| Formulary Chapter 2: Cardiovascular system - Full Chapter
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| Chapter Links... |
 Cardiology guidelines (NICE) |
 Heart failure traffic lights - Nottinghamshire management of heart failure patients |
| UKMI: MI - secondary prevention - Summary of NICE guidance (CG172) |
| Details... |
| 02.09 |
Antiplatelet drugs |
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Aspirin (antiplatelet)
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Formulary
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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.
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Aspirin’s effect on reducing cancer risk
NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
SFH advice on NSAIDS with low dose aspirin
UKMI Q&A Lack of evidence to support EC aspirin to reduce GI side-effects
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Clopidogrel
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Formulary
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Tablet
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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
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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
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Link to reviews
MHRA: Aquired haemophilia risk (Dec13)
NICE Evidence summary: Clopidogrel for transient ischaemic attack
NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
PPIs and clopidogrel advice
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Dipyridamole
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Formulary
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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
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Eptifibatide (Integrilin®)
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Formulary
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Injection (secondary care only)
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Price comparison graph of eptifibatide vs tirofiban
SFH eptifibatide dose table
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Prasugrel
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 Restricted
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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.
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Independent reviews
MHRA safety information on hypersensitivity May 2011
MHRA: increased risk of bleeding—information on timing of loading dose
NICE TA317 (replaces TA182): Acute coronary syndrome - prasugrel
NUH Lite Bite: Co-prescribing of anticoagulant and antiplatelet drugs (Oct 18)
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Ticagrelor (Brilique®)
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Restricted
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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.
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Link to reviews
NICE TA420: Ticagrelor for preventing atherothrombotic events after myocardial infarction
NICE TAG 236: Ticagrelor for ACS
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Tirofiban (Aggrastat®)
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Restricted
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Infusion (secondary care only)
- NUH: Specialist use only
- SFH: Not routinely stocked. Eptifibatide should be used for cardiac indications.
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Link to reviews
Price comparison graph of eptifibatide vs tirofiban
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| Non Formulary Items |
Abciximab
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Non Formulary
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Injection - Discontinued Jan 2019
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Link to reviews
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Cangrelor
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Non Formulary
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Link to reviews
NICE advice [ESNM64]
NICE TA351: Reducing Artherothrombotic Events
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Clopidogrel 300mg (Plavix®)
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Non Formulary
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Use 75mg generic tablets instead |
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Dipyridamole and Aspirin
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Non Formulary
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Each capsule contains 200mg dipyridamole MR and 25 mg aspirin
Discontinued July 2020 |
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Vorapaxar (Zontivity®)
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Non Formulary
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No formal submission |
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
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Description |
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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.
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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.
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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.
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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
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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.
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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. |
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