| Formulary Chapter 2: Cardiovascular system - Full Chapter
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| Chapter Links... |
 LSCMMG: Atrial Fibrillation Pathway for the prevention of stroke and systemic embolism in AF in the absence of valvular heart disease |
| NICE NG196: Atrial fibrillation: diagnosis and management |
| NICE NG106: Chronic heart failure in adults: diagnosis and management |
| NICE NG187: Acute heart failure: diagnosis and management |
| Enoxaparin for Treatment of Venous Thromboembolism **FOR USE IN THE BLACKPOOL REGION ONLY** |
| LSC Hypertension in Adults: Diagnosis and Management |
| LSC Patient Pathway for Commencing Inclisiran |
| LSC Statin Intolerance Pathway |
| LSCMMG: Lipid Management Pathway for Primary Prevention of Cardiovascular Disease |
| LSCMMG: Lipid Management Pathway for Secondary Prevention of Cardiovascular Disease |
| NICE NG136: Hypertension in adults: diagnosis and management |
| NICE NG185: Acute Coronary Syndromes |
| NICE NG203: Chronic kidney disease: assessment and management |
| NICE NG95: Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis |
| Policy and procedure for prophylaxis against, and treatment of, VTE in adult patients **FOR USE IN THE CENTRAL LANCS REGION ONLY** |
| Prevention of VTE in Medical Surgical Patients (16 years +) and those requiring lower limb plaster casts/immobilisations **FOR USE IN THE BLACKPOOL REGION ONLY** |
| Renal: Enhanced Supportive Kidney Care Guideline |
| Enoxaparin Shared Care Guideline **FOR USE IN THE MORECAMBE BAY REGION ONLY** |
| Low Molecular Weight Heparins - Use in Primary care Best Practice Guideline *FOR USE IN PENNINE REGION ONLY* |
| Details... |
| 02.05 |
Drugs affecting the renin-angiotensin system and some other antihypertensive drugs |
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| 02.05.01 |
Vasodilator antihypertensive drugs |
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Hydralazine
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Formulary
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Tablets 25mg, 50mg
 Hypertension
 Heart failure (Initiated in hospital or under specialist supervision)
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 NG106: Chronic heart failure in adults: diagnosis and management
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Sildenafil
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Formulary
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Tablets 20mg
Tertiary centre only
Sildenafil and bosentan are licensed for use in pulmonary arterial hypertension (PAH). Treatment of this condition is commissioned nationally through a small number of PAH centres based in hospitals across the UK.
All patients should be referred to one of these centres, who carry out all prescribing of these therapies.
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MHRA Drug Safety Update Nov 18: Sildenafil (Revatio and Viagra): reports of persistent pulmonary hypertension of the newborn (PPHN) following in-utero exposure in a clinical trial on intrauterine growth restriction
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Sodium Nitroprusside
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Formulary
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Injection 50mg vials 
Specialist use only
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Sotatercept  (Winrevair®)
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Formulary
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Solution for injection 45 mg, 60 mg
Specialist use only
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NICE TA1161: Sotatercept for treating pulmonary arterial hypertension
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Hydralazine
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Formulary
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Injection 20mg/2mL
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| 02.05.02 |
Centrally acting antihypertensive drugs |
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Methyldopa
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Formulary
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Tablets 125mg, 250mg, 500mg
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NG133: Hypertension in pregnancy: diagnosis and management
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Moxonidine
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Formulary
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Tablets 200micrograms, 300micrograms, 400micrograms
 Restricted to use in resistant hypertension
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Clonidine Hydrochloride
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Formulary
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Tablets 25 microgram
Vasomotor symptoms (VMS) associated with menopause
Clonidine is considered less suitable for prescribing in hypertension
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LSCMMG: Clonidine for VMS associated with menopause NMR
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| 02.05.04 |
Alpha-adrenoceptor blocking drugs |
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Doxazosin
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Formulary
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Tablets 1mg, 2mg, 4mg
 Doxazosin modified-release tablets
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NHSE: Items which should not routinely be prescribed in primary care: policy guidance
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| 02.05.04 |
Phaeochromocytoma |
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Phenoxybenzamine Hydrochloride
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Formulary
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Capsules 10mg
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Phentolamine
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Formulary
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Injection
Critical care and theatre use only
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| 02.05.05 |
Drugs affecting the renin-angiotensin system |
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| 02.05.05 |
Heart Failure |
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Dapagliflozin
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First Choice
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Tablets 5mg, 10mg
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MHRA: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
MHRA: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
NICE TA679: Dapagliflozin for treating chronic heart failure with reduced ejection fraction
NICE TA902: Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction
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Empagliflozin
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Formulary
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Tablets 10mg, 25mg
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MHRA: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
MHRA: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
NICE TA773: Empagliflozin for treating chronic heart failure with reduced ejection fraction
NICE TA929: Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction
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| 02.05.05.01 |
Angiotensin-converting enzyme inhibitors (ACE inhibitors) |
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Ramipril
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First Choice
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Capsules 1.25mg, 2.5mg, 5mg, 10mg
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Lisinopril
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First Choice
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Tablets 2.5mg, 5mg, 10mg, 20mg
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Perindopril erbumine
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Formulary
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Tablets 2mg, 4mg, 8mg
Perindopril ARGININE is considered ‘Not suitable for prescribing’.
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NHSE: Items which should not routinely be prescribed in primary care: policy guidance
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Enalapril
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Formulary
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Tablets 2.5mg, 5mg, 10mg, 20mg
Restricted to use in post-natal women, in line with NG133.
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NG133: Hypertension in pregnancy: diagnosis and management
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| 02.05.05.02 |
Angiotensin-II receptor antagonists |
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Angiotensin-II receptor antagonists reserved for use when ACE inhibitors are not tolerated. |
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Losartan
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First Choice
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Tablets 12.5mg, 25mg, 50mg, 100mg
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Candesartan
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First Choice
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Tablets 2mg, 4mg, 8mg, 16mg, 32mg
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Irbesartan
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Formulary
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Tablets 75mg, 150mg, 300mg
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Sacubitril/valsartan (Entresto®)
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Formulary
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Film-coated tablets
24.3 mg sacubitril and 25.7 mg valsartan (as sacubitril valsartan sodium salt complex).
48.6 mg sacubitril and 51.4 mg valsartan (as sacubitril valsartan sodium salt complex).
97.2 mg sacubitril and 102.8 mg valsartan (as sacubitril valsartan sodium salt complex).
Entresto® tablets and granules contain sacubitril and valsartan in the form x/y where x and y are the strength in milligrams of sacubitril and valsartan respectively. Doses in BNF Publications are expressed as the total of both drug strengths.
For Entresto® tablets, the 24/26 mg, 49/51 mg, 72/78 mg, and 97/103 mg strengths are referred to as 50 mg, 100 mg, 150 mg, and 200 mg, respectively.
See BNF for more detail.
Ensure that all other ACE inhibitor and/or angiotensin receptor blocker therapy is stopped.
Initiation should be by the heart failure specialist team.
The specialist team must titrate, prescribe, and monitor until the patient is stabilised on an optimised dose (2-3 weeks on optimised dose).
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NICE TA388 Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
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Valsartan
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Formulary
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tablets and capsules
Existing patients only
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| 02.05.05.03 |
Renin inhibitors |
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Aliskiren
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Formulary
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NHSE: Items which should not routinely be prescribed in primary care: policy guidance
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| .... |
Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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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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Homecare |
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ICB commissioned |
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NHS England commissioned |
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Blueteq form needed |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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