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Nottinghamshire Area Prescribing Committee
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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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02.01  Positive inotropic drugs
02.01.01  Cardiac glycosides
Digoxin
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Formulary
Green

Tablets, Elixir, Injection

  • Bioavailabilites are approximately: Injection 100%, Liquid 75%, Tablets 63%.
  • ONE 62.5microgram tablet is ~ equivalent to 50microgram (1mL) elixir. (See table of liquid medicines requiring dose adjustment) 
 
Link  NUH: Therapeutic Drug Monitoring in Adults at NUH
Link  SFH digoxin dose calculator
Link  SFH Drug levels information - compilation table
Link  SFH Loading dose advice
Link  UKMI suggested drug monitoring schedule
   
02.01.01  Digoxin-specific antibody
Digoxin specific antibody fragments (Digifab®)
(Cardiac glycoside (digoxin) toxicity)
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Restricted Drug Restricted
Red
High Cost Medicine

Infusion

  • Very rarely needed and extremely expensive (~£1,000 per vial and upto 20 vials may be needed). Discuss with the National Poisons Centre (03448920111) first, then local Medicines Information (SFH: ext 3163 NUH: ext 64185) or the on call pharmacist (via switchboard after 17:30).
  • SFH only: How to get supplies (Pharmacy guide)(A&E guide)
  • DigiFab® replaced Digibind® (Dec 2011).
 
Link  DigiFab SPC
Link  Toxbase: National Poisons Information Service
   
02.01.02  Phosphodiesterase type-3 inhibitors
Enoximone (Perfan®)
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Formulary
Red

Injection.

  • Secondary Care only. Specialist use for severe heart failure.
  • SFH: Not stocked. Milrinone is the preferred PDE3 inhibitor.
  • Injection contains propylene glycol and so less ideal for use in neonates.
 
   
Milrinone (Primacor®)
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Formulary
Red

Injection.

  • Secondary care only. Specialist use for severe heart failure.
 
   
02.02  Diuretics to top
02.02.01  Thiazides and related diuretics
Bendroflumethiazide
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Formulary
Green

Tablet 2.5mg

  • Historically was first choice in hypertension.
  • Tablets disperse in water if needed, click here for more information. See here for general advice on dispersing tablets.
  • For use in heart failure see Heart failure lights
 
   
Chlorothiazide
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Restricted Drug Restricted
Red

Suspension 250mg/5ml for paediatric use only - available as an unlicensed product, more information here.

 
   
Chlortalidone
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Restricted Drug Restricted
Amber 2
Mentioned in the NICE hypertension guidelines (CG127) at a dose of 12.5mg-25mg, but only available as a 50mg tablet.
  • For initiation by specialists in hypertension in patients that cannot tolerate bendroflumethiazide or indapamide.
  • Hygroton® tablets discontinued by manufacturer October 2013. New generic product available as 50mg tabx30=£88.04. 
  • Link  Chlortalidone availability- UKMI Q & A
    Link  Link to reviews
       
    Indapamide
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    Formulary
    Green
    Tablet 2.5mg (preferred)
    Tablet MR 1.5mg
  • First choice in NICE hypertension guidelines. 2.5mg daily (£1pm). (1.5mg MR is also mentioned but costs £4pm.)
  • If needed standard tablets can be dispersed in water for patients with swallowing difficulties or enteral tubes terminating in the stomach. MR tablets should not be crushed. More Info
     
  •    
    Metolazone
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    Restricted Drug Restricted
    Red

    Tablet

    • Discontinued on the UK market 2012 but an unlicensed import may be available for use by secondary care. Unlicensed imported tablets require hospital prescription (not GP) and maybe very expensive to supply via retail chemists.
    • For patients in whom bendroflumethiazide is not suitable, See Nottinghamshire Heart Failure Lights.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    02.02.02  Loop diuretics
    Furosemide
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    Formulary
    Green

    Tablet, liquid, Injection.

    • IV doses of 40mg or 80mg can be slow bolused. Larger doses must be infused at a max rate of 4mg/min. (This advice keeps changing, but it's now in the BNF. Some sources say infuse over 50mg but for no good reason)
    • Liquid:
      • Various strengths available. 40mg/5mL oral solution usually used for adults (~ £20 per 150ml), contains 10% alcohol.
      • 50mg/5mL (licensed) is the preferred strength for paediatric patients (as this minimises ethanol exposure). 
      • 5mg/5mL may be used at NUH for inpatient initiation in neonates and infants ONLY (patients should be switched to 50mg/5mL strength at discharge).
     
       
    Bumetanide
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    Formulary
    Green

    Tablet, Oral solution (1mg/5ml)*

    • *Oral solution available, but extremely expensive (approx £200 per 28 days vs £1.30 for tablets, DT May18).
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
    • Injection (non-formulary) has been discontinued in the UK, but an unlicensed import may be available. Contact Medicines Information for further info.
     
       
    02.02.03  Potassium-sparing diuretics and aldosterone antagonists
    Amiloride Hydrochloride
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    Formulary
    Green

    Tablet, Oral solution (5mg/5ml)

    • Licensed oral solution (sugar free) available (approx £37 per 28 days vs £1.25 for tabs).
    • Tablets disperse in water if necessary (not licensed). See here for general advice on dispersing tablets.
     
       
    02.02.03  Aldosterone antagonists
    Spironolactone
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    First Choice

    Green- Tablet

    • Low dose (25mg daily) in addition to an ACE inhibitor for severe heart failure (£2 per month)
    • Monitor renal function and electrolytes. See Nottinghamshire heart failure lights
      for monitoring requirements
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • Amber2 Amber2 - Unlicensed liquid medicine available for paediatrics:
      10mg in 5mL (at SFH)
      25mg in 5mL
       (at NUH) - For paediatric patients, it is recommended to use a product which does not contain propylene glycol (e.g. from NUH NSM)
    • Grey for polycystic ovary syndrome related hirsutism
     
    Eplerenone
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    Restricted Drug Restricted
    Amber 2
    Tablet
  • Second line agent if spironolactone is not tolerated for use within the licensed indication of stable post MI patients with left ventricular dysfunction and clinical evidence of heart failure in line with NICE guidance. Classified Amber 2.
  • Second line aldosterone antagonist if spironolactone is not tolerated for NYHA class II heart failure. Classified amber 2.
  • See Nottinghamshire heart failure lights for more information on hyperkalaemia and dosing.
  • Tablets may be crushed and dispersed in water or mixed in apple sauce. See here for general advice on dispersing tablets.
     
  • Link  Independent reviews
    Link  NICE NG106: Chronic heart failure
       
    02.02.04  Potassium-sparing diuretics with other diuretics to top
    Co-amilofruse (furosemide and amiloride)
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    Formulary
    Green
    Tablet
  • If needed tablets can be dispersed in water. They disperse within 1 minute. More Info 
  •    
    02.02.05  Osmotic diuretics
    Mannitol
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    Formulary
    Red

    10% and 20% available

    • Infusion- due to the risk of crystallization use an administration set with an in-line filter (most of them contain filters).
    • Solution - used in radiology at NUH, named patient use only.

     

    • NUH info:
    • 10% infusions stocked in agreed clinical areas
    • 20% infusions used in Pharmacy Production, also available from pharmacy for elective use in ophthalmology
    • SFH info:
    • 10% infusions stocked in emergency areas.
    • 20% infusions kept in a fluid warmer in  Day case theatres (KMH) and Newark Theatres for elective ophthalmology procedures.
     
    Link  Link to reviews
    Link  Mannitol crystallization fix
    Link  NUH: Memo re switch to using mannitol 10% (Jan2020)
       
    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
    02.03.02  Supraventricular arrhythmias
    Adenosine
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    Formulary
    Red
    Injection- secondary care only
     
       
    Dronedarone
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    Formulary
    Amber 1
    Tablets
  • For cardiologist initiation in accordance with NICE guidance (TA197). Patients should be retained by secondary care for at least the first 12 months of treatment.
  • The need for 6 monthly ECGs should be highlighted when shared care is requested and a copy of the patient's recent ECG sent to primary care for comparison purposes.
  • For patients unable to swallow tablets, there are no known problems with dispersing tabs. However, it should be taken with meals- the fed state greatly increases bioavailability. No data is available on administration with enteral feeds - Doctors should be aware of this and efficacy monitored. 
  • Link  Dronedarone Shared Care Protocol: dronedarone information sheet
    Link  Dronedarone Shared Care Protocol: dronedarone overarching SCP
    Link  Link to reviews
    Link  MHRA Oct 2011: Cardiovascular, hepatic and pulmonary adverse effects - restrictions and monitoring requirements
    Link  NICE TA197: Atrial fibrillation - dronedarone
       
    02.03.02  Supraventricular and ventricular arrhythmias
    Amiodarone
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    Formulary
    Amber 2

    Tablet, Injection (secondary care only)

    • Tablets disperse in water if needed, more information here.
    • SFH: In an emergency amiodarone injection is stocked in ED majors, ICCU, wards 23 & 24 and CCS
     
    Link  APC amiodarone information sheet
    Link  SFH guidance on drugs and Central administration
    Link  SFH guidance on drugs which need special giving sets
    Link  Amiodarone oral loading calculator following IV doses
    Link  UKMI suggested drug monitoring schedule
       
    Disopyramide
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    Formulary
    Amber 2

    Capsule, Tablet MR

    (Injection – Discontinued in 2013)

     
       
    Flecainide
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    Formulary
    Amber 2

    Tablet, Injection (secondary care only)

    Tablets disperse in de-ionised water if needed. See here for more information. NB: Crushed tablets have a local anaesthetic effect-use with care in patients with swallowing difficulties.

    • NUH:  Flecainide acetate 25mg/5mL oral solution available for patients under the care of paediatric cardiology. (NB: Rosemont brand NOT suitable for neonates)
     
    Link  Link to review
       
    Procainamide
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    Restricted Drug Restricted
    Red
    Injection (unlicensed), Specialist use at NUH only
     
       
    Propafenone
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    Formulary
    Amber 2
    Tablet
     
       
    02.03.02  Ventricular arrhythmias to top
    Lidocaine
    (Cardiac)
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    Formulary
    Red
    Secondary Care only
    Injection
    Minijet 2%
    Infusion (in 5% glucose)
     
       
    02.04  Beta-adrenoceptor blocking drugs
    Atenolol
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    Formulary
    Green
    Tablet, Liquid, (Injection - secondary care only)
     
    Link  SFH guide: IV atenolol for perioperative betablocker replacement
       
    Bisoprolol
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    Formulary
    Green

    Tablet

    • First line use for heart failure
    • Tablets disperse in water if needed, click here for more information. See here for general advice on dispersing tablets.
     
       
    Carvedilol
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    Formulary
    Green
    Tablet
    Second line use for heart failure 
       
    Esmolol
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    Formulary
    Red

    Injection (secondary care only)

    • Current supply problem with no date available for resupply. (Jan 2020)
     
    Link  SFH esmolol infusion information
       
    Labetalol
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    Formulary
    Green

    Tablet, (Injection - secondary care only)

    • Tablets disperse in water if needed but administer immediately as the drug is sensitive to oxidisation. See here for general advice on dispersing tablets.
     
    Link  SFH: Labetalol infusion guidance
    Link  SFH: Labetalol- Prescription and Administration Record for Labetalol IV Infusion (Acute stroke)
       
    Metoprolol
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    Formulary
    Green
    Tablet, (Injection - secondary care only)
    (Tablet MR is non formulary)
  • Heart failure- third line, where there is a perceived need to use a short acting cardioselective beta-blocker. Consideration should be given to switching to a once daily beta blocker once patient is stable
  • Tablets disperse in water if needed. Do not crush or disperse MR tablets. See here for general advice on dispersing tablets. 
  •    
    Nadolol
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    Formulary
    Amber 2
    Tablet
  • For patients with Long QT syndrome. Use in other indications is classified grey (APC Nov 14).
  • The only beta blocker suitable for some patients in long QT syndrome. 
  • Link  Link to reviews
       
    Propranolol
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    Formulary
    Green

    Tablet, Capsule MR, Oral solution*, (Injection - secondary care only)

    • If needed MR capsules can be opened and beads mixed with water - do not crush. (Personal communication with manufacturer, 2009) More Info
    • *Oral solution: Locally recommended strength for oral solution is 50mg/5mL, but note that dermatology use 5mg/5mL (unlicensed) for infantile haemangioma.
     
       
    Sotalol
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    Formulary
    Amber 2
    Tablet
  • Sotalol should not be used as a beta blocker purely for rate control of AF, but is a useful class 3 antiarrhythmic for a rhythm control strategy.
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    Timolol
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    Formulary
    Amber 2
    Tablet
  • For post MI use
  • Tablets disperse in water if needed immediately before administration. See here for general advice on dispersing tablets. 
  • Link  Link to reviews
       
    02.05  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
    02.05.01  Vasodilator antihypertensive drugs
    Bosentan
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    Formulary
    Red
    High Cost Medicine
    • Medicines for pulmonary hypertension are commissioned via specialist centres only, see the policy below.
    • Contact High Cost Drugs pharmacists or Medicines Information for further info.
    • Nottingham NHS Treatment Centre: for the treatment of digital ulceration in systemic sclerosis as per commissioning policy.
    • Risk Minimisation Materials are available for bosentan (available from the eMC)
     
    Link  NHSE Clinical Commissioning Policy: Treatment of Digital Ulceration in Systemic Sclerosis
    Link  NHSE: National Pulmonary Hypertension commissioning policy
       
    Hydralazine
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    Formulary
    Green
    Tablet
  • May be used in combination with a nitrate in the management of heart failure in patients who are intolerant of ACE inhibitors.
  • Tablets disperse in water if needed but this may increase the rate of absorption. See here for general advice on dispersing tablets. Tablets are sugar coated and are likely to block enteral feeding tubes. Blood pressure monitoring recommended.  
  •    
    Iloprost injection
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    Formulary
    Red
    High Cost Medicine

    Injection

    • Restricted for peripheral vascular and rheumatology use (prescribing out of hours should be avoided for rheumatology indications at NUH).
     
    Link  SFH: Iloprost guidelines for Raynaud’s (links to everything needed)
    Link  Commissioning Policy - Pulmonary hypertension in adults
    Link  Link to reviews
       
    Iloprost nebules (Vantavis®)
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    Formulary
    Red
    Nebule
  • Restricted for NUH use in pulmonary hypertension on advice of tertiary centre 
  • Link  Link to reviews
       
    Minoxidil
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    Formulary
    Amber 2

    Tablets

    • May be used in severe hypertension where other medication is unable to achieve control.
    • Should not be used as monotherapy but in conjunction with a diuretic and beta-blocker.
     
       
    Sildenafil
    (digital ulcers)
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    Formulary
    Amber 2
    • For Systemic Sclerosis patients with digital ulcers as advised by NHS E policy.
    • Initiated at treatment centre. 6 weeks provided, to be passed to primary care after review at this point.
     
    Link  NHSE Clinical Commissioning Policy: Treatment of Digital Ulceration in Systemic Sclerosis
    Link  NICE Evidence summary: Sildenafil for digital ulcers
       
    Sildenafil (Revatio®)
    (pulmonary hypertension)
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    Formulary
    Red
    High Cost Medicine
  • Medicines for pulmonary hypertension are commissioned via specialist centres only.
  • Contact High Cost Drugs pharmacists or Medicines Information for further info
  • At SFH for Commissioning detail see Information sheet here
  • Licensed liquid available for use in paediatric intensive care at NUH in line with local guidance
  •  
    Link  NHSE: National Pulmonary Hypertension commissioning policy
    Link  NICE ESUOM51: Pulmonary hypertension in neonates
       
    Sodium nitroprusside
    Formulary
    Red
    Injection (secondary care only)
  • Unlicensed supply available through importing companies
     
  •    
    Tolazoline
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    Formulary
    Red
    Injection
  • Named patient use
  • Restricted for neonatal use only 
  •    
    02.05.02  Centrally acting antihypertensive drugs
    Clonidine
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    Formulary

    Tablet 25microgram Green for menopausal symptoms, particularly flushing and vasomotor conditions (other strengths and indications Red)
    Injection Catapres® (secondary care only )
    Oral solution 50microgram/5mL (NUH paediatrics only )
    Patches (unlicensed, NUH paediatrics only )

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • Oral solution restricted to paediatric use at NUH for sedation on PICU and spasticity.
    • Patches restricted to paediatric use at NUH for spasticity.

    Attention Deficit Hyperactivity Disorder (ADHD):
    Specialist only - Should only be used in the context of tertiary services

     
    Link  Link to reviews
    Link  NICE Evidence Summary: Clonidine for ADHD in children and young people
       
    Methyldopa
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    Formulary
    Green
    Tablet
  • Should only be used for hypertension when other agents have failed or aren't suitable.
  • Tablets disperse in water if needed. Flush tube well to prevent blockage. See here for general advice on dispersing tablets. 
  •    
    Moxonidine
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    Restricted Drug Restricted
    Green
    Tablet
  • Restricted for resistant or refractory cases
  • Tablets disperse in 50mL water if needed. Disperse well before administering to prevent tube blockage. See here for general advice on dispersing tablets. 
  •    
    02.05.03  Adrenergic neurone blocking drugs to top
    02.05.04  Alpha-adrenoceptor blocking drugs
    Doxazosin
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    Formulary

    Green Traffic Light  Tablet (2mg = 72p for 28. 4mg = 81p for 28)
    Amber Traffic Light  Tablet MR (4mg = £5 for 28. 8mg = £9.98 for 28)

    • Doxazosin may be used as a 4th line option in the management of hypertension when control has not been achieved with other agents.
    • Modifed release (MR) reserved for specialist initiation in patients with difficult to treat hypertension who are unable to tolerate IR doxazosin. MR is on the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
    • If switching from MR to IR the dose of standard doxazosin could be re-initiated at 1mg daily, as if newly starting therapy, or at half the modified-release doxazosin dose - see UKMI link below.
    • If needed tablets can be crushed and dispersed in water. Do not crush MR formulations. More Info
     
    Link  SPS Q&A: Switching from doxazosin XL tablets to doxazosin standard release tablets
    Link  UKMI Q&A: How should conversion between doxazosin formulations be carried out?
    Link  UKMI Q&A: What is the evidence comparing doxazosin XL with standard doxazosin?
       
    02.05.04  Phaeochromocytoma
    Phenoxybenzamine (Dibenyline®)
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    Formulary
    Red
    Capsules
  • Specialist use only for hypertensive episodes in phaeochromocytoma 
  •    
    Phentolamine (Rogitine®, Regitin®)
    (antihypertensive)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • Secondary care only for hypertensive episodes in phaeochromocytoma
  • Licensed product discontinued in the UK but imported unlicensed product should be available. At SFH this is kept in Emergency Department Resus. 
  •    
    02.05.05  Drugs affecting the renin-angiotensin system
    02.05.05.01  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
    Ramipril
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Capsule, Oral solution (2.5mg/5ml)
    1st line choice

    • If needed capsules can be opened and the contents mixed with water (not licensed). General info on opening capsules.
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
    • Oral solution (sugar free) available (£96 for 150ml, DT May18).
     
    Lisinopril
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    Formulary
    Green

    Tablet, Oral solution (5mg/5ml)
    2nd line choice

    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
    • Oral solution available but very expensive (>£300 for 28 days, DT May18).
     
       
    Enalapril
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    Formulary
    Green

    Tablet
    3rd line choice

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.

     Available at NUH only: Oral suspension 5mg/5ml (unlicensed), for use in paediatric patients who require a dose less than 2.5mg

     
       
    Perindopril erbumine or tert-butylamine
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    Formulary
    Green
    Tablets 2mg, 4mg and 8mg
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
  • Absorption may be reduced if given via an enteral tube that terminates in the jejunum. 
  •    
    Captopril
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    Restricted Drug Restricted
    Amber 2

    Tablets, Oral solution - see below for restriction

    • Oral solution is restricted for paediatric use and existing stable adult patients only (~£100 per 100ml bottle). Recommended strength is 25mg/5mL as per RCPCH guidance.
    • Red 5mg/5mL strength is used at NUH for inpatient initiation in neonates and infants ONLY (patients should be switched to 25mg/5mL strength at discharge). 5mg/5mL not routinely stocked at SFH.
    • If needed tablets disperse in water (for stable doses of whole tablets). Flush enteral tubes well after administration. Absorption may be reduced if given via enteral tube that terminates in the jejunum. See here for general info on crushing tablets.
     
    Link  NUH: Initiation of Captopril for Paediatric Cardiology Patients
    Link  Medicines for Children: Captopril for Heart Failure
       
    02.05.05.02  Angiotensin-II receptor antagonists to top
    Losartan
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    Formulary
    Green

    Tablets

    • 1st line choice ARB if patients haven't tolerated an ACE inhibitor
    • Licensed for Renal protection in type 2 diabetic patients with nephropathy (macroalbuminuria) (unlike candesartan).
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
     
       
    Candesartan
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    Formulary
    Green

    Tablets

    • 2nd line choice ARB if patients haven't tolerated an ACE inhibitor. Used to be the most cost-effective ARB but now losartan is.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    Irbesartan
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    Restricted Drug Restricted
    Green
    Tablets
  • For use in type 2 diabetic patients with hypertension and renal disease who have not tolerated the use of ACE-inhibitor
  • Tablets disperse in water if needed but they are poorly soluble. See here for general advice on dispersing tablets. 
  • Link  Link to reviews
       
    Sacubitril valsartan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Approved in line with NICE TA388 for treating symptomatic chronic heart failure with reduced ejection fraction
     
  • Link  NICE TA388: Sacubitril valsartan for heart failure
    Link  SMC advice (March 2016)
       
    02.05.05.03  Renin inhibitors
    02.06  Nitrates, calcium-channel blockers, and potassium-channel activators
    02.06.01  Nitrates
    Glyceryl Trinitrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Available as S/L Tablet, Spray, Patches, Injection.
  • Injection (secondary care only)- Use Polyethylene (PE), giving set for infusion (NOT PVC!).
  • Buccal tablets (Suscard®) discontinued 2008 - Alternatives include IV/sublingual GTN or oral Isosorbide Mononitrate depending on the indication. 
  • Link  SFH IV GTN guidelines
    Link  SFH: GTN- Prescription and Administration Record for GTN IV Infusion (Acute stroke)
    Link  SFH: IV drugs which need special giving sets
       
    Glyceryl Trinitrate 2% Ointment
    Formulary
    Red

    Ointment

    Available at NUH only for:

    • Treatment and prevention of digital gangrene in children and young people with severe septic shock (unlicensed indication).
     
       
    Isosorbide Mononitrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet
  • Short acting preparations should be prescribed asymmetrically to reduce the risk of nitrate tolerance
  • Tablets disperse in water if needed. Do not crush MR preperations. See here for general advice on dispersing tablets. 
  • Link  PrescQIPP: ISMN review
       
    Isosorbide Mononitrate MR
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Long acting, once daily preparation
    • Preferred brands in primary care are Tardisc XL, Monomil XL or Chemydur 60XL. See Preferred Prescribing List.
     
       
    Isosorbide Dinitrate
    (Injection)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection- Isoket® (secondary care only)
  • At SFH injection is restricted for intracoronary use on Cardiac Catheter Suite. (For IV use GTN)
     
  •    
    02.06.02  Calcium-channel blockers
    Amlodipine
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Tablet, Oral solution (5mg/5ml or 10mg/5ml)
    1st line choice

    • Licensed oral solution available (approx £115 for 28 days for 10mg dose, DT Sep20)
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
     
    Nifedipine
    (cardiac)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Oral formulations
    Drops 20mg/ml (unlicensed) are for named patient use only

    • Preferred brands in primary care are Tensipine MR® for the twice daily preparation and Adipine XL® for the once daily preparation. At SFH see advice on brand switching.
    • If needed Coracten MR capsules can be opened and beads mixed with water (do not crush). However consider changing to a long acting calcium antagonist such as amlodipine which disperses in water. See here for general advice on dispersing tablets.
     
    Link  Adalat discontinuations and shortages (Specialist Pharmacy Service)
    Link  Discontinuation of immediate release nifedipine (Memo Dec 2018)
    Link  Nifedipine MR preparations cost comparison graph
    Link  SFH advice about brand switching
       
    Diltiazem
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • Once daily preparations preferred.  
      • Zemtard®, Zemret XL or Viazem XL are the preferred once daily brands in primary care.
      • Zemtard® is stocked at SFH. At SFH see advice on brand switching.
      • If needed, Zemtard® capsules can be opened and beads mixed with water (do not crush). More info.
      • Slozem ® brand due to be discontinued 2020.
    • Tildiem® is the current recommended brand for 60mg tablets ("TDS" preparation) in primary care - see Preferred Prescribing List
      • If needed 60mg tablets can be dispersed in water (despite misleadingly being called modified release). More info. See here for general advice on dispersing tablets.
    • Angitil SR® or Tildiem Retard® are the preferred twice daily brands in primary care.
     
    Link  Diltiazem products price comparison graph
    Link  Erythromycin and calcium channel blocker interaction
    Link  SFH advice about brand switching
       
    Lercanidipine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets

    • Second line option. Amlodipine first line
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
     
       
    Nicardipine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
    NUH: PICU and NNU use only for hypertensive crisis or uncontrolled hypertension. 
       
    Verapamil
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Tablet MR, Injection (secondary care only), Oral solution (40mg/5ml)

    • Tablets disperse in water if needed (not licensed). Do not crush MR formulations. See here for general advice on dispersing tablets.
    • Oral solution available, but is expensive (>£200 for 28 days at 80mg TDS dose, DT May18).
     
    Link  Evidence for verapamil for cluster headache UKMI Q+A
       
    Nimodipine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Tablet

    • Injection- use Polyethylene (PE) giving set for infusion (NOT PVC!). See further info.
    • Specialist use in secondary care only
    • Tablets disperse in water if needed but administer immediately as rapid degredation occurs. See here for general advice on dispersing tablets.
     
    Link  SFH guidance on drugs requiring central line administration
    Link  SFH: IV drugs which need special giving sets
       
    02.06.03  Other anitanginal drugs to top
    Ivabradine
    (Angina)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet 5mg, 7.5mg (note that 2.5mg tablets* VERY expensive ~£100 for 56 tablets)

    • Cardiology initiation only.
    • Cardiology specialist initiation only in line with NICE Clinical Guidance on stable angina for patients who remain symptomatic despite maximal doses of other anti-anginal medication.
    • *2.5mg tablets restricted to those unable to have half a 5mg tablet. Note that 5mg tablets are scored and licensed to be divided into equal doses.
    • Tablets can be dispersed in water if needed. See here for general advice on dispersing tablets.
     
    Link  Link to reviews
    Link  MHRA: Cardiac side effects of ivabradine- risk minimisation advice (Dec 14)
    Link  MHRA: emerging clinical trial evidence of increased cardiovascular risk—carefully monitor for bradycardia
    Link  NICE Guidance on Stable Angina (2011)
       
    Ivabradine
    (Heart failure)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablets 5mg,7.5mg (2.5mg tablets* are VERY expensive ~£100 for 56 tablets)

    • NICE TA 267: Ivabradine is recommended as an option for treating chronic heart failure for people:
      - with NYHA class II to IV stable chronic heart failure with systolic dysfunction and
      - who are in sinus rhythm with a heart rate of 75 bpm or more and
      - who are given ivabradine in combination with standard therapy including beta-blocker therapy, ACE inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
      - with a left ventricular ejection fraction of 35% or less.
    • Initiation:
      Amber 2 - specialist intiation. In line with NICE recommendations, Ivabradine for heart failure should be initiated by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration and monitoring should be carried out by a heart failure specialist, or in primary care by a heart failure specialist nurse. Ivabradine should only be initiated after a stabilisation period of 4 weeks on optimised standard therapy with ACE inhibitors, beta-blockers and aldosterone antagonists.
    • Titration and more information: See Nottinghamshire Heart failure lights.
    • *2.5mg tablets restricted to those unable to have half a 5mg tablet. Note that 5mg tablets are scored and licensed to be divided into equal doses.
    • Tablets can be dispersed in water if needed. See here for general advice on dispersing tablets.
     
    Link  Link to reviews
       
    Nicorandil
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet
  • Do not use as first-line treatment for angina in line with NICE and MHRA guidance.
  • See recent warnings regarding risk of serious skin, mucosal, and eye ulceration, which persists unless treatment is discontinued.
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  • Link  MHRA drug safety update Nov 2015 risk of serious skin, mucosal, and eye ulceration, gastrointestinal ulcers which may progress to perforation, haemorrhage, fistula, or absces
       
    Ranolazine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet MR
  • Cardiology specialist initiation only in line with NICE Clinical Guidance on stable angina for patients who remain symptomatic despite maximal doses of other anti-anginal medication. 
  • Link  Independent reviews
    Link  NICE Guidance on Stable Angina (2011)
       
    02.06.04  Peripheral vasodilators and related drugs
    Naftidrofuryl
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsules
    For use in line with NICE guideline (TAG 223)

     
    Link  NICE CG147: Lower limb peripheral arterial disease management
    Link  NICE TA223: Intermittent claudication drugs
       
    02.06.04  Other preparations used in peripheral vascular disease
    02.07  Sympathomimetics
    02.07.01  Inotropic sympathomimetics
    Dobutamine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Infusion (secondary care only)
     
    Link  SFH dobutamine administration guide
    Link  SFH guidance on drugs requiring central line administration
       
    Dopamine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Infusion (secondary care only)
     
    Link  SFH dopamine administration guide
    Link  SFH guidance on drugs requiring central line adminstration
       
    Isoprenaline
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (secondary care only)

    • Named patient use (unlicensed)
    • (SFH) Isoprenaline Sulphate 2.25mg in 2ml available from ICCU and Cardiac Cathether Suit
    • Isoprenaline hydrochloride 1mg is equivalent to isoprenaline sulphate 1.125mg (from UCL guide). 
     
    Link  SFH guidance on drugs requiring central line adminstration
    Link  SFH isoprenaline infusion rate table
       
    02.07.02  Vasoconstrictor sympathomimetics to top
    Ephedrine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only)
  • 25p for 30mg 
  •    
    Metaraminol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection 10mg/1ml (secondary care only)

     
    Link  SFH: Metaraminol to treat hypotension on CCS
    Link  SFH: Metaraminol to treat hypotension on ICCU
       
    Midodrine
    View adult BNF View SPC online
    Formulary
    Amber 2

    Tablets 2.5 mg, 5mg.

    • 2015: Now available as a licensed product Bramox®
    • Jan 2016: Amber Traffic Light GPs can continue supplies, see GP information sheet.
    • Consultant initiation only when fludrocortisone ineffective for orthostatic hypotension.
    • NUH: Used by renal for resistant dialysis related hypotension, generally given pre-haemodialysis and as a top up dose during haemodialysis. May also be used for those with chronic hypotension (usually due to dialysis related autonomic neuropathy). Fludrocortisone would not be effective in patients with established renal failure.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  Midodrine information sheet for prescribers
    Link  NICE: Orthostatic hypotension: midodrine (ESNM61)
    Link  Link to reviews
    Link  Price Comparison: Hypertensives
       
    Noradrenaline / Norepinephrine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only) 
    Link  SFH guidance on drugs requiring central line adminstration
       
    Phenylephrine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
  • Injection (secondary care only)- 1mg/10ml unlicensed
  • At SFH restricted for the treatment of spinal anaesthetic induced hypotension during caesarean section only. The 1mg/10ml unlicensed preparation should be used, the 10mg in 1ml (1%) preparation is non-formulary. 
  • Link  Link to reviews
    Link  SFH guideline:Phenylephrine to treat spinal-induced hypotension
       
    02.07.03  Cardiopulmonary resuscitation
    Adrenaline / Epinephrine 1 in 10,000 (dilute)
    (CPR)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Injection
  • Adult dose is 10ml of 1:10,000 given IV.
  • Note: For anaphylaxis the dose is usually 0.5ml of 1:1,000 given IM. Although this product may be given in some circumstances (see BNF). 
  •    
    02.08  Anticoagulants and protamine
    Idarucizumab (Praxbind®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection

    • Reversal agent for dabigatran. ~£1000 per dose.
    • On recommendation of haematologist only.
    • At SFH: Available via Blood bank.
    • At NUH: Available via pharmacy.
     
    Link  NUH: Haemorrhage or Emergency Surgery Guideline for Dabigatran
       
    02.08.01  Parenteral anticoagulants
    Argatroban (Exembol®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Infusion

    • NUH only See guideline
     
    Link  Link to reviews
    Link  NUH: Treatment of heparin induced thrombocytopenia (HIT) in Adults
       
    02.08.01  Heparin
    Heparin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Heparin sodium 1000 units in 1mL (20ml amps no longer available)
    NUH only:
    Heparin sodium mucous 1000 units in 1ml (5mL vial) for renal dialysis patients
    Heparin sodium 1000 units in 1ml (5mL ampoule) preservative free for X-ray only
    Heparin sodium mucous 5000 units in 1ml for renal dialysis patients
    Heparin sodium 25000 units in 5mL vial with preservative for renal dialysis patients
    Heparin calcium injection - prefilled syringes
     
    Link  NUH Lite Bite: Errors with Anticoagulation
    Link  SFH Unfractionated Heparin Schedules and Guidelines
       
    02.08.01  Low molecular weight heparins to top
    Enoxaparin (Inhixa® or Clexane®)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Amber 2

    Injection

    • Two brands now available: Inhixa® and Clexane®.
      - Inhixa is the preferred brand in Nottinghamshire, but Clexane is still available in primary care for existing patients.
      - Enoxaparin should be BRAND PRESCRIBED and patients should be maintained on the same brand where possible. If a need to switch arises (eg during supply problems), appropriate patient counselling should occur as there are device differences.
    • Used for prophylactic use and treatment of DVT and PE.
    • For unstable angina - see fondaparinux.
    • SFH: Dosing table and links to guidelines
    • NUH: Dosing guidelines
     
    Dalteparin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Injection
  • Restricted use at NUH only.
  • Glass ampoules for latex allergy patients
  • For prophylactic use and treatment of DVT and PE
     
  • Link  Link to reviews
       
    Tinzaparin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection

    • Restricted for prophylaxis against VTE in haemodialysis patients.
     
    Link  Renal unit tinzaparin algorithm 1
    Link  Renal unit tinzaparin algorithm 2
    Link  Renal unit tinzaparin algorithm 3
    Link  Renal unit tinzaparin administration record
       
    02.08.01  Heparinoids
    Danaparoid (Orgaran®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection (secondary care only)
    Specialist use only for HITT
     
    Link  NUH: Anticoagulation in HIT or heparin allergy / danaparoid guidance - (NUH Guideline In Development-June 2014)
    Link  SFH danaparoid prescribing guideline
       
    02.08.01  Hirudins
    Bivalirudin (Angiox®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only)
    SFH only for anticoagulation during PCI as an alternative to abciximab and heparin
    NUH: Restricted to use in accordance with NICE TAG 230 and CG94. Consultant recommendation only. 
    Link  Bivalirudin PCI dosing table
    Link  Cost comparison of bivalirudin vs abciximab
    Link  Link to reviews
    Link  MHRA Drug Safety Update: Risks associated with incorrect dose
    Link  NICE CG 94:Unstable angina and NSTEMI
    Link  NICE TAG 230 : Bivalirudin for the treatment of STEMI, 2011
       
    02.08.01  Heparin flushes
    Heparin
    (Flush)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Available as:
    - 1 unit in 1mL (500mL sodium chloride 0.9%)
    - 10 units in 1mL (5mL ampoule)-prev known as Hepsal
    - 100 units in 1mL (2mL ampoule)-prev known as Canusal
    - 100 units in 1mL (500mL sodium chloride 0.9%)
  • Shouldn't be used for flushing peripheral cannulas- use 0.9% sodium chloride instead. 
  • Link  Notts Children’s Hospital: CF Management Guideline (see pages 21/22 for heparin flushes)
    Link  NUH Lite Bite: Errors with Anticoagulation
    Link  SFH guide to central lines and heparin flushes
    Link  UKMI Q&A: Heparin vs saline flushes for maintenance of patency in intravascular catheters & cannulae
       
    02.08.01  Epoprostenol
    Epoprostenol (Flolan®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Infusion (secondary care only)
  • At SFH restricted to ICCU haemofiltration patients only.
  • Product has been reformulated. Carefully read reconstitution and administration instructions. 
  • Link  MHRA: incompatibilities between Veletri and some administration devices
    Link  NHSE policy for the treatment of pulmonary hypertension
       
    02.08.01  Fondaparinux to top
    Fondaparinux (Arixtra®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection
  • For patients with ACS/NSTEMI in line with guidelines below.
  • For use within its licensed indication for patients intolerant of heparin or heparinoids (due to HITT or allergy) or where it is inappropriate due to patient beliefs. 
  • Link  Link to reviews
    Link  Fondaparinux guideline for the management of acute coronary syndromes – NUH 2016
    Link  SFH only: Fondaparinux guidelines for ACS/NSTEMI
       
    02.08.02  Oral anticoagulants
    Warfarin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Available as:
    - Only 3mg tablets are routinely used in Nottinghamshire
    - Suspension 1mg/ml, £110 per 150ml, 28 day expiry (DT Sep20)
    - 1mg tablet - Restricted for anticoagulant clinic request only and for prophylaxis in oncology patient with indwelling catheter.

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  NUH warfarin dosing protocols
    Link  SFH warfarin dosing protocol
    Link  Anticoagulation in AF guideline (NottsAPC)
    Link  COVID19: Can we extend the INR testing interval? (Notts CCG)
    Link  COVID19: Should I switch warfarin to a DOAC? (Notts CCG)
    Link  NPSA warfarin booklet
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  Oral anticoagulant therapy patient booklets in different languages
    Link  SFH patient counselling guidelines
    Link  UKMI Q&A: IM injections in warfarin patients
    Link  UKMI Q&A: Warfarin and PPI interaction
       
    Edoxaban (Lixiana®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Treatment of DVT or PE and prevention of recurrent DVT or PE:
     - Specialist initiation in line with NICE TA354. For advice regarding switching between anticoagulants check the local prescribing information and the SPC.

    Stroke prevention in AF:
     For use in line with Atrial Fibrillation (AF) anticoagulation guideline. Edoxaban is the first line DOAC for patients with NVAF unless there is a specific clinical reason to use a different DOAC - see Notts APC DOAC position statement.

     
    Link  Anticoagulant dosing links & information (DOACs & Enoxaparin)
    Link  COVID19: Can the DOAC monitoring interval be extended? (Notts CCG)
    Link  Edoxaban dose compilation table (SFH)
    Link  NICE TA355:Edoxaban for preventing stroke/systemic embolism in non‑valvular AF
    Link  Nottinghamshire DOAC alert card
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  NUH: Counselling of patients starting DOACs (pharmacy procedure)
    Link  NUH: Haemorrhage or Emergency Surgery guideline for apixaban/edoxaban/rivaroxaban patients
    Link  Risk minimisation resources
       
    Apixaban (Eliquis®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Stroke prevention in non-valvular AF:
    For use in line with Atrial Fibrillation (AF) anticoagulation guideline. Note that Edoxaban is the first line DOAC for patients with NVAF unless there is a specific clinical reason to use a different DOAC - see Notts APC DOAC position statement.


    Treatment of DVT or PE and prevention of recurrent DVT or PE:
     As an option per NICE TA341. See Prescribing Information

     
    Link  Anticoagulant dosing links & information (DOACs & Enoxaparin)
    Link  Apixaban dosing table (SFH)
    Link  Atrial Fibrillation (AF) anticoagulation guideline (NottsAPC)
    Link  COVID19: Can the DOAC monitoring interval be extended? (Notts CCG)
    Link  Link to reviews
    Link  Manufacturers Patient Alert Card
    Link  MHRA: Risk of Haemorrhage - clarification on contraindications, 2013
    Link  NICE TA275: Apixaban for AF
    Link  Nottinghamshire DOAC alert card
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  NUH: Counselling of patients starting DOACs (pharmacy procedure)
    Link  NUH: Haemorrhage or Emergency Surgery guideline for apixaban/edoxaban/rivaroxaban patients
       
    Dabigatran (Pradaxa®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Capsules
    Stroke prevention in non valvular AF:
    -As per Atrial Fibrillation (Non-valvular) - anticoagulation choice

    • Do not crush or open capsules as this increases bioavailability by 75%.
    • Note that Edoxaban is the first line DOAC for patients with NVAF unless there is a specific clinical reason to use a different DOAC - see Notts APC DOAC position statement.

    Treatment of DVT or PE and prevention of recurrent DVT or PE:
     -Specialist initiation in line with NICE TA327

    • See Prescribing Information
    • For advice regarding switching between anticoagulants check the local guidelines and the SPC.
     
    Link  COVID19: Can the DOAC monitoring interval be extended? (Notts CCG)
    Link  Link to reviews
    Link  MHRA: prosthetic heart valves contraindication alert, 2013
    Link  MHRA: Renal function information
    Link  MHRA: Risk of haemorrhage - clarification on contraindications, 2013
    Link  NICE TA249: Dabigatran for Stroke prevention in AF
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  NUH: Counselling of patients starting DOACs (pharmacy procedure)
    Link  NUH: Haemorrhage or Emergency Surgery guideline for dabigatran
    Link  Manufacturers DOAC alert card (Dabigatran only)
       
    Rivaroxaban (Xarelto®)
    View adult BNF View SPC online View childrens BNF
    Formulary

    Stroke prevention in AF:
    For use in line with Atrial Fibrillation (AF) anticoagulation guideline. Note that Edoxaban is the first line DOAC for patients with NVAF unless there is a specific clinical reason to use a different DOAC - see Notts APC DOAC position statement.

    Treatment of DVT or PE and prevention of recurrent DVT or PE: Tablets 10mg, 15mg & 20mg
     - GPs may continue after specialist initiation in line with NICE. See Prescribing Information

    Treatment of ACS:
    - Cardiology specialist recommendation only. An option as per NICE TA. Course length to be specified by specialist and regular review advised. N.B. lower dose and different frequency of administration compared to other indication. Care as dose corresponds to therapeutic dosing of apixaban

    Prevention of thrombotic events in CAD or PAD.
    - As per NICE TA607
    Prevention of CVD in AF patients undergoing cardioversion
    -Non-formulary (no formal assessment)
    Prophylaxis of VTE post hip and knee replacement surgery:
    Complete course will be supplied by hospital.

    • Rivaroxaban PILs for AF, DVT & PE
    • NICE Guidelines for AF, DVT, PE & ACS
    • Approved for use at SFH only in line with trust thromboprophylaxis guidelines.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • 15mg and 20mg tablets should be taken with or after food.
    • 2.5mg and 10mg tablets can be taken with or without food.
     
    Link  Link to reviews
    Link  MHRA: Risk of haemorrhage - clarification on contraindications (2013)
    Link  Anticoagulant dosing links & information (DOACs & Enoxaparin)
    Link  COVID19: Can the DOAC monitoring interval be extended? (Notts CCG)
    Link  MHRA: reminder that 15 mg and 20 mg tablets should be taken with food (2019)
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  NUH: Counselling of patients starting DOACs (pharmacy procedure)
    Link  NUH: Haemorrhage or Emergency Surgery guideline for apixaban/edoxaban/rivaroxaban patients
    Link  Rivaroxaban dosing table (SFH)
    Link  Manufacturers Alert Card for patients (Rivaroxaban only)
    Link  Nottinghamshire DOAC alert card
       
    Acenocoumarol (Sinthrome®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet
    For patients intolerant of warfarin
     
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
       
    Phenindione
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet
    For patients intolerant of warfarin 
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
       
    02.08.02  Stroke prevention in AF
    02.08.02  VTE treatment
    02.08.02  VTE prophylaxis in hip/knee surgery
    02.08.03  Protamine sulphate to top
    Protamine Sulphate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only)
  • Remember maximum dose is 50mg.
  • To be given by slow intravenous injection over 10 minutes.
     
  •    
    02.09  Antiplatelet drugs
    Aspirin (antiplatelet)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets - dispersible and EC, (Suppository - Named patient use)

    • Enteric coated aspirin is second line to dispersible aspirin.
    • EC is not better tolerated and may have an impaired antiplatelet effect. See UKMI Q&A below.
    • In acute situations such as unstable angina or myocardial infarction, a single dose of 300mg soluble aspirin is recommended. This may be sucked or chewed.
    • Life long use of aspirin 75mg is of benefit for all patients with established cardiovascular disease, unless the patient has an adverse effect to it. Review of aspirin for primary prevention (2017)
    • For recommendation for use of aspirin in pregnant women at high risk of pre-eclampsia see NICE CG107.
     
    Link  Aspirin’s effect on reducing cancer risk
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  SFH advice on NSAIDS with low dose aspirin
    Link  UKMI Q&A Lack of evidence to support EC aspirin to reduce GI side-effects
       
    Clopidogrel
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • If needed tablets can be dispersed in water (unlicensed). More Info

    • In line with guidance from the Royal College of Physicians’, the Nottinghamshire Area Prescribing Committee recommends that clopidogrel at a dose of 75mg daily (following initial 300mg loading dose) is used for stroke and TIA patients in sinus rhythm. See link below

    • Occasionally on advice from a stroke consultant, clopidogrel may be used in combination with 75mg aspirin for up to 3 weeks following minor stroke or TIA before the maintenance dose of clopidogrel 75mg alone is continued. The duration of DAPT should be documented and communicated on discharge. 

     
    Link  Link to reviews
    Link  MHRA: Aquired haemophilia risk (Dec13)
    Link  NICE Evidence summary: Clopidogrel for transient ischaemic attack
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
    Link  PPIs and clopidogrel advice
       
    Dipyridamole
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Capsule MR

    • Secondary prevention of ischaemic stroke and TIA normally in combination with aspirin for existing patients and those unable to take clopidogrel. 
    • If needed capsules can be opened and beads mixed with water (do not crush). Flush enteral tubes well as there is potential for blockage. More Info
     
       
    Eptifibatide (Integrilin®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection (secondary care only)
     
    Link  Price comparison graph of eptifibatide vs tirofiban
    Link  SFH eptifibatide dose table
       
    Prasugrel
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet

    • For consultant cardiologist initiation only. Restricted to use as per NICE TA 317 for the treatment of patients with ACS undergoing PCI.
    • To be prescribed for upto 12 months post PCI for ACS. Ensure duration of therapy is indicated on discharge.
    •  NUH approved: for interventional neuroradiology for patients with clopidogrel resistance.
    • Although SPC states tablets should not be broken, the manufacturers 'off-licence' advice is that they can be crushed and mixed with water, apple juice, or apple sauce so long as taken straight away.
     
    Link  Independent reviews
    Link  MHRA safety information on hypersensitivity May 2011
    Link  MHRA: increased risk of bleeding—information on timing of loading dose
    Link  NICE TA317 (replaces TA182): Acute coronary syndrome - prasugrel
    Link  NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
       
    Ticagrelor (Brilique®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet, Orodispersible tablet
  • For use in patients that meet NICE criteria. Specify duration of therapy on discharge.
  • Treatment should be stopped when clinically indicated or at a maximum of 3 years post MI as per NICE TA 420
  • Orodispersible tablets can be dispersed in water for nasogastric tube (CH8 or greater) administration. It is important to flush the nasogastric tube through with water after administration of the mixture. 
  • Link  Link to reviews
    Link  NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
    Link  NICE TAG 236: Ticagrelor for ACS
       
    Tirofiban (Aggrastat®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Infusion (secondary care only)

    • NUH: Specialist use only
    • SFH: Not routinely stocked. Eptifibatide should be used for cardiac indications.
     
    Link  Link to reviews
    Link  Price comparison graph of eptifibatide vs tirofiban
       
    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
    Alteplase (Actilyse Cathflo®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Line lock NUH only
  • Line lock for paediatric haemodialysis patients 
  •    
    Alteplase (Actilyse®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (secondary care only)
    At NUH:

    • 20mg vial restricted for vascular surgery, 50mg vial restricted for Pulmonary Embolism (PE) (specialist advice)
    • A dedicated NUH prescription and administration record is available for alteplase (rTPA) infusions for catheter directed arterial or venous thrombolysis – see link
      At SFH:
    • 20mg vial stocked in theatre for femoral arterial thrombolysis. (Can be borrowed by x-ray)
    • 50mg vial stocked in A&E for emergency treatment of massive PE as per BTS guidelines - See SFH protocol.
    • Stroke thrombolysis in ED (kept in a box labelled 'alteplase (stroke thrombolysis)’ in resus). May be used upto 4.5hrs after the onset of symptoms (use after 3 hrs is unlicensed). Use in patients >80yrs may be considered but is unlicensed. See dose table.
     
    Link  NICE TA264: Ischaemic stroke (acute) - alteplase
    Link  NUH: Prescription and administration record for Alteplase (rTPA) infusion for catheter directed arterial or venous thrombolysis
    Link  SFH: Alteplase for stroke dose table
    Link  SFH: Alteplase in empyema administration guide
    Link  Link to reviews
       
    Defibrotide
    Formulary
    Red
    High Cost Medicine
    BlueTeq

    Infusion

    Available at NUH only:

    Approved in accordance with NHS England commissioning policy for severe veno-occlusive disease following stem cell transplant.

    • BlueTeq form required
     
    Link  Link to reviews
    Link  NUH: Haematology guidance on Veno-Occlusive Disease in Bone Marrow Transplant
       
    Streptokinase
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (secondary care only)

    • Used as a pre-flush for non heart beating kidney retreival for transplantation
     
       
    Tenecteplase (Metalyse®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (secondary care only)

    • Restricted for use in Myocardial Infarction (MI)
     
    Link  Tenecteplase administration guide
       
    Urokinase
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (secondary care only)

    • For unblocking lines, instructions are in the UCL Injectable Medicines Administration guide book ("the Blue IV guide book") or SPC.
    • Further information on unblocking lines can be found in the Royal Marsden Manual.
     
    Link  Nottingham Children’s Hospital: Instillation of urokinase in chest drain
       
    02.11  Antifibrinolytic drugs and haemostatics to top
    Tranexamic Acid
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
  • Tablet
  • Injection
  • Nasal drops- tranexamic acid 8%W/V and glycerin 20% V/V (unlicensed)- SFH only
  • Topical solution (unlicensed). In an emergency 500mg/5ml injection can be used topically.
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  • Link  DTB review:OTC tranexamic acid for heavy menstrual bleeding (password protected)
    Link  NICE Evidence summary: Tranexamic acid for significant haemorrhage following trauma
    Link  NICE guideline on heavy menstrual bleeding
       
    02.11  Blood-related products
    Albutrepenonacog alfa (Idelvion®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     
       
    Antithrombin III (Kybernin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item please contact blood bank for details and availability.

     
       
    Efmoroctocog alfa (Elocta®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Eftrenonacog alfa (Alprolix®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability.

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Emicizumab (Hemlibra®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Injection

    Available at NUH only:

    • Approved in accordance with the Clinical Commissioning Policy for the prophylaxis in people with cogential haemophilia A with factor VIII inhibitors (all ages).
    • Approved in accordance with the Clinical Commissioning Policy for the prophylaxis in people with severe cogential haemophilia A without factor VIII inhibitors (all ages).

    Available through homecare for NUH patients.  Please contact pharmacy medicines homecare team for further information.

     
       
    Factor Eight Inhibitor Bypassing Fraction (Feiba®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Factor VIIa (Recombinant), Eptacog alfa (NovoSeven®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item please contact blood bank for details and availability.

    • At SFH, one dose is stocked in blood bank. In the event of further doses being required (consultant haematologist request only), contact pharmacy (or on call pharmacist out of hours). See memo for further details.
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
       
    Factor VIII (NovoEight®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Factor VIII - Von willebrand factor (Type 8Y®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     
       
    Factor VIII - Von willebrand factor (Wilate®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     
       
    Factor VIII + von Willebrand factor (Voncento®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Factor VIII, von willebrand factor - NUH only

    Non pharmacy item please contact blood bank for details and availability

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Human Fibrinogen (Riastap®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Moroctocog alfa (Refacto®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Nonacog alfa (BeneFIX®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Octocog alfa (Advate®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Non pharmacy item, please contact blood bank for details and availability

     

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Octocog alfa (Kogenate®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     
       
    Protein C Concentrate (Ceprotin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Non pharmacy item please contact blood bank for details and availability. 
       
    Prothrombin Complex Concentrate  (Octaplex®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    SFH:  Pharmacy to order in for pathology to keep as stock

    Non pharmacy item please contact blood bank for details and availability.

     
    Link  (SFH) Octaplex administration guide
    Link  Manufacturers data sheet (SPC)
       
    Simoctocog alfa (Nuwiq®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Recombinant Factor VIII Product - NUH only

    Non pharmacy item please contact blood bank for details and availability

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
       
    Susoctocog alfa (Obizur®)
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Injection

    Approved in accordance with the Clinical Commissioning Policy for use in treating bleeding episodes in people with acquired haemophilia A (all ages).

    Non pharmacy item, please contact haemophilia unit for details and availability.

     
       
    Von willebrand factor (Willfact®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Non pharmacy item, please contact blood bank for details and availability

     
       
    02.12  Lipid-regulating drugs
    Alirocumab (Praluent®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Homecare

    Injection (pre-filled pen)

    • Approved in line with NICE TA393 for treating primary hypercholesterolaemia and mixed dyslipidaemia. For use under supervision of consultant lipidologists only
    • Available through homecare for NUH and SFH patients.  Please contact pharmacy medicines homecare team for further information.
     
    Link  NICE TA393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    Evolocumab (Repatha® )
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Homecare

    Injection (pre-filled pen, pre-filled syringe)

    • Approved in line with NICE TA394 for treating primary non-familial hypercholesterolaemia and mixed dyslipidaemia and primary heterozygous familial hypercholesterolaemia. For prescribing by consultant lipidologists only.
    • Use for homozygous familial hypercholesterolaemia is commissioned by NHS England only through established apheresis centres. Any request for treatment in this circumstance would need to be referred to one of the following: Central Manchester University Hospitals NHS Foundation Trust; Queen Elizabeth Hospital Birmingham; Royal Brompton and Harefield NHS Foundation Trust; Imperial College NHS Trust and University Hospitals Bristol NHS Foundation Trust.
    • Available through homecare for NUH and SFH patients.  Please contact pharmacy medicines homecare team for further information.
     
    Link  NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
       
    02.12  Bile acid sequestrants
    Colestyramine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Powder, sugared and sugar free options

    • July 2019: Major supply problems. See here for SFH and wholesaler current stocks and here for details of alternatives.
     
    Link  Price graph: colestyramine and other agents used in bile acid related diarrhoea
    Link  SPS (Jun19): Shortage of Bile acid sequestrants
       
    Colesevelam
    (Bile Acid Malabsorption)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • July 2019: Major supply problems. See here for SFH and wholesaler current stocks and here for details of alternatives.
    • 2nd line for patients with clinically confirmed BAM by SEHCAT testing (except for patients post ileal resection) and problematic diarrhoea causing incontinence or nocturnal frequency.  
    • Only for patients unable to take colestyramine due to unpalatability after a reasonable trial. It is expected that a patient will have tried mixing colestyramine with other liquids such as fruit juice, skimmed milk, thin soup, fruit smoothies if mixing it with water is unpalatable. Colestyramine can also be mixed with pulpy fruits with a high moisture content such as apple sauce. Once the powder has soaked into the liquid it should be thoroughly stirred or shaken and consumed immediately. It will thicken if left for a prolonged period.
    • Colesevelam should not be offered as an alternative to patients experiencing side effects from colestyramine such as constipation and bloating as this is a class effect of bile acid sequestrants.
    • Limited evidence base and significantly more expensive than colestyramine.
    • Secondary care will confirm effectiveness of colesevelam before transfer to primary care. Phone follow up is acceptable.
    • NB colesevelam for hypercholesterolaemia is classified Grey (see below).
     
    Link  Link to reviews
    Link  NICE Evidence Summary: Colesevelam for bile acid malabsorption
    Link  Price graph: colestyramine and other agents used in bile acid related diarrhoea
    Link  SPS (Jun19): Shortage of Bile acid sequestrants
       
    02.12  Ezetimibe
    Ezetimibe (Ezetrol®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Overused drug. See quick guide.
    • Note: not licensed or evidenced for prevention of CV events.
    • Combined preparation with simvastatin (Inegy®) non-formulary (£11 per month more expensive than single constituents)
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  Independent drug reviews
    Link  NICE TA385: Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia
       
    02.12  Fibrates to top
    Fenofibrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Micro Capsule
  • Supralip 160mg is equivalent to 200mg of the other micronised brands.  
  • Link  Link to reviews
       
    02.12  Statins
    Atorvastatin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Chewable tablet

    • Licensed chewable tablets available (approx £26 per month for 20mg vs £0.80 for tablets, DT Mar18).
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
     
    Link  MHRA Drug Safety Update (Dec 2014)
       
    Simvastatin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Licensed liquid is very expensive (approx £200 for 28 days, DT Aug20). 
    • Tablets disperse in water if needed. They are poorly soluble and degrades rapidly so give immediately (not licensed). See here for general advice on dispersing tablets.
    • Atorvastatin chewable tablets are available (expensive 80mg =£105/mo.) if simvastatin tablets cannot be swallowed or dispersed.
     
    Link  MHRA Drug Safety Update (Dec 2014)
       
    Pravastatin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet.
  • Pravastatin is not very potent and should only be needed in rare cases of important interactions with other drugs, or minor intolerance to simvastatin.
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    Rosuvastatin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green

    Tablet

    • May be considered amongst alternative options if atorvastatin not tolerated.
     
    Link  Link to reviews
    Link  Rosuvastatin PrescQIPP review
    Link  Rosuvastatin QIPP further information
    Link  Rosuvastatin QIPP summary
       
    02.12  Nicotinic acid group
    02.12  Omega-3 fatty acid compounds
    Omega-3-Acid Ethyl Esters
    (Hypertriglyceridaemia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3
     
       
    02.13  Local sclerosants
    Ethanolamine Oleate
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
    NUH only 
       
    Sodium Tetradecyl Sulphate (Fibro-Vein®)
    Formulary
    Red
    Injection (secondary care only) 
       
    02.14  Other to top
    Bretschneider’s HTK-Solution (CUSTODIOL®)
    (Cardioplegia Solution)
    Restricted Drug Restricted

    Solution
    (Medical Device - CE marked)

    NUH only: Consultant Cardiac Surgeon use only for minimally invasive procedures when cross clamping of the aorta is required.

     
       
     ....
     Non Formulary Items
    Abciximab

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Injection - Discontinued Jan 2019

    Link  Link to reviews
     
    Acebutolol  (Sectral®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Acipimox  (Olbetam®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Aliskiren  (Rasilez®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Not included in NICE hypertension guideline as insufficient evidence of its effectiveness. Also some safety concerns (see links below).
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value that should NEVER be prescribed in primary care.
    Link  EMA advise clinicians to review Aliskiren prescribing following termination of ALTITUDE study
    Link  Link to reviews
    Link  MHRA warning 2014: Aliskiren: risk of cardiovascular and renal adverse reactions
     
    Ambrisentan

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    Medicines for pulmonary hypertension are commissioned via specialist centres only.

    • Contact High Cost Drugs pharmacists or Medicines Information for further info
    Link  Link to reviews
    Link  NHSE: National Pulmonary Hypertension commissioning policy
     
    Amlodipine and Valsartan  (Exforge®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Andexanet alfa  (Ondexxya®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Aprotinin  (Trasylol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Withdrawn 2007.
    See Chapter 20 for unlicensed product
     
    Atenolol and Co-amilozide  (Kalten®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Atenolol and Nifedipine  (Beta-Adalat®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Atenolol and Nifedipine  (Tenif®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Atorvastatin and Ezetimibe  (Atozet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment (APC July 15)
     
    Azilsartan
    (Edarbi)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  •  
    Bemiparin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Bezafibrate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
     
    Burinex A®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Burinex K®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cangrelor

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • No formal submission
    Link  Link to reviews
    Link  NICE advice [ESNM64]
    Link  NICE TA351: Reducing Artherothrombotic Events
     
    Captopril and Hydrochlorothiazide  (Capozide®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Captopril and Hydrochlorothiazide  (Co-zidocapt®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Catridecacog  (NovoThirteen®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    No formal submission
     
    Celiprolol

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Centyl K®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cilazapril  (Vascace®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Discontinued 2014
  •  
    Cilostazol  (Pletal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Not recommended by NICE for Intermittent Claudication.

    Link  Independent reviews
    Link  MHRA: Cilostazol (Pletal) - Risks of cardiovascular and bleeding events
     
    Ciprofibrate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment
     
    Clopidogrel 300mg  (Plavix®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Use 75mg generic tablets instead
     
    Co-amilozide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    amiloride/ hydrochlorothiazide
     
    Co-flumactone

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Colesevelam
    (Hypercholesterolaemia)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Reviewed and rejected due to a lack of supporting evidence, APC September 2017.

     
    Colestipol  (Colestid®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • July 2019: Major supply problems. See here for SFH and wholesaler current stocks and here for details of alternatives.
    • APC (Jul 19) agreed that colestipol may be prescribed for bile acid malabsorption (on specialist advice) in the event that colesevelam and colestyramine are unavailable due to current stock shortage. See SPS info.
    • Reviewed and rejected for bile acid malabsorption Sept 17 due to a lack of supporting evidence.
    Link  Price graph: colestyramine and other agents used in bile acid related diarrhoea
    Link  SPS (Jun19): Shortage of Bile acid sequestrants
     
    Co-tenidone (atenolol and chlortalidone)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Co-triamterzide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cozaar- Comp®
    (Losartan & hydrochlorothiazide)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cyclopenthiazide  (Navidrex®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Digitoxin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Dipyridamole and Aspirin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Each capsule contains 200mg dipyridamole MR and 25 mg aspirin

    Discontinued July 2020

     
    Diumide-K Continus®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Dopexamine

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Infusion (secondary care only)
  • Discontinued April 2016
  • Link  SFH guidance on drugs requiring central line adminstration
     
    Drotrecogin Alfa (Activated)  (Xigris®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Marketing authorisation withdrawn October 2011
  • Link  Link to reviews
     
    Dyazide®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Enalapril and Hydrochlorothiazide  (Innozide®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Enoxaparin  (BECAT® )

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Eprosartan  (Teveten®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Etamsylate  (Dicynene®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Tablets discontinued in the UK in 2012. Unlicensed tablets (more expensive) are available through IDIS. IV discontinued Nov 2002.
  •  
    Factor IX Fraction, Dried

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
     
    Factor IX, recombinant  (Rixubis®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal submission
     
    Factor VIII Fraction, Dried

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
     
    Factor VIII Inhibitor Bypassing Fraction

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
     
    Factor XIII Fraction, Dried

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
     
    Felodipine

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Tablet MR

     
    Fluvastatin  (Lescol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Fosinopril

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Fresh Frozen Plasma

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Frusene®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Gemifibrozil

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Glyceryl Trinitrate
    (AEROSOL spray)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Use the PUMP spray as this is much less expensive than the aerosol spray.
  •  
    Guanethidine Monosulphate  (Ismelin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Human Coagulation Factor X  (Coagadex®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Injection

    • Not recommended in the NHS England Clinical Commissioning Policy 
    Link  Clinical Commissioning Policy: Human coagulation factor X for hereditary factor X deficiency (all ages)
     
    Human fibrinogen & thrombin  (Raplixa® )

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission (APC May 15)
  •  
    Imidapril  (Tanatril®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Indoramin  (Baratol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Inositol Nicotinate  (Hexopal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Not recommended by NICE for Intermittent Claudication.
     
    Isosorbide Dinitrate
    (Oral)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Prodrug of isosorbide mononitrate - use that instead.
     
    Isradipine  (Prescal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued and removed from BNF 2014
     
    Kalspare®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lacidipine  (Motens®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lasikal®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lasilactone®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lepirudin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Injection
  • Previously available at SFH during danaparoid supply problems.
  • Was discontinued April 2012
  •  
    Lisinopril and Hydrochlorothiazide  (Carace® Plus)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lisinopril and Hydrochlorothiazide  (Lisicostad®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lisinopril and Hydrochlorothiazide  (Zestoretic®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lomitapide  (Lojuxta®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    Capsules

    • GREY Non-formulary
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value that should never be prescribed.
    • Costs over £17,000 per month
    • Licensed as an adjunct to diet and other lipid-lowering drugs in homozygous familial hypercholesterolaemia.
    Link  Link to reviews
     
    Macitentan  (Opsumit®
    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    Medicines for pulmonary hypertension are commissioned via specialist centres only.

    Link  Link to reviews
     
    Moexipril  (Perdix®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Moracizine

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued 2007
     
    Moxisylyte  (Opilon®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Navispare®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Nebivolol  (Nebilet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Classified grey for essential hypertension
    Link  Link to reviews
     
    Neo-NaClex-K®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Nicotinic Acid  (Niaspan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued July 2011
    Link  Link to reviews
     
    Nicotinic acid/ laropiprant  (Tredaptive ®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Withdrawn Jan 21st 2013
  • No further Tredaptive tablets should be dispensed. Patients should be referred to their doctor for review on a non-urgent basis.
  • Previously approved for use on specialist initiation (Amber 2) for patients with high lipoprotein a, familial hypercholesterolaemia and secondary prevention in line with NICE guidance for nicotinic acid (if other agents are contraindicated or not tolerated) - now classified Grey as above pending EMA decision.
  • Classified grey for primary prevention in patients who do not have familial hypercholesterolaemia
  • Link  EMA recommends withdrawal of Tredapative
    Link  Independent reviews
     
    Nisoldipine  (Syscor® MR)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Octocog alfa sucrose plasma protein-free  (Iblias®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Olmesartan  (Sevikar®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Omega-3-Acid Ethyl Esters

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Independent reviews
    Link  NICE: schizophrenia - omega-3 fatty acid medicines
    Link  PrescQIPP: Omega 3 fatty acids review
     
    Omega-3-Marine Triglycerides  (Maxepa®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  NICE: schizophrenia - omega-3 fatty acid medicines
    Link  PrescQIPP: Omega 3 fatty acids review
     
    Oxerutins  (Paroven®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Oxprenolol

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Oxprenolol and Cyclopenthiazide  (Trasidrex®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Pentoxifylline  (Trental®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Not recommended by NICE for Intermittent Claudication.
    Link  UKMI Q&A: Oral treatments for treating Peyronie’s disease
     
    Perindopril Arginine  (Coversyl® Arginine)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    More expensive different salt form of perindopril to extend patent life.
  • Perindopril erbumine 2mg is equivalent to perindopril arginine 2.5mg
  • Coversyl® Arginine Plus also contains indapamide is also non-formulary.
  •  
    Pindolol  (Visken®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Pindolol and Clopamide  (Viskaldix®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Prazosin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Quinapril  (Accupro®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Quinapril and Hydrochlorothiazide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Ramipril and Felodipine  (Triapin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Rasitro®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Aliskiren, amlodipine and hydrochlorothiazide combination
     
    Reteplase  (Rapilysin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
    Discontinued March 2016
    Injection (secondary care only)
    Restricted for use in Myocardial Infarction (MI)
    see - Tenecteplase (Metalyse®) entry above
     
    Riociguat  (Adempas®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    Medicines for pulmonary hypertension are commissioned via specialist centres only.
  • Contact High Cost Drugs pharmacists or Medicines Information for further info
  • Grey non-formulary (no formal assessment) - awaiting National Commissioning policy (APC May 2014 horizon-scanning)
  • Link  Link to reviews
     
    Sevikar HCT®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Olmesartan, amlodipine, hydrochlorothiazide combination
     
    Simvastatin and Ezetimibe  (Inegy®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Link to reviews
     
    Sitaxentan Sodium  (Thelin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Withdrawn 2010
     
    Tadalafil  (Adcirca®)
    (Pulmonary hypertension)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Medicines for pulmonary hypertension are commissioned via specialist centres only.
  • Contact High Cost Drugs pharmacists or Medicines Information for further info
  • At SFH for Commissioning detail see Information sheet here
  • Link  National Pulmonary Hypertension commissioning policy
     
    Telmisartan

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Terazosin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Timolol and Bendroflumethiazide  (Prestim®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Timolol and Co-amilozide  (Moducren®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Torasemide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Trandolapril  (Gopten®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Trandolapril and Verapamil  (Tarka®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Triamterene  (Dytac®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Valsartan

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Memo about alternatives during the shortage (March 2014)
     
    Vorapaxar  (Zontivity®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  •  
    Xipamide  (Diurexan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
      
    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

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

    netFormulary