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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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02.09  Expand sub section  Antiplatelet drugs
Aspirin (antiplatelet)
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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
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Formulary
Green

Tablet

  • 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. 

  • 25mg/5ml unlicensed liquid special available for paediatric use at NUH only.  
  • If needed tablets can be dispersed in water (unlicensed). More Info
 
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
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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®)
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Formulary
Red
Injection (secondary care only)
 
Link  Price comparison graph of eptifibatide vs tirofiban
Link  SFH eptifibatide dose table
   
Prasugrel
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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®)
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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®)
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    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
       
     ....
     Non Formulary Items
    Abciximab

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    Non Formulary
    Grey

    Injection - Discontinued Jan 2019

    Link  Link to reviews
     
    Cangrelor

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    Non Formulary
    Grey
    • No formal submission
    Link  Link to reviews
    Link  NICE advice [ESNM64]
    Link  NICE TA351: Reducing Artherothrombotic Events
     
    Clopidogrel 300mg  (Plavix®)

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    Non Formulary
    Grey
    Use 75mg generic tablets instead
     
    Dipyridamole and Aspirin

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    Non Formulary
    Grey

    Each capsule contains 200mg dipyridamole MR and 25 mg aspirin

    Discontinued July 2020

     
    Vorapaxar  (Zontivity®)

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    Non Formulary
    Grey
  • No formal submission
  •  
      
    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

      

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