 10mg in 50ml sodium chloride 0.9% administered intrapleurally Dornase 5mg in sodium chloride 0.9% administered intrapleurally separately
    • Dose: Every 12 hours for a maximum of 3 days
     
       
    Dornase alpha nebuliser liquid (Off-label use in intrapleural fibrinolysis)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    • Intrapleural fibrinolysis for complex pleural infection (together with alteplase)

    UNDER SPECIALIST SUPERVISION ONLY Follow local guidelines at GSTT

    Regimen: Dornase 5mg in 50ml sodium chloride 0.9% administered intrapleurally

    Alteplase 10mg in sodium chloride 0.9% administered intrapleurally separately

    Dose: Every 12 hours for a maximum of 3 days

     
       
    Streptokinase injection
    View adult BNF View SPC online
    Formulary
    Red
     
       
    Streptokinase injection
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Treatment of airway thrombus in patients receiving ECMO

    CONSULTANT ICU SPECIALIST ONLY

     
       
    Tenecteplase injection
    View adult BNF View SPC online
    Formulary
    Red
     
       
    Urokinase injection
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Intrapleural use for treatment of loculated malignant pleural effusions.

    Dose: 100,000 units every 12 hours for 3 doses only

    CONSULTANT RESPIRATORY PHYSICIAN PRESCRIBING AND ADMINISTRATION ONLY

     
       
    02.11  Antifibrinolytic drugs and haemostatics to top
    Tranexamic acid tabs, injection
    View adult BNF View SPC online
    Formulary  
       
    Adrenaline solution 1mg/ml (1 in 1000)
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Capillary bleeding. Apply gauze soaked in adrenaline solution to the affected area.

     
       
    Etamsylate tabs
    View adult BNF View SPC online
    Formulary  
       
    Tranexamic acid injection
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    For use in accordance with the ECMO guideline for adults in critical care.

    For continuous administration by infusion.

     
       
    Tranexamic acid mouthwash 5%
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed Prescribing restricted to Haematology or ENT advice only 
       
    02.11  Blood-related products
    Aprotinin injection
    Restricted Drug Restricted
    Red
    USE UNDER CONSULTANT SPECIALIST CARDIAC ANAESTHETIST SUPERVISION ONLY

    Refer to advice from CHM 
       
    02.12  Lipid-regulating drugs
    Alirocumab injection
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Specialist initiation only

    Restricted to use as per stipulations in NICE guidance (see below)

     
    Link  NICE TA393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    Evolocumab injection
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Specialist initiation only

    Restricted to use as per stipulations in NICE guidance (see below)

     
    Link  NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    02.12  Bile acid sequestrants
    Colesevelam tabs (hypercholesterolaemia)
    View adult BNF View SPC online
    Restricted Drug Restricted

    CONSULTANT LIPIDOLOGISTS ONLY

    • Fifth-line monotherapy after statins, fibrates, niacin and ezetimibe for patients intolerant of other lipid-lowering drugs
    • Add-on therapy for patients on multiple lipid lowering drugs not achieving LDL-C and total cholesterol serum targets currently defined by the National Service Framework for Cornonary Heart Disease
     
       
    Colestyramine sachets (hypercholesterolaemia)
    View adult BNF View SPC online
    Formulary

     
       
    02.12  Ezetimibe
    Ezetimibe tabs
    View adult BNF View SPC online
    Formulary  
    Link  NICE TA385:Ezetimibe for primary heterozygous-familial and non-familial hypercholesterolaemia
       
    02.12  Fibrates to top
    Bezafibrate tabs, m/r tabs
    View adult BNF View SPC online
    Formulary  
       
    Fenofibrate tabs
    View adult BNF View SPC online
    Formulary  
       
    Ciprofibrate tabs
    View adult BNF View SPC online
    Formulary  
       
    Gemifibrozil tabs
    View adult BNF View SPC online
    Formulary  
       
    02.12  Statins
    Atorvastatin tabs
    View adult BNF View SPC online
    First Choice  
    Pravastatin tabs
    View adult BNF View SPC online
    Formulary  
       
    Rosuvastatin tabs
    View adult BNF View SPC online
    Restricted Drug Restricted Initiation on the recommendation of a Consultant in the Lipid Clinic, Diabetes Unit, HIV Unit or Cardiology only Restricted to use for:
  • Familial hyperlipidaemia (FH), where other statins have failed to achieve a >50% fall in LDL cholesterol. These patients should be under the care of a lipid clinic
  • Second line for patients requiring ‘high intensity statin’ post ACS, with contraindications or drug interactions that prevent the use of high doses of atorvastatin
  • Third line for patients with CVD or diabetes requiring substantial falls in cholesterol to achieve the minimum QoF audit standard (total cholesterol <5mmol/L and LDL <3mmol/L) with previous failure to tolerate up titrated doses of / or max doses of atorvatatin, and where pravastatin is unlikely to deliver the lipid lowering potency required to reach these target levels 
  •    
    Simvastatin tabs
    View adult BNF View SPC online
    Formulary  
       
    02.12  Nicotinic acid group
    Nicotinic acid tabs, m/r tabs caps
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Amber 2

    INITIATION BY CONSULTANT SPECIALISTS ONLY

    Note: currently there are no licensed preparations available in the UK

     
       
    02.12  Omega-3 fatty acid compounds
    Omega-3-Acid Ethyl Esters capsules
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 2

    New patients should only be initiated omega-3 fatty acids by a lipid specialists. The place of omega 3 fatty acids supplements in hypertriglyceridemia is clearly defined in the SE London APC guidance: Management of hypertriglyceridaemia

     

     
       
    Omega-3-Marine Triglycerides capsules
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 1
    Adjunctive therapy in the reduction of plasma triglycerides in patients with hypertriglyceri-daemia at risk of ischaemic heart disease or pancreatitis 
       
    02.12  PCSK9 inhibitors
    02.12  Other lipid modifying agents to top
    02.13  Local sclerosants
    Ethanolamine oleate injection
    View adult BNF View SPC online
    Formulary  
       
    Sodium tetradecyl sulphate injection
    Formulary  
       
     ....
     Non Formulary Items
    Cilostazol tabs

    View adult BNF View SPC online
    Non Formulary
    Grey

    Not approved for use in SE London

    See NICE TA223

     
    Doxazosin m/r tabs

    View adult BNF View SPC online
    Non Formulary
    Grey

    Not for prescribing in SE London

    Link  SE London APC: Patient Information Leaflet: Changes to prescribing of prolonged release doxazosin
    Link  SE London APC: Doxazosin review - prescribing fact sheet
     
    Inositol Nicotinate

    View adult BNF View SPC online
    Non Formulary

    Not approved for use in SE London

    See NICE TA223

     
    Omega-3-Acid Ethyl Esters capsules

    View adult BNF View SPC online
    Non Formulary
    Grey

    NHS England considers omega-3 fatty acid supplements as an item which should not be routinely prescribed in primary care and will monitor the prescribing of omega-3 fatty acid supplements. Refer to the prescribing factsheet for more information (link below)

    Link  Omega-3 fatty acid and other fish oil supplements review – prescribing fact sheet
     
    Perindopril arginine tabs

    View adult BNF View SPC online
    Non Formulary
    Grey

    Not for prescribing in SE London

    Link  SE London APC Patient Information Leaflet: Changes to perindopril arginine prescribing
     
      
    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 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

    Red

    Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

    Amber 1

    Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

    Amber 2

    Specialist initiation followed by maintenance prescribing in primary care  

    Amber 3

    Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

    Green

    Specialist and non-specialist initiation  

    Grey

    Not recommended for prescribing  

    netFormulary