Download The formulary has been developed to promote safe, evidence based

The formulary has been developed to promote safe, evidence based and cost effective
prescribing in general practice.
Main features of the formulary:
Applies to all practices within Telford and Wrekin
Provides guidance on first line and second line drug choices
Developed in collaboration with secondary care colleagues
Is a constantly evolving document
Provides prescribing notes with key messages on best practice and links to the CCG’s
prescribing guidelines
Classification key:
Suitable for General Practice initiation and
continuation
Suitable for continued prescribing in General Practice
following initiation by a specialist
Restricted use – only prescribe following specialist
initiation and stabilisation, under a shared care
agreement (ESCA).
Specialist prescribing only – not suitable for
prescribing in General Practice
NB.
The formulary is not designed to replace the BNF and all prescribers should continue to refer to
the BNF and the relevant Summary of Product Characteristics (SPCs) for further information on
side effects, drug interactions and more comprehensive information on a wider range of drugs.
Disclaimer
Whilst every effort has been made to ensure the accuracy of the information contained within the formulary, errors or omissions
may occur in the content. Interpretation and application of the formulary remains the responsibility of the individual clinician.
Section 2: Cardiovascular System
Section
Description
BNF 2.1.1
Cardiac glycosides
BNF 2.2.1
Thiazides and related diuretics
BNF 2.2.2
Loop diuretics
BNF 2.2.3
Potassium-sparing diuretics and aldosterone antagonists
BNF 2.2.4
Potassium-sparing diuretics with other diuretics
BNF 2.2.8
Diuretics with potassium
BNF 2.3.2
Anti-arrhythmic drugs
BNF 2.4
Beta-adrenoreceptor blocking drugs
BNF 2.5
Hypertension and heart failure
BNF 2.5.1
Vasodilator antihypertensive drugs
BNF 2.5.2
Centrally acting antihypertensive drugs
BNF 2.5.4
Alpha-adrenoreceptor blocking drugs
BNF 2.5.5.1
Angiotensin-converting enzyme (ACE) inhibitors
BNF 2.5.5.2
Angiotensin-II receptor antagonists
BNF 2.6.1
Nitrates
BNF 2.6.2
Calcium-channel blockers
BNF 2.6.3
Other antianginal drugs
BNF 2.6.4
Peripheral vasodilators and related drugs
BNF 2.7.3
Cardiopulmonary resuscitation
BNF 2.8.1
Parenteral anticoagulants
BNF 2.8.2
Oral anticoagulants
BNF 2.9
Antiplatelet drugs
BNF 2.11
Antifibrinolytic drugs and haemostatics
BNF 2.12
Lipid-regulating drugs
Section 2: Cardiovascular System
BNF 2.1.1 Cardiac glycosides
Digoxin
Prescribing notes
Dosage guide
Available as Digoxin tablets 62.5micrograms, 125micrograms, 250micrograms; Elixir
50micrograms/mL
Digoxin is indicated for rate control in atrial fibrillation and symptomatic heart
failure; it has no role in the prophylaxis of atrial fibrillation.
For rapid rate control in atrial fibrillation, a loading dose of digoxin may be given
orally.
Regular measurements of plasma digoxin concentrations are not usually
required except to confirm toxic or sub–therapeutic levels, or to check
compliance. The plasma digoxin concentration range of 1.0 to 2.5nmol/L
should never be considered in isolation and should be used with other patient
data as an important component in clinical decision making.
Digoxin should be used with particular caution in the elderly and patients with
renal impairment.
Hypokalaemia predisposes to digoxin toxicity.
Digoxin levels may be increased by drugs such as amiodarone (halve the dose
of digoxin), calcium channel blockers, quinidine, quinine, hydroxychloroquine.
Bioavailability of digoxin varies between its forms. If moving from tablet to liquid the
dose should be reduced by 20% i.e. 62.5mcg tablet is equivalent to 50mcg (1ml)
liquid.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2309.htm
Maintenance, 62.5 to
250micrograms ONCE daily
Older Patients - Digoxin
Loading and maintenance
doses of digoxin should be
adjusted according to renal
function: age, sex and weight
need to be considered. A
lower maintenance dose (i.e.
62.5 to 125 micrograms daily)
is usually adequate in older
patients.
BNF 2.2.1 Thiazides and related diuretics
Thiazides are used to relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure.
If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as indapamide (2.5 mg once daily) in
preference to a conventional thiazide diuretic such as bendroflumethiazide.
NHS Telford & Wrekin CCG - Guidance on the management of hypertension
Prescribing notes
First Line
Indapamide 2.5mg
Second Line
Bendroflumethiazide
Modified Release formulation NOT required use standard release Hypertension: 2.5mg daily
2.5mg tablets
Step 3 for hypertension (NICE CG127)
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/PHP792indapamide.htm
Hypertension: For existing patients only
Prescribe indapamide to new patients.
Bendroflumethiazide 2.5mg daily produces a maximal or nearmaximal blood pressure lowering effect, with very little
biochemical disturbance. Higher doses cause more marked
changes in plasma potassium, uric acid, glucose and lipids, with
no advantage in blood pressure control.
Metolazone
Dosage guide
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/2324.htm
Specialist initiation only - only unlicensed formulation
available as 2.5mg
Continue prescribing only on advice of cardiologist
Hypertension: 2.5mg daily
Allow 4 weeks for maximal
antihypertensive effect of
bendroflumethiazide.
Oedema, initially 5–10 mg daily in the
morning or on alternate days;
maintenance 5–10 mg 1–3 times weekly
BNF 2.2.2 Loop diuretics
Loop diuretics are used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure.
Furosemide and bumetanide are similar in activity; both act within 1 hour of oral administration and diuresis is complete within 6
hours so that. If necessary, they can be given twice in one day without interfering with sleep
Prescribing notes
Furosemide Available as
furosemide 20 mg, 40 mg, 500 mg
Tablets
furosemide Oral solution, sugarfree
20 mg/5 mL (150ml) OR
40 mg/5 mL ( 150 mL)
Bumetanide Available as bumetanide 1 mg and
5 mg Tablets
If liquid formulation is needed use
Furosemide
Dosage guide
Oedema: initially 40mg daily then adjusted according to response.
maintenance 20–40 mg daily.
Furosemide produces a dose-dependent diuresis within 1 hour if given orally
or 30 minutes if given intravenously; duration of action, 6 hours.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2353.htm
Oedema: 1 mg in the morning, repeated after 6–8 hours if necessary; severe
cases, 5 mg daily increased by 5 mg every 12–24 hours according to
response; Elderly 500 micrograms daily may be sufficient
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2356.htm
BNF 2.2.3 Potassium-sparing diuretics and aldosterone antagonists
Prescribing notes
Amiloride and spironolactone are weak diuretics with potassium–sparing properties, given with other diuretics if
hypokalaemia is a problem; may take 2-3 days for full effect.
Potassium supplements must not be given with potassium-sparing diuretics. Administration of a potassium-sparing
diuretic to a patient receiving an ACE inhibitor or an angiotensin-II receptor antagonist can also cause severe
hyperkalaemia.
Spironolactone is used for oedema in hepatic cirrhosis or chronic heart failure, and primary hyperaldosteronism.
Spironolactone 25mg daily has been shown to reduce mortality in patients with chronic heart failure receiving
standard therapy including ACE inhibitors; renal function and electrolytes, especially potassium, should be monitored.
Eplerenone is licensed for use with standard therapy including beta blockers to reduce risk of cardiovascular mortality
and morbidity in stable patients with left ventricular dysfunction (left ventricular ejection fraction ≤ 40%) and clinical
evidence of heart failure after recent MI. Therapy should be started within 3 to 14 days of the MI.
Eplerenone is accepted for use in addition to standard optimal therapy, to reduce the risk of cardiovascular mortality
and morbidity in adult patients with NYHA class II (chronic) heart failure and left ventricular systolic dysfunction (LVEF
≤30%).
Patients taking spironolactone or eplerenone particularly if also taking an ACE inhibitor or an angiotensin -II receptor
antagonist must have their U&E’s checked regularly to monitor for signs of hyperkalaemia. Therapy with eplerenone
must be reviewed by prescribers after one year as the evidence of benefit beyond one year is not known at this
stage.
Eplerenone may also be used as adjunctive treatment in chronic heart failure if patients cannot tolerate
spironolactone.
Use with caution in renal impairment.
Amiloride
Prescribing notes
Amiloride is a weak diuretic. It causes retention of potassium and is
therefore given with thiazide or loop diuretics as a more effective
alternative to potassium supplements.
Potassium supplements must not be given with potassium-sparing
diuretics. Administration of a potassium-sparing diuretic to a patient
receiving an ACE inhibitor or an angiotensin-II receptor antagonist can
also cause severe hyperkalaemia.
Dosage guide
Used alone, initially 10 mg daily or
5 mg twice daily, adjusted
according to response; max. 20 mg
daily
With other diuretics, congestive
heart failure and hypertension,
initially 5–10 mg daily
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2363.htm
Available as tablets 5 mg and Oral solution, sugar-free 5 mg/5 mL
Aldosterone Antagonists
Prescribing notes
Dosage guide
Spironolactone HEART FAILURE: Spironolactone 25mg daily has been shown to reduce
Oedema and ascites in cirrhosis
symptoms and mortality in patients with severe heart failure who are
of the liver, 100–400 mg daily,
already receiving an ACE inhibitor and a diuretic and possibly digoxin.
adjusted according to response
Close monitoring of serum creatinine and potassium is necessary. Start
Oedema in congestive heart
at spironolactone 25 mg once daily. Check blood chemistry at: 1, 4, 8
failure, initially 100 mg (range 25–
and 12 weeks; 6, 9 and 12 months; 6/12 thereafter:
200 mg) daily in single or divided
doses; maintenance dose
If K+ rises to between 5.5 and 5.9 mmol/litre or creatinine rises to
adjusted according to response
200 µmol/litre: reduce dose to 25 mg on alternate days and monitor
Moderate to severe heart failure
UE’s closely
(adjunct), initially 25 mg once
If K+ rises to > 6.0 mmol/litre or creatinine to > 200 µmol/litre: stop
daily, increased according to
spironolactone and seek specialist advice
response to max. 50 mg once
Resistant hypertension (adjunct),
For use in Hypertension see below
NHS Telford and Wrekin CCG Heart Failure Prescribing Guidelines
25 mg once daily [unlicensed
indication]
NICE Guidance for Management of Chronic Heart Failure
Eplerenone
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2371.htm
For initiation by Cardiologist only, in patients for whom spironolactone Initially 25 mg once daily, increased
is not appropriate, and then continuation in primary care.
within 4 weeks to 50 mg once daily
Eplerenone is licensed for use as an adjunct in left ventricular
dysfunction with evidence of heart failure after a myocardial infarction; it
is also licensed as an adjunct in chronic mild heart failure with left
ventricular systolic dysfunction.
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/129013.htm
Available as 25mg and 50mg tablets
Renal impairment: increased risk of
hyperkalaemia—close monitoring
required; initially 25 mg on alternate
days if eGFR 30–60 mL/minute/1.73 m2,
adjust dose according to serumpotassium concentration—consult
product literature; avoid if eGFR less
than 30 mL/minute/1.73 m2
BNF 2.2.4 Potassium-sparing diuretics with other diuretics
Potassium-sparing diuretics are not usually necessary in the routine treatment of hypertension, unless hypokalaemia develops.
Prescribe amiloride and furosemide or amiloride and bumetanide separately as required. Review renal function.
Prescribing notes
Combination products containing a diuretic plus potassium do not contain sufficient potassium to correct hypokalaemia
and are not recommended.
Fixed combinations of diuretics should only be considered if compliance is a problem.
Potassium-sparing diuretics such as amiloride are usually only necessary if hypokalaemia develops.
Prescribe a potassium sparing diuretic only if there is a clinical need to conserve potassium e.g. if potassium falls below
3.0mmol/L on diuretic alone or the patient is taking other drugs that prolong the QT interval- antipsychotics, antimalarials,
tricyclic antidepressants, antiarrhythmics, or if the patient is taking digoxin.
Potassium sparing diuretics should be discontinued before introducing an ACE inhibitor because of the risk of
hyperkalaemia. A low dose of spironolactone with an ACE inhibitor, however, may be beneficial in severe heart failure
provided serum potassium is monitored carefully.
There is an increased risked of hyperkalaemia when potassium-sparing diuretics are given with angiotensin-II receptor
antagonists
Dosage guide
Co-amilofruse Co-amilofruse 2.5/20 tablets (each containing amiloride 2.5mg, furosemide 20mg): oedema, 1 tablet daily.
Co-amilofruse 5/40 tablets (each containing amiloride 5mg, furosemide 40mg): oedema, 1 to 2 tablets daily.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/200390.htm
BNF 2.2.8 Diuretics with potassium
NO preparations recommended.
BNF 2.3.2 Drugs for arrhythmias
BNF Link: Management of arrhythmias
NICE CG37 The management of atrial fibrillation
Preparation
Further Information
Prescribing Guidance
Amiodarone
Amiodarone is used in the treatment Initiated by hospital specialist only.
of arrhythmias, particularly when other Amiodarone has a very long half-life and many weeks may be required to
drugs are ineffective or contraachieve steady-state plasma concentrations. This is particularly important
indicated. It can be used for
when interactions with amiodarone are considered. Please see BNF for
paroxysmal supraventricular, nodal and further details of interactions.
ventricular tachycardias, atrial
Patients should be advised to use a wide-spectrum sunscreen (to protect
fibrillation and flutter, and ventricular
against both long ultraviolet and visible sunlight) because of the possibility
fibrillation. It can also be used for
of phototoxic reactions with amiodarone.
tachyarrhythmias associated with
Monitoring:
Wolff-Parkinson-White syndrome. It
Chest X-ray, LFTs and TFTs before starting treatment.
should be initiated only under hospital Check LFTs and TFTs every six months.
or specialist supervision
Usual Dose:
200 mg 3 times daily for 1 week reduced to 200 mg twice daily for a further
week; maintenance, usually 200 mg daily or the minimum required to
control the arrhythmia
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2417.htm
Other Anti-arrhythmic drugs
Disopyramide Prevention and treatment of ventricular and supraventricular
arrhythmias, including after myocardial infarction; maintenance of
sinus rhythm after cardioversion
Oral administration of disopyramide is useful, but it has an
antimuscarinic effect which limits its use in patients susceptible to
angle-closure glaucoma or with prostatic hyperplasia.
Initiated by hospital specialist only.
300–800 mg daily in divided doses
Dronedarone Dronedarone is a multi-channel blocking anti-arrhythmic drug; it is Initiated by hospital specialist only.
licensed for the maintenance of sinus rhythm after cardioversion in Continued by GP under shared care
clinically stable patients with paroxysmal or persistent atrial
agreement. (usual dose 400 mg twice daily)
fibrillation, when altenative treatments are unsuitable; dronedarone
should be initiated and monitored under specialist supervision
Avoid if eGFR less than 30 mL/minute/1.73 m2
NICE Atrial fibrillation - dronedarone (TA197)
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/PHP904dronedarone.htm
Flecainide
Sotalol
Initiated by hospital specialist only.
Ventricular arrhythmias, initially 100 mg twice
Flecainide belongs to the same general class as lidocaine and
may be of value for serious symptomatic ventricular arrhythmias. It daily (max. 400 mg daily usually reserved for
may also be indicated for junctional re-entry tachycardias and for rapid control or in heavily built patients),
reduced after 3–5 days to the lowest dose that
paroxysmal atrial fibrillation
controls arrhythmia
Supraventricular arrhythmias, 50 mg twice
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/2426.htm
daily, increased if required to max. 300 mg
daily
Beta-blockers act as anti-arrhythmic drugs principally by
Initiated by hospital specialist only.
attenuating the effects of the sympathetic system on automaticity With ECG monitoring and measurement of
corrected QT interval, arrhythmias, initially
and conductivity within the heart
Sotalol, a non-cardioselective beta-blocker with additional class III 80 mg daily in 1–2 divided doses increased
gradually at intervals of 2–3 days to usual dose
anti-arrhythmic activity, is used for prophylaxis in paroxysmal
of 160–320 mg daily in 2 divided doses; higher
supraventricular arrhythmias. It also suppresses ventricular ectopic doses of 480–640 mg daily for life-threatening
beats and non-sustained ventricular tachycardia
ventricular arrhythmias under specialist
supervision
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/2521.htm
use half normal dose if eGFR 30–
60 mL/minute/1.73 m2; use one-quarter normal
dose if eGFR 10–30 mL/minute/1.73 m2; avoid
if eGFR less than 10 mL/minute/1.73 m2
Mexiletine
Unlicensed medication hospital prescribing only
Propafenone
Hospital initiation only not for primary care
prescribing
For treatment of life-threatening ventricular
arrhythmias.
Hospital initiation only not for primary care
prescribing
For the prophylaxis and treatment of
ventricular arrhythmias and also for some
supraventricular arrhythmias
BNF 2.4 Beta-adrenoreceptor blocking drugs
Diagnosis
Angina
Preparation
Prescribing Guidance
NHS Telford and Wrekin CCG Stable Angina Treatment Algorithm
NICE Clinical Guideline 126 Stable Angina
Atenolol tablets 25mg, 50mg, 100mg; syrup 25mg/5mL:
Atenolol
Angina, 100 mg daily in 1 or 2 doses. Low twice daily doses of atenolol should be considered
in certain patients e.g. angina with low BP
Bisoprolol
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2468.htm
Bisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg
Metoprolol
Hypertension and angina, usually 10 mg once daily (5 mg may be adequate in some
patients); max. 20 mg daily
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2481.htm
Metoprolol tablets 50mg,100mg
Angina, 50–100 mg 2–3 times daily
Anxiety
Propranolol
Arrhythmias
Sotalol
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP993-metoprololtartrate.htm
Anxiety with symptoms such as palpitation, sweating, tremor, 40 mg once daily, increased to
40 mg 3 times daily if necessary
Initiated by hospital specialist only.
Heart Failure
Bisoprolol
NHS Telford and Wrekin CCG - Guidance on the management of chronic heart failure
Initiation and titration by hospital consultant and/or specialist Heart Failure Service,
then suitable for GP prescribing.
Bisoprolol: Adjunct in heart failure initially 1.25 mg once daily (in the morning) for 1 week
Carvedilol
then, if well tolerated, increased to 2.5 mg once daily for 1 week, then 3.75 mg once daily for
1 week, then 5 mg once daily for 4 weeks, then 7.5 mg once daily for 4 weeks, then 10 mg
once daily; max. 10 mg daily
Carvedilol: Adjunct in heart failure initially 3.125 mg twice daily (with food), dose increased
at intervals of at least 2 weeks to 6.25 mg twice daily, then to 12.5 mg twice daily, then to
25 mg twice daily; increase to highest dose tolerated, max. 25 mg twice daily in patients with
severe heart failure or body-weight less than 85 kg and 50 mg twice daily in patients over
85 kg
Hypertension
NHS Telford & Wrekin CCG - Guidance on the management of hypertension
NICE Clinical Guideline 127 Hypertension
Beta-blockers are no longer preferred as a routine initial therapy for hypertension but consider them for
younger people, particularly;
o Women of child bearing potential
o Patients with evidence of increased sympathetic drive
o Patients with intolerance of or contraindications to ACEIs or A2RAs
If a patient’s BP is well controlled (<140/90) on regimen that includes a beta-blocker there is no absolute need
to replace the beta-blocker. However if the decision is made to stop a beta-blocker, the dose should be
stepped down gradually. Beta-blockers should not be withdrawn if the patient has a compelling reason (e.g.
symptomatic angina, previous MI) for being treated with one.
Atenolol
Hypertension, 25–50 mg daily (higher doses rarely necessary)
Bisoprolol
Hypertension in
Pregnancy
Labetalol
Migraine
prophylaxis
Propranolol
Hypertension and angina, usually 10 mg once daily (5 mg may be adequate in some
patients); max. 20 mg daily
Iinitially 100 mg twice daily with food, increased at intervals of 14 days to usual dose of
200 mg twice daily; up to 800 mg daily in 2 divided doses (3–4 divided doses if higher); max.
2.4 g daily
Migraine prophylaxis, 80–240 mg daily in divided doses
Propranolol
NICE CG 150 Headaches: Diagnosis and management of headaches in young people and
adults
Essential tremor, initially 40 mg 2–3 times daily; maintenance 80–160 mg daily
Essential tremor
Post-myocardial
infarction
Bisoprolol
NICE Clinical Guideline 172 MI – secondary prevention: Secondary prevention in primary
and secondary care for patients following a myocardial infarction
Metoprolol
Thyrotoxicosis
Propranolol
Early after an acute MI, all patients without left ventricular systolic dysfunction or
with left ventricular systolic dysfunction (symptomatic or asymptomatic) should be
offered treatment with a beta-blocker
For patients after an MI with left ventricular systolic dysfunction, who are being
offered treatment with a beta-blocker, clinicians may prefer to consider treatment
with a beta-blocker licensed for use in heart failure
Beta-blockers should be continued indefinitely after an acute MI
After a proven MI in the past, all patients with left ventricular systolic dysfunction
should be offered treatment with a beta-blocker whether or not they have
symptoms, and those with heart failure plus left ventricular systolic dysfunction
should be managed in line with 'Chronic heart failure' guidance
After a proven MI in the past, patients with preserved left ventricular function
who are asymptomatic should not be routinely offered treatment with a betablocker, unless they are identified to be at increased risk of further
cardiovascular events, or there are other compelling indications for betablocker treatment
Beta-blockers should be initiated as soon as possible when the patient is clinically
stable and titrated upwards to the maximum tolerated dose.
Initiated by hospital specialist only.
BNF 2.5 Hypertension and Heart Failure
BNF Link: Hypertension and Heart Failure
NHS Telford and Wrekin CCG - Guidance on the management of chronic heart failure
NHS Telford & Wrekin CCG - Guidance on the management of hypertension
NICE Clinical Guideline 127 Treatment of Hypertension
NICE Clinical Guideline 108 Chronic heart failure: Management of chronic heart failure in adults in primary and secondary
care
BNF 2.5.1 Vasodilator antihypertensive drugs
Hydralazine
Minoxidil
Sildenafil
Moderate to severe hypertension (initiated in hospital): 25 mg twice daily, increased Initiated by hospital
to usual max. 50 mg twice daily
specialist only Profound
Heart failure (initiated in hospital) 25 mg 3–4 times daily, increased every 2 days if
hypotension may occur
necessary; usual maintenance dose 50–75 mg 4 times daily
during first few days of
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1048-hydralazinetreatment.
hydrochloride.htm
Severe Hypertension (initiated in hospital): Initially 5 mg (elderly, 2.5 mg) daily, in 1–2 Initiated by hospital
divided doses, increased in steps of 5–10 mg at intervals of at least 3 days; max.
specialist only Severe
100 mg daily (seldom necessary to exceed 50 mg daily)
hypertension, in addition to
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1055diuretic + beta-blocker.
minoxidil.htm
Pulmonary arterial hypertension: 20 mg 3 times daily
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1059sildenafil.htm
Initiated by hospital
specialist only.
BNF 2.5.2 Centrally acting antihypertensive drugs
Methyldopa
Hypertension: Initially 250 mg 2–3 times daily, increased
gradually at intervals of at least 2 days, max. 3 g daily;
elderly initially 125 mg twice daily, increased gradually, max.
2 g daily
Caution: Monitor blood counts and liver-function before
treatment and at intervals during first 6–12 weeks or if
Hospital initiation only
Methyldopa is a centrally acting antihypertensive; it
may be used for the management of hypertension in
pregnancy. Side-effects are minimised if the daily
dose is kept below 1 g. Labetalol should be
considered first line
Moxonidine
unexplained fever occurs
BNF Link:
http://www.medicinescomplete.com/mc/bnf/current/PHP1077methyldopa.htm
Mild to moderate hypertension: 200 micrograms once daily in Hospital initiation only
the morning, increased if necessary after 3 weeks to
Moxonidine, a centrally acting drug, is licensed for
400 micrograms daily in 1–2 divided doses; max.
mild to moderate essential hypertension. It may have
600 micrograms daily in 2 divided doses (max. single dose a role when thiazides, calcium-channel blockers,
400 micrograms)
ACE inhibitors, and beta-blockers are not appropriate
BNF Link:
or have failed to control blood pressure
http://www.medicinescomplete.com/mc/bnf/current/PHP1081moxonidine.htm
BNF 2.5.4 Alpha-adrenoreceptor blocking drugs
Doxazosin
Dosage Information
Prescribing Guidance
Doxazosin tablets 1mg, 2mg,
Doxazosin is a fourth-line agent in the treatment of hypertension. It should
4mg: hypertension, 1mg daily,
be used with caution in patients with heart failure or impaired left ventricular
increased after 1 to 2 weeks to
function and should not be used as monotherapy.
2mg once daily and thereafter
Doxazosin may cause postural hypotension and first dose hypotension.
to 4mg once daily, if
Treatment should be initiated at the lowest dose possible.
necessary. Max 16mg daily.
Doxazosin may be prescribed with other antihypertensive drugs, particularly
beta-blockers, in the treatment of hypertension. It may be especially useful in
Use immediate release
patients with prostatism.
formulations of doxazosin
Doxazosin has a half life of approximately 22hours and will exert it’s effect
only.
for 24 hours thus allowing once daily dosing. (Avoid use of expensive
modified release (XL/MR) preparations)
Use at Step 4 in the treatment of hypertension NICE Clinical Guideline Treatment
of Hypertension
PHAEOCHROMOCYTOMA
Phenoxybenzamine
Hospital initiation only not for primary care prescribing
Phentolamine
Hospital initiation only not for primary care prescribing
BNF 2.5.5.1 Angiotensin-converting enzyme (ACE) inhibitors
All patients with type 1 diabetes and persisting microalbuminuria should be considered for treatment with an ACE inhibitor.
Patients with type 2 diabetes and persistent microalbuminuria should have cardiovascular risk factors aggressively tackled.
Patients who are post MI should be on an ACE inhibitor unless contra-indicated. e.g. in patients with renal artery stenosis.
For heart failure the dose of the ACE inhibitor should be titrated to a ‘target’ dose (or to the maximum tolerated dose if
lower). See BNF.
ACE inhibitors should be considered first-line antihypertensives in diabetics. In those who are intolerant of ACE inhibitors,
an angiotensin-II receptor antagonist may be considered as an alternative
NHS Telford and Wrekin CCG - Guidance on the management of chronic heart failure
NHS Telford & Wrekin CCG - Guidance on the management of hypertension
NICE Clinical Guideline 127 Treatment of Hypertension
NICE Clinical Guideline 108 Chronic heart failure: Management of chronic heart failure in adults in primary and secondary
care
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1124-angiotensin-converting-enzyme-inhibitors.htm
Hypertension
Lisinopril
Ramipril
Perindopril
Dosage Information
Lisinopril tablets 2.5mg, 5mg, 10mg, 20mg:
Hypertension, initially 2.5mg daily, maintenance 10mg to 20mg daily, max 40mg daily.
Ramipril capsules 1.25mg, 2.5mg, 5mg, 10mg:
Hypertension and heart failure (with a diuretic), 1.25mg to 10mg daily in 1 or 2 divided doses;
Perindopril erbumine tablets 2mg, 4mg, 8mg.
Hypertension: initially 4 mg once daily in the morning for 1 month, subsequently adjusted according to response; if
used in addition to diuretic, in elderly, in renal impairment, in cardiac decompensation, or in volume depletion, initially
2 mg once daily; max. 8 mg daily
Heart failure and prophylaxis after myocardial infarction
Dosage Information
Lisinopril
Lisinopril tablets 2.5mg, 5mg, 10mg, 20mg:
Heart failure (with a diuretic): initially 2.5mg daily, maintenance 5mg to 20mg daily.
Prophylaxis after myocardial infarction: dose dependent on blood pressure
Ramipril
Ramipril capsules 1.25mg, 2.5mg, 5mg, 10mg:
Heart failure 1.25mg daily increasing gradually over one to two weeks to a maximum of 10mg daily if tolerated
(preferably in 2 divided doses)
Prophylaxis after myocardial infarction 2.5mg to 5mg twice daily
Perindopril Perindopril Erbumine: initially 2 mg once daily in the morning, increased after at least 2 weeks to max. 4 mg once
daily if tolerated
Prophylaxis after myocardial infarction: initially 4 mg once daily in the morning increased after 2 weeks to 8 mg once
daily if tolerated; elderly 2 mg once daily for 1 week, then 4 mg once daily for 1 week, thereafter increased to 8 mg
once daily if tolerated
Monitoring ACE Prescribing:
Check renal function before initiating treatment.
Check renal function 7 – 14 days after initiating treatment and every dose change
Check renal function once a year (more frequent monitoring may be required in patients with risk factors predisposing them
to uraemia e.g. old age, concomitant treatment with high-dose diuretics or NSAIDs)
BNF 2.5.5.2 Angiotensin-II receptor antagonists
Reserve A2RAs for patients with 'true' ACE inhibitor intolerance (for patients who develop a persistent cough with ACE
inhibitors); where an A2RA is indicated losartan should be used first line (other than in heart failure where candesartan should be
the A2RA of choice)
First line Angiotensin-II receptor antagonists
Losartan
Losartan tablets 25mg, 50mg, 100mg: recommended dose is 25mg to 100mg daily First line ARB except in
management of heart failure
Hypertension / diabetic nephropathy in type 2 diabetes mellitus: usually 50 mg when candesartan should be
once daily (intravascular volume depletion, initially 25 mg once daily); if necessary used first line
increased after several weeks to 100 mg once daily; elderly over 75 years initially
25 mg daily
Chronic heart failure: initially 12.5 mg once daily, increased at weekly intervals to
max. 150 mg once daily if tolerated
Candesartan Candesartan tablets 2mg, 4mg, 8mg, 16mg
Hypertension: initially 8mg (hepatic impairment 2mg, renal impairment or
intravascular volume depletion 4mg) once daily, increased if necessary at intervals
of 4 weeks to max.32mg once daily; usual maintenance dose 8mg once daily.
Heart failure with or without LVSD: initially 4mg once daily and the dose titrated
up to a target dose of 32mg once daily or to the highest tolerated dose. The dose
should be titrated upwards by doubling the dose at intervals of at least 2 weeks until
the target dose is reached.
Use first line in Heart Failure
Second line Angiotensin-II receptor antagonists
Irbesartan
Irbesartan tablets 75mg, 150mg, 300mg
Hypertension: initially 150 mg once daily, increased if necessary to 300 mg once
daily (in haemodialysis or in elderly over 75 years, initial dose of 75 mg once daily
may be used)
Renal disease in hypertensive type 2 diabetes mellitus: Initially 150 mg once
daily, increased to 300 mg once daily if tolerated (in haemodialysis or in elderly over
75 years, consider initial dose of 75 mg once daily)
Valsartan
ONLY PRESCRIBE AS VALSARTAN CAPSULES 40mg, 80mg, 160mg
Hypertension: usually 80 mg once daily (initially 40 mg once daily in intravascular
volume depletion); if necessary increased at intervals of 4 weeks up to max. 320
mg daily
Heart failure: Initially 40 mg twice daily increased at intervals of at least 2 weeks
up to max. 160 mg twice daily
Myocardial infarction: initially 20 mg twice daily increased over several weeks to
160 mg twice daily if tolerated
Licensed for adults with
hypertension or renal disease in
hypertensive type 2 diabetes
BNF 2.6.1 Nitrates
NICE Clinical Guideline 126 Management of Stable angina
NHS Telford and Wrekin CCG – Stable angina treatment algorithm
Prescribing notes
Sublingual glyceryl trinitrate is one of the most effective drugs for providing rapid symptomatic relief of angina, but its effect
lasts only for 20 to 30 minutes; the 300-microgram tablet is often appropriate when glyceryl trinitrate is first used. The
aerosol spray provides an alternative method of rapid relief of symptoms for those who find difficulty in dissolving sublingual
preparations.
To reduce the risk of nitrate tolerance, isosorbide mononitrate should be given twice daily 6-8 hours apart.
Long-acting and transdermal nitrate preparations are significantly more expensive than standard formulations. A long-acting
preparation should be prescribed only for patients who have a problem with compliance.
ACUTE ATTACK
Glyceryl trinitrate spray
400mcg/dose
Sublingual
Glyceryl trinitrate 500 mcg tablets Sublingual
Glyceryl trinitrate 400 micrograms/metered dose, 200-dose unit
Dose treatment or prophylaxis of angina, spray 1–2 doses under tongue
and then close mouth
500mcg tablets. Only for patients unable to use spray.
PROPHYLAXIS – If a long acting nitrate is indicated in addition to a short acting nitrate a MODIFIED RELEASE preparation
should be used first line
Isosorbide mononitrate M/R 60mg prophylaxis of angina, 1
Prescribe as Monomil 60mg MR tablets
Prescribe by brand name
tablet daily in the morning
Monomil 60mg MR tablets
(half a tablet daily for first 2–
4 days to minimise
possibility of headache),
increased if necessary to 2
Isosorbide mononitrate
Glyceryl trinitrate patches
tablets once daily
10mg and 20mg Asymmetric dosing: recommend second of two daily doses given after about
tablets
8 hours. Rather than after 12 hours e.g. 8am and 4pm (to avoid the
development of nitrate tolerance).
Brand Name
5mg/24 hours
10mg/24 hours
15mg/24 hours
Oral nitrates must be considered first Minitran®
line. Patch formulations are
Nitro-Dur®
considerably more expensive.
Always prescribe patches by
brand name






BNF 2.6.2 Calcium-channel blockers
Prescribing notes
Sudden withdrawal of calcium-channel blockers may exacerbate angina; withdraw if ischaemic pain occurs or worsens after
starting treatment.
Diltiazem is first choice calcium-channel blocker for angina if a beta–blocker cannot be used; can also be given for
hypertension.Use with caution if given with beta-blockers due to risk of bradycardia. Do not use in patients
with LV dysfunction.
The most cost-effective brands of diltiazem should be prescribed - detailed above.
Verapamil is used for angina, hypertension and arrhythmia; it reduces cardiac output, slows the heart rate and may affect
atrioventricular conduction. Do not use in patients with LV dysfunction or who have bradycardia. It may produce heart failure,
exacerbate conduction disorders, and high doses may cause hypotension. It should not be used with beta-blockers.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1309-calcium-channel-blockers.htm
Rate Limiting Calcium-Channel Blockers
Diltiazem
Verapamil
Prescribers should specify the brand to be dispensed.
Once daily
Twice daily
Dose
m/r diltiazem preparations
m/r diltiazem preparations
90mg
Angitil SR® capsules
120mg
Slozem® capsules
Angitil SR® capsules
180mg
Slozem® capsules
Angitil SR® capsules
240mg
Slozem® capsules
300mg
Slozem® capsules
Licensed indications vary for verapamil preparations – please check product details before prescribing.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1372-verapamil-hydrochloride.htm
Supraventricular arrhythmias: 40–120 mg 3 times daily (Hospital Initiation only)
Angina, 80–120 mg 3 times daily
Hypertension, 240–480 mg daily in 2–3 divided doses
Prophylaxis of cluster headache [unlicensed] (under specialist supervision), 240–960 mg daily in 3–4
divided doses
Modified Release Formulation
Securon SR® : Tablets m/r verapamil hydrochloride 240 mg
Half Securon SR: Tablets m/r verapamil hydrochloride 120mg
o Hypertension, 240 mg daily (new patients initially 120 mg), increased if necessary to max. 480 mg daily (doses
above 240 mg daily as 2 divided doses)
o Angina, 240 mg twice daily (may sometimes be reduced to once daily)
o Prophylaxis after myocardial infarction where beta-blockers not appropriate (started at least 1 week after
infarction), 360 mg daily in divided doses, given as 240 mg in the morning and 120 mg in the evening or
120 mg 3 times daily
Non Rate limiting - Dihydropyridine Calcium-Channel Blockers
NICE Clinical Guideline 126 Management of Stable angina
NICE Clinical Guideline 127 Management of Primary Hypertension in adults
NICE Clinical Guideline 107 Hypertension in Pregnancy
First choice
Second choice
Nifedipine
Amlodipine
maleate
Amlodipine maleate tablets 5mg, 10mg: One tablet
daily.
Lacidipine
Lacidipine tablets 2mg, 4mg: Initially 2 mg as a single
daily dose, preferably in the morning; increased after 3–
4 weeks to 4 mg daily, then if necessary to 6 mg daily
Felodipine m/r tablets 2.5mg, 5mg, 10mg: One tablet
Metabolised via cytochrome P450
daily.
system – check BNF for
interactions
Felodipine
Prescribers should specify the brand to be dispensed. Licensed indications vary for nifedipine preparations please check product details before prescribing.
Dose hypertension and angina prophylaxis, 30 mg once daily, increased if necessary; max. 90 mg once daily
Modified
release
preparations
Dose
ONCE daily
TWICE daily
XL nifedipine preparations
M/r nifedipine preparations
Dose hypertension and angina prophylaxis, 30 mg
once daily, increased if necessary; max. 90 mg once
daily
10mg
20mg
30mg
60mg
Raynaud’s Phenomenon
Nifedipine
hypertension and angina prophylaxis, 10 mg twice daily,
adjusted according to response to 40 mg twice daily
Adipine MR® tablets
Adipine MR® tablets
Coracten XL® capsules
Coracten XL® capsules
5mg three times a day
BNF 2.6.3 other antianginal drugs
Nicorandil 10mg and 20mg
Potassium-channel activators
Nicorandil tablets 10mg, 20mg: initially 10mg twice daily (if susceptible to headache, 5mg twice
daily); usual dose 10-20mg twice daily; up to 30mg twice daily may be used
Potassium–channel activators are used when other anti-anginal drugs are contra-indicated or
provide insufficient control ; they have similar efficacy to other anti-anginal drugs in controlling
symptoms but there is little evidence regarding their efficacy in combination with other anti-anginal
drugs. Initiation should be under specialist supervision.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1387-nicorandil.htm
Ivabradine
Initiated under specialist supervision
Angina, initially 5 mg twice daily, increased if necessary after 3–4 weeks to 7.5 mg twice
daily (if not tolerated reduce dose to 2.5–5 mg twice daily); elderly initially 2.5 mg twice daily
Heart failure, initially 5 mg twice daily, increased if necessary after 2 weeks to 7.5 mg twice
daily (if not tolerated reduce dose to 2.5 mg twice daily)
Lowers the heart rate by its action on the sinus node. It is licensed for the treatment of angina in
patients who are in normal sinus rhythm in combination with a beta-blocker, or when beta-blockers
are contra-indicated or not tolerated. Ivabradine, in combination with standard therapy including a
beta-blocker (unless contra-indicated or not tolerated), is also licensed for mild to severe stable
chronic heart failure in patients who are in sinus rhythm.
NICE Management of stable angina CG126
NICE – Ivabradine for the treatment of chronic heart failure TA267
Ivabradine, in combination with standard therapy including a beta-blocker (unless contra-indicated
or not tolerated), an ACE inhibitor, and an aldosterone antagonist, is an option for treating mild to
severe stable chronic heart failure in patients who:
have a left ventricular ejection fraction of ≤ 35%, and
are in sinus rhythm with a heart rate of ≥ 75 beats per minute
Ivabradine should be initiated only by a heart failure specialist after 4 weeks of stable optimal
standard therapy; monitoring and dose titration should be carried out by a heart failure specialist, or
a GP with special interest in heart failure, or by a heart failure specialist nurse.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1385-ivabradine.htm
Ranolazine
Initiated under specialist supervision
As adjunctive therapy in the treatment of stable angina in patients inadequately controlled or
intolerant of first-line antianginal therapies.
over 18 years, initially 375 mg twice daily, increased after 2–4 weeks to 500 mg twice daily
and then adjusted according to response to max. 750 mg twice daily (reduce dose to 375–500 mg
ADULT
twice daily if not tolerated)
NICE managment of stable angina Clinical Guideline 126
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1390-ranolazine.htm
BNF 2.6.4 Peripheral vasodilators and related drugs
Prescribing notes
Patients suffering intermittent claudication should be advised to exercise and stop smoking. First–line management of Raynaud’s
phenomenon includes avoiding exposure to cold and stopping smoking.
NICE TA223 Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in
people with peripheral arterial disease
PERIPHERAL VASCULAR DISORDERS
NICE Guidance: Naftidrofuryl oxalate is an option for the treatment of intermittent claudication in patients with peripheral arterial
disease in whom vasodilator therapy is considered appropriate.
Cilostazol, pentoxifylline, and inositol nicotinate are not recommended for the treatment of intermittent claudication in patients with
peripheral arterial disease; patients currently receiving these treatments should have the option to continue until they and their
clinician consider it appropriate to stop
Naftidrofuryl
100mg-200mg three times a day. Assess for improvement after 3 to 6 months
RAYNAUD’S SYNDROME
Reduce frequency and severity of Nifedipine
attacks
Symptomatic improvement
Naftidrofuryl 100mg -200mg three times a day
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1402-naftidrofuryl-oxalate.htm
BNF 2.7.3 Cardiopulmonary resuscitation
Resuscitation Council (UK) guidelines http://www.resus.org.uk/SiteIndx.htm
Adrenaline
See local PGD for use in emergency anaphylaxis
Adrenaline 1:1000 Patient Group Direction
BNF Link : http://www.medicinescomplete.com/mc/bnf/current/PHP1434-cardiopulmonary-resuscitation.htm
BNF 2.8.1 Parenteral anticoagulants
Treatment with heparin is continued until no longer required, or until warfarin takes effect (at least 3 days).
Low molecular weight heparins are usually preferred over unfractionated heparin in the prevention of venous
thromboembolism because they are as effective and they have a lower risk of heparin-induced thrombocytopenia
The standard prophylactic regimen does not require anticoagulant monitoring. The duration of action of low molecular weight
heparins is longer than that of unfractionated heparin and once-daily subcutaneous administration is possible for some
indications, making them convenient to use
Routine monitoring of anti-Factor Xa activity is not usually required during treatment with low molecular weight heparins, but
may be necessary in patients at increased risk of bleeding (e.g. in renal impairment and those who are underweight or
overweight)..
Heparins may induce two types of thrombocytopenia: the first, usually develops within 1 to 4 days of initiation, is acute,
usually mild, and may resolve spontaneously. The second type has an immunological basis and is more serious: it usually
occurs after 7 to 11 days, or more quickly in previously exposed patients, and is often associated with serious
thromboembolic complications or bleeding. Serial platelet counts should be measured if heparin is given for longer than 5
days (or sooner if previously exposed), and heparin stopped if thrombocytopenia develops.
LOW MOLECULAR WEIGHT HEPARINS
Initiation by hospital specialist only - Suitable for prescribing in primary care for prophylaxis and acute treatment of
thromboembolism
Indication
Choice of LMWH
Prescribing guidance
Prophylaxis of DVT
Tinzaparin
Treatment of DVT and Tinzaparin
PE
Tinzaparin 20,000 units/mL (0.5mL, 0.7mL, 0.9mL syringes or 2mL vial)
Dosage see BNF
Tinzaparin 20,000 units/mL (0.5mL, 0.7mL, 0.9mL syringes or 2mL vial)
Dosage see BNF
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1463-tinzaparin-sodium.htm
BNF 2.8.2 Oral anticoagulants
NHS Telford and Wrekin CCG Anticoagulation Algorithm for Atrial Fibrillation
The warfarin dose is adjusted according to the international normalised ratio (INR). The target INR should be clearly
identified at initiation of therapy, and measured daily or on alternate days initially, then at longer intervals (depending on
response) then up to every 12 weeks. Indication and duration of treatment should be clearly recorded at initiation of
treatment; the patient-held anticoagulant treatment booklet should be used. See BNF for details.
The plasma half–life of warfarin is 35 hours; a steady anticoagulant effect is achieved after about one week. If immediate
anticoagulation is required, heparin must be given concomitantly.
There are many clinically important interactions with warfarin; clinicians are strongly advised to consult the BNF before
prescribing.
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1484-oral-anticoagulants.htm
Dosage Guidance
Warfarin
Daily dosage will be dependent on target INR
(international normalised ratio) for the particular
Warfarin tablets indication.
3mg (blue)
1mg (brown)
Prescribing guidance
Indications for these oral anticoagulants include deepvein thrombosis, pulmonary embolism, atrial fibrillation
in those who are at risk of embolisation), and
mechanical prosthetic heart valves (to prevent emboli
developing on the valves).
NPSA Patient Safety Alert for Anticoagulants
http://www.npsa.nhs.uk/nrls/alerts-anddirectives/alerts/anticoagulant
Guidelines for oral anticoagulation for patients with Atrial Fibrillation
Rivaroxaban
Prophylaxis of venous thromboembolism following NICE guidance
knee replacement surgery, adult over 18 years,
Rivaroxaban is an option for the prophylaxis of
10 mg once daily for 2 weeks starting 6–10 hours
venous thromboembolism in adults after total
after surgery
hip replacement or total knee replacement
Prophylaxis of venous thromboembolism following
surgery.
hip replacement surgery, adult over 18 years,
Rivaroxaban is an option for the prevention of
10 mg once daily for 5 weeks starting 6–10 hours
stroke and systemic embolism in accordance
after surgery
with its licensed indication (see notes above).
Treatment of deep-vein thrombosis and
The risks and benefits of rivaroxaban compared
prophylaxis of recurrent deep-vein thrombosis and
with warfarin should be discussed with the
pulmonary embolism, adult over 18 years, 15 mg
patient.
twice daily with food for 21 days, then 20 mg once
daily with food
Rivaroxaban is an option for the treatment of
Prophylaxis of stroke and systemic embolism in
deep-vein thrombosis and prevention of
non-valvular atrial fibrillation adult over 18 years,
recurrent deep-vein thombosis and pulmonary
embolism in adults after diagnosis of acute
20 mg once daily with food
deep-vein thrombosis.
Apixaban
Prophylaxis of venous thromboembolism following NICE guidance
Apixaban for the prevention of venous
knee replacement surgery, ADULT over 18 years,
2.5 mg twice daily for 10–14 days, starting 12–24
thromboembolism after total hip or knee
hours after surgery
replacement in adults (January 2012)
Prophylaxis of venous thromboembolism following
Apixaban is an option for the prevention of
hip replacement surgery, ADULT over 18 years,
venous thromboembolism in adults after
2.5 mg twice daily for 32–38 days, starting 12–24
elective hip or knee replacement surgery
hours after surgery
Apixaban for the prevention of stroke and
Prophylaxis of stroke and systemic embolism in
systemic embolism in non-valvular atrial
non-valvular atrial fibrillation (see notes above)
fibrillation (February 2013)
Apixaban is an option for the prevention of
ADULT over 18 years, 5 mg (ELDERLY over 80
stroke and systemic embolism in non-valvular
years with body-weight ≤ 60 kg, 2.5 mg) twice
atrial fibrillation in accordance with its licensed
daily
indication (see notes above).
The risks and benefits of apixaban compared to
warfarin, dabigatran etexilate, and rivaroxaban
should be discussed with the patient.
Dabigatran
etexilate
Prophylaxis of venous thromboembolism following NICE guidance
Dabigatran etexilate is an option for the
total knee replacement surgery, adult over 18
years, 110 mg (elderly over 75 years, 75 mg) 1–4
prophylaxis of venous thromboembolism in
hours after surgery, then 220 mg (elderly over 75
adults after total hip replacement or total knee
years or patient receiving concomitant treatment
replacement surgery.
with amiodarone or verapamil, 150 mg) once daily
Dabigatran etexilate is an option for the
for 9 days
prevention of stroke and systemic embolism in
Prophylaxis of venous thromboembolism following
accordance with its licensed indication (see
total hip replacement surgery, adult over 18 years,
notes above).The risks and benefits of
110 mg (elderly over 75 years, 75 mg) 1–4 hours
after surgery, then 220 mg (elderly over 75 years
or patient receiving concomitant treatment with
amiodarone or verapamil, 150 mg) once daily for
27–34 days
Prophylaxis of stroke and systemic embolism in
non-valvular atrial fibrillation adult over 18 years,
150 mg (elderly over 80 years, patients at high risk
of bleeding, or receiving concomitant treatment
with verapamil, 110 mg) twice daily
dabigatran compared to warfarin should be
discussed with the patient.
BNF 2.9 Antiplatelet drugs
Antiplatelet drugs decrease platelet aggregation and inhibit thrombus formation in the arterial circulation, because in
faster-flowing vessels, thrombi are composed mainly of platelets with little fibrin.
NICE TA210 Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1519-antiplatelet-drugs.htm
Prescribing notes
Dosage guide
75mg daily
Aspirin 75mg
Use of aspirin in primary prevention of cardiovascular events, in
patients with or without diabetes, is of unproven benefit. Long-term use
of aspirin, in a dose of 75 mg daily, is of benefit in established
cardiovascular disease (secondary prevention); unduly high blood
pressure must be controlled before aspirin is given
Clopidogrel 75mg Clopidogrel is licensed for the prevention of atherothrombotic events in Prevention of atherothrombotic events
patients with a history of symptomatic ischaemic disease. Clopidogrel, in peripheral arterial disease or after
in combination with low-dose aspirin, is also licensed for acute coronary myocardial infarction or ischaemic
syndrome without ST-segment elevation.
stroke, 75 mg once daily
Clopidogrel is also licensed, in combination with low-dose aspirin, for
the prevention of atherothrombotic and thromboembolic events in
patients with atrial fibrillation (and at least one risk factor for a vascular
event), and for whom warfarin is unsuitable.
Acute coronary syndrome (without STsegment elevation), initially 300 mg
then 75 mg daily
Acute myocardial infarction (with STsegment elevation), initially 300 mg
then 75 mg daily
Prevention of atherothrombotic and
thromboembolic events in patients with
atrial fibrillation 75 mg once daily
secondary prevention of ischaemic
stroke and transient ischaemic attacks
(used alone or with aspirin), adjunct to
oral anticoagulation for prophylaxis of
thromboembolism associated with
prosthetic heart valves, 200 mg twice
daily preferably with food
ADULT over 18 years, initially 60 mg as
Prasugrel for the treatment of acute coronary syndromes with
a single dose then body-weight over
percutaneous coronary intervention (October 2009)
60 kg, 10 mg once daily or bodyPrasugrel, in combination with aspirin, is an option for the prevention of weight under 60 kg or ELDERLY over 75
years, 5 mg once daily
atherothrombotic events in patients with acute coronary syndromes
undergoing percutaneous coronary intervention, only when:
Dipyridamole MR
200mg Capsules Dipyridamole is used by mouth as an adjunct to oral anticoagulation for
prophylaxis of thromboembolism associated with prosthetic heart
valves. Modified-release preparations are licensed for secondary
prevention of ischaemic stroke and transient ischaemic attacks
Prasugrel 10mg
immediate primary percutaneous coronary intervention is
necessary for ST-segment elevation myocardial infarction, or
stent thrombosis occurred during treatment with clopidogrel, or
the patient has diabetes mellitus.
Ticagrelor 90mg
NICE TA128 Prasugrel for the treatment of acute coronary syndromes
with percutaneous coronary intervention
Ticagrelor for the treatment of acute coronary syndromes
over 18 years, initially 180 mg
as a single dose, then 90 mg twice
Ticagrelor, in combination with low-dose aspirin, is recommended for up daily
to 12 months as a treatment option in adults with acute coronary
syndromes, that is, people:
with ST-segment elevation myocardial infarction—defined as ST
elevation or new left bundle branch block on electrocardiogram—
that cardiologists intend to treat with primary percutaneous
coronary intervention, or
with non-ST-segment elevation myocardial infarction (NSTEMI),
or
admitted to hospital with unstable angina—defined as ST or T
wave changes on electrocardiogram suggestive of ischaemia
plus one of the characteristics defined below. Before ticagrelor is
continued beyond the initial treatment, the diagnosis of unstable
angina should first be confirmed, ideally by a cardiologist.
Characteristics to be used in defining treatment with ticagrelor for
unstable angina are:
o age 60 years or older;
o previous myocardial infarction or previous coronary artery
bypass grafting;
o coronary artery disease with stenosis of 50% or more in at
least two vessels;
o previous ischaemic stroke;
o previous transient ischaemic attack, carotid stenosis of at
ADULT
o
o
o
least 50%, or cerebral revascularisation;
diabetes mellitus;
peripheral arterial disease, or
chronic renal dysfunction (creatinine clearance less than
60 mL/minute/1.73 m2).
NICE TA236 Ticagrelor for the treatment of acute coronary
syndromes
For all indications where aspirin or clopidogrel is prescribed - Add proton pump inhibitor or H2-receptor antagonist if
patients at high risk of gastro-intestinal bleeding. If patients with dyspepsia or for patients that develop dyspepsia
consider adding proton pump inhibitor or H2-receptor antagonist
Formulary choices are listed by indication
Secondary Prevention:
 Ischaemic Stroke
Does not include:
Stroke associated with AF
(warfarinisation)
Aspirin 300mg daily for 14 days (N.B. Continue only until discharge if patient discharged within 14 days)
THEN: Clopidogrel
75mg daily long term
If clopidogrel contraindicated or not tolerated aspirin 75mg daily plus dipyridamole MR 200mg twice daily long term
If both clopidogrel and aspirin contraindicated or not tolerated* dipyridamole MR 200mg twice daily long term
If both clopidogrel and dipyridamole contraindicated or not tolerated aspirin 75mg daily monotherapy long term
Secondary Prevention:
 TIA
Does not include:
TIA associated with AF
(warfarinisation)
Secondary Prevention:
 Symptomatic
Peripheral Arterial
Disease or
multivascular
disease
Clopidogrel 75mg daily long term (unlicensed use recommended 1st line option- RCP National Clinical Guideline for
Stroke 4th Ed. 2012) or Aspirin 75mg daily plus dipyridamole MR 200mg twice daily long term
If aspirin contraindicated or not tolerated*
dipyridamole MR 200mg twice daily long term
If dipyridamole contraindicated or not tolerated
aspirin 75mg daily monotherapy long term
Clopidogrel 75mg daily long term
If clopidogrel contraindicated or not tolerated
aspirin 75mg daily monotherapy long term
ST Segment
Elevation Acute
Myocardial
Infarction
(STEMI)
Non-ST Segment
Elevation Acute
Coronary Syndrome
Treated with urgent PCI
Has patient a history of CVA or TIA or cerebral
bleed? Is patient >75 years or <60 kg?
No to all
Yes to
any
Aspirin 75mg daily long term with Clopidogrel
75mg daily for 28 days
Aspirin 75mg daily long term with
Clopidogrel 75mg daily for 12 months
PCI with Drug Eluting
Stent(s) (DES)
Aspirin 75mg daily long term with
Clopidogrel 75mg daily for 12 months
Elective Procedures
PCI with Bare Metal
Stent(s) (BMS) Elective
Procedures
Aspirin 75mg daily long term with
Clopidogrel 75mg daily for 28 days
Secondary Prevention
Stable Angina (unless
PCI planned)
Aspirin 75mg daily long term
Type 2 Diabetes
Age 50+ and BP<145/90
Age<50 and CV risk factors
Aspirin 75mg daily long term with Clopidogrel
75mg daily for 12 months
Medically managed – no PCI procedure
(NSTEMI and
Unstable angina)
Primary Prevention of
Cardiovascular Events
Aspirin 75mg daily long term with Prasugrel 10mg
daily for 12 months
Important:
Aspirin – prescribe dispersible aspirin
The duration of antiplatelet treatments must be
stated clearly on all discharge letters sent to GPs
Important: premature discontinuation of clopidogrel with
aspirin increases risk of stent thrombosis. If individual
patient review indicates benefit of dual antiplatelet for more
than 12 months, request to GP must state risk factors.
Important: Clopidogrel Patient Card to be given to all
patients newly prescribed clopidogrel on discharge from
hospital, to state duration of treatment
Routine antiplatelet therapy for primary prevention is not recommended.
Consider aspirin 75mg daily on an individual basis.
Secondary prevention - Aspirin 75mg daily long term
Primary prevention - See Primary prevention of Cardiovascular Events
BNF 2.11 Antifibrinolytic drugs and haemostatics
Tranexamic acid
Menorrhagia (initiated when menstruation has started), 1 g 3 times daily for up to 4 days; max. 4 g daily
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1600-tranexamic-acid.htm
BNF 2.12 Lipid-regulating drugs
NHS Telford and Wrekin Guidelines for the prescribing Lipid Regulating Drugs can be accessed via the links below
NHS Telford and Wrekin CCG: Lipid modification therapy primary and secondary prevention
NHS Telford and Wrekin CCG: Lipid Modification in Patients with Type 2 Diabetes
NHS Telford and Wrekin CCG: Statins – A Patients Guide
NICE Guidance LIPID MODIFICATION: Cardiovascular risk assessment and the modification of blood lipids for the primary and
secondary prevention of cardiovascular disease
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1623-statins.htm
Simvastatin
For Primary prevention if a statin is indicated – Simvastatin 40mg take ONE each night
If there are potential drug interactions or simvastatin 40mg is contraindicated or poorly tolerated, offer
pravastatin or a lower dose of simvastatin.
Pravastatin
For Secondary prevention - Simvastatin 40mg (or drug of similar efficacy and acquisition cost) to all
adults with clinical evidence of CVD. If there are potential drug interactions or 40mg simvastatin is
contraindicated or poorly tolerated, offer a lower dose of simvastatin (maximum of 20mg) or pravastatin.
Consider increasing dose to simvastatin 80mg or drug of similar efficacy and cost if the total cholesterol
does not fall below 4mmol/l OR the LDL cholesterol does not fall below 2mmol/l.
e.g.
TC 4.2 mmol/L, LDL-C 2.2 mmol/L - consider increasing to simvastatin 80mg
TC 4.2 mmol/L, LDL-C 1.9 mmol/L - don’t consider increasing statin
TC 3.9 mmol/L, LDL-C 2.2 mmol/L - don’t consider increasing statin
TC 3.9 mmol/L, LDL-C 1.9 mmol/L - don’t consider increasing statin
Atorvastatin
For patients who are intolerant of simvastatin or who fail to reach target reduction in cholesterol levels after
3-6 months of maximum tolerated dose of simvastatin.
Dose can be increased from 20mg, 40mg then 80mg daily at 6-8 weekly intervals. Check compliance at
each stage before increasing dose.
Monitoring Statin Therapy
Monitor liver function tests (LFTs) at beginning of treatment and at 1-3 months, 6 months, 12 months, then annually.
Check baseline creatinine kinase (CK) and re-check if patient complains of musculoskeletal symptoms.
Discontinue statins if:
o strong suspicion of myopathy, if CK exceeds 5 times upper limit of normal range
o alanine transaminase (ALT) persists above 3 times upper limit of normal range.
Prescribing notes
Dosage guide
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1671-fibrates.htm
Fenofibrate 200mg daily
Fenofibrate 200mg: one capsule
Fibrates act mainly by decreasing serum
daily
triglycerides; they have variable effects on LDLcholesterol. Although a fibrate can reduce the risk
of coronary heart disease events in those with low
HDL-cholesterol or with raised triglycerides, a statin
should be used first. Fibrates are first-line therapy
only in those whose serum-triglyceride
Bezafibrate 400mg MR
Bezafibrate m/r tablets 400mg: one
concentration is greater than 10 mmol/litre or in
Tablets
tablet daily
those who cannot tolerate a statin.
Fibrate may be added to statin therapy if
Bezafibrate 200mg
Bezafibrate 200mg tablets: One
triglycerides remain high even after the LDLtablet threetimesdaily
Tablets
cholesterol concentration has been reduced
adequately.
Doses in renal Impairment
The prescribing of this combination statin and
fibrate requires care as the risk of myopathy is
greater.
Reduce dose to 400 mg daily if
eGFR 40–60 mL/minute/1.73 m2
Reduce dose to 200 mg every
1–2 days if eGFR 15–40
mL/minute/1.73 m2
Avoid immediate-release
preparations if eGFR less than
15 mL/minute/1.73 m2
Avoid modified-release
preparations if eGFR less than
60 mL/minute/1.73 m2
Patients Intolerant of Statins
Patients who do not tolerate statins at all may be prescribed
ONLY for patients who are completely intolerant of statin therapy
Ezetimibe 10mg
10 mg once daily
NICE TA132 Ezetimibe for the treatment of primary (heterozygousfamilial and non-familial) hypercholesterolaemia
Do not use combination preparations of Simvastatin and Ezetimibe
BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1667ezetimibe.htm
Cholestyramine Sachets 12-24g daily in divided Specialist initiation only. Other drugs should be taken at least 1 hour
doses
before or 4-6 hours after colestyramine to reduce possible interference
with absorption.
Omega-3-acid ethyl esters (Omacor®) and Omega 3 Marine Triglycerides (Maxepa®) are NOT recommended for
prescribing in general practice.