The following local guidance is available for cardiovascular disease:
Area Prescribing Committee website
Guideline for lipid modification in primary and secondary prevention of CVD:
Area Prescribing Committee website
FATS7 - A strategy for the use of cholesterol lowering drugs across the North East and North Cumbria
Antiplatelet Drugs – Guidance for the use in Primary Care & NECVN Network Guidelines for Antiplatelet Use in STEMI, NSTEMI & Unstable Angina
Area Prescribing Committee website
Hypertension Guidelines (based upon NICE CG127)
Area Prescribing Committee website
Stroke Risk Stratification & Thromboprophylaxis Guideline
Area Prescribing Committee website
NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism
County Durham and Darlington DVT Pathway:
County Durham and Darlington DVT Pathway Information
Important Update to the County Durham and Darlington DVT Pathway
County Durham Darlington DVT Investigation Proforma -Rivaroxaban
County Durham Darlington DVT Investigation Proforma -Enoxaparin
NICE CG172: MI – Secondary Prevention
Other NICE Cardiovascular Guidelines are available via this link
CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
Tablets - 62.5microgram, 125microgram, 250microgram
Elixir - 50microgram/ml
Drug Protocol – digoxin loading dose (CDDFT intranet access only)
Please note – metolazone has been discontinued in the UK and as such has been removed from the formulary. Please see advice from the British Society for Heart Failure which recommends bendroflumethiazide as the most suitable alternative.
Tablets - 2.5mg
For indapamide use standard release only (not modified release)
Tablets - 20mg, 40mg,
Oral Solution - 20mg/5ml, 40mg/5ml, 50mg/5ml
20mg in 2ml, 50mg in 5ml & 250mg in 25ml injections
Drug protocols: (CDDFT intranet access only)
Tablets - 25mg, 50mg, 100mg
Suspension - 5mg/5ml, 10mg/5ml, 25mg/5ml, 50mg/5ml and 100mg/5ml u
Prescribe Oral Solution as Rosemont brand
Notes: post-acute myocardial infarction patients and patients with heart failure treatment should be initiated on instructions from a cardiologist or GP with a specialist interest in cardiology. Spironolactone is first choice (ahead of eplerenone) for severe heart failure.
MHRA Drug Safety Update (Feb 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia
MHRA Drug Safety Update (Dec 2016): Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia—clarification, December 2016
25mg & 50mg tablets
Indication: to reduce the risk of cardiovascular mortality and morbidity in stable patients with left ventricular dysfunction and clinical evidence of heart failure after myocardial infarction, usually initiated on day 4 or 5 post-acute MI.
Notes: Eplerenone may have a place in those patients unable to tolerate spironolactone (due to gynaecomastia or nausea).
Restrictions: treatment should only be initiated on instructions from a consultant cardiologist or a GP with a specialist interest in cardiology.
The use of combination diuretics is not recommended.
Only available in combination with other formulary drugs e.g. co-amilozide
MHRA Drug Safety Update (Nov 2018): Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
Tablets - 100mg, 200mg
Initiated and titrated to maintenance dose only under specialist supervision
Drug protocols: Amiodarone IV and oral (CDDFT intranet access only)
Patient information leaflet (CDDFT intranet access only)
400mg tablets
As recommended by NICE approved for patients who are unsuitable for or not tolerant of amiodarone. Treatment is to be initiated by cardiologists.
Tablets - 100mg, 150mg
Initiated and titrated to maintenance dose only under specialist supervision
Tablets- 50mg, 100mg
MR Capsules - 200mg
Initiated and titrated to maintenance dose only under specialist supervision
Flecainide IV: CDDFT Drug Protocol
Tablets - 150mg, 300mg
Initiated and titrated to maintenance dose only under specialist supervision
Drug protocol: magnesium sulphate infusion (CDDFT intranet access only)
MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
First Choice
Bisoprolol - Cardioselective
Propranolol - non-cardioselective
Alternatives
Atenolol
Meteoprolol - metoprolol indication: for less stable patients
Labetalol - for the management of hypertension in pregnancy
Carvedilol - for use in the treatment of heart failure only
Sotalol
Tablets - 10mg, 40mg, 80mg, 160mg
Oral Solution - 5mg/5ml, 10mg/5ml, 40mg/5ml, 50mg/5ml
Non-cardioselective
Propranolol indication: for migraine prophylaxis and to control somatic symptoms associated with anxiety
Drug protocol: paediatric oral propranolol in haemangioma (CDDFT intranet access only)
Tablets - 3.125mg 6.25mg, 12.5mg, 25mg
Carvedilol indication: for use in the treatment of heart failure only
50mg, 100mg & 200mg tablets
Labetalol indication: for the management of hypertension in pregnancy
Tablets - 50mg
Liquid - 50mg/5ml
Metoprolol indication: for less-stable patients
Tablets - 25mg
Hydralazine restriction: usually hospital initiation
5mg & 10mg tablets
For hypertension. All other indications considered RED drug.
Treatment should only be on the advice of a cardiologist/ nephrologist.
Red drug for Raynaud's (Unlicensed indication)
Tablets - 25mg and 50mg
MHRA Drug Safety Update (Nov 2018): Sildenafil (Revatio and Viagra): reports of persistent pulmonary hypertension of the newborn (PPHN) following in-utero exposure in a clinical trial on intrauterine growth restriction
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
Capsules - 1.25, 2.5mg, 5mg, 10mg
Ramipril dosage form restriction: use capsules – do not use tablets
24mg/26mg, 49mg/51mg & 97mg/103mg tablets
See Place in therapy for Sacubitril valsartan in both newly diagnosed and existing heart failure
MHRA Drug Safety Update (June 2014): Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings
Pulmonary Arterial Hypertension – specialist centres only (Freeman, Newcastle)
62.5mg & 125mg tablets
NHS England – Not Routinely Commissioned for digital ulcers
Commissioner: NHS England - Policy - A11/P/a & A11/PS/b
10mg tablets
Commissioner: NHS England - Policy - A11/P/a & A11/PS/b
20mg tablets (Revatio®)
25mg, 50mg and 100mg tablets u
Commissioner: NHS England - Policy - A11/P/a & A11/PS/b
MHRA Drug Safety Update (Nov 2018): Sildenafil (Revatio and Viagra): reports of persistent pulmonary hypertension of the newborn (PPHN) following in-utero exposure in a clinical trial on intrauterine growth restriction
50 microgram in 0.5ml & 100 microgram in 1ml inj u
10 microgram in 1ml and 20 microgram in 2ml nebules
Commissioner: NHS England - Policy - A11/PS/b
Tablets - 10mg, 20mg, 40mg
Dosage form restriction: avoid using modified release or patch preparations. Standard release isosorbide mononitrate should be prescribed using twice daily asymmetric dosing (e.g. 8am & 4pm)
5mg in 5ml , 50mg in 10ml & 50mg in 50ml injections
Glyceryl Trinitrate IV Infusion: CDDFT Drug Protocol
Tablets- 5mg, 10mg
Notes: if a 10mg dose is not tolerated e.g. due to leg/ankle oedema, consider reducing dose before changing to an alternative such as lercanidipine
Hypertension Guidelines (based upon NICE CG127) Primary Care Website
MR Tablets - 60mg
MR Tablets/Capsules (BD preparations) - 90mg, 120mg, 180mg
MR Tablets/Capsules (OD preparations) - 120mg, 180mg, 240mg, 300mg, 360mg.
Different versions of modified release diltiazem containing more than 60mg may not have the same clinical effect. Specify brand to avoid confusion
Brand – Viazem XL is the Formulary brand of choice for starting new patients on long acting diltiazem
Tablets - 10mg, 20mg
Indication: for use as a 2nd line calcium channel blocker where amlodipine is not tolerated
Once Daily formulations (Preferred)
20mg controlled release tablets (Adalat LA), 30mg &
60mg m/r capsules (Coracten XL)
Other Formulations
5mg & 10mg capsules
10mg & 20mg retard tablets
20mg per ml (1mg/drop) dropsu
Nifedipine Modified Release Brand: Coracten XL is the once daily brand of choice
30mg tablets
10mg in 50ml (200 micrograms/ml) for IV infusion
Nimodipine indication: only for the prevention of vascular spasm following subarachnoid haemorrhage
Tablets - 10mg, 20mg
MHRA Drug Safety Update (Jan 2016): Nicorandil (Ikorel): now second-line treatment for angina - risk of ulcer complications
Tablets - 5mg, 7.5mg
Indication: for symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm for whom heart rate control is desirable and who have a contra-indication or intolerance for beta-blockers and rate-limiting calcium-channel blockers.
Restrictions: for initiation on advice from consultant cardiologists in patients with contra-indications to or intolerance of standard therapy
MHRA Drug Safety Update (Dec 2014): Ivabradine (Procoralan) in the symptomatic treatment of angina: risk of cardiac side effects
Approved for use in accordance with the following NICE TAs:
100mg capsules
In Raynaud’s phenomenon some patients may require treatment with a vasodilator. Nifedipine may be of use, especially in primary Raynaud’s syndrome.
250mg in 20ml injection
250mg in 50ml injection
Dobutamine: CDDFT Drug Protocol
100 microgram in 2ml injection, 2mg in 2ml injectionu
Isoprenaline: CDDFT Drug Protocols
2mg in 2ml & 4mg in 4ml (1 in 1,000) injections
See Letter Sent to Healthcare Professionals (March 2016): Noradrenaline (Norepinephrine) 0.08 mg/ml (4 mg in 50 mil solution for infusion in a vial with potential risk of medication errors
To be prescribed by brand name to prevent prescribing/dispensing errors.
Clexane Brand
2,000 IU (20 mg)/0.2 ml solution for injection in pre-filled syringe
4,000 IU (40 mg)/0.4 ml solution for injection in pre-filled syringe
6,000 IU (60 mg)/0.6 ml solution for injection in pre-filled syringe
8,000 IU (80 mg)/0.8 ml solution for injection in pre-filled syringe
10,000 IU (100 mg)/1 ml solution for injection in pre-filled syringe
12,000 IU (120 mg)/0.8 ml solution for injection in pre-filled syringe
15,000 IU (150 mg)/1 ml solution for injection in [pre-filled syringe
Inhixa Brand
20mg/0.2mll solution for injection in pre-filled syringe
40mg/0.4mlsolution for injection in pre-filled syringe
60mg/0.6ml solution for injection in pre-filled syringe
80mg/0.8ml solution for injection in pre-filled syringe
100mg/ml solution for injection in pre-filled syringe
Arovi Brand (formerly Enoxaparin Becat)
20mg/0.2ml solution for injection in pre-filled syringe
40mg/0.4mlsolution for injection in pre-filled syringe
60mg/0.6ml solution for injection in pre-filled syringe
80mg/0.8ml solution for injection in pre-filled syringe
100mg/ml solution for injection in pre-filled syringe
120mg/0.8ml solution for injection in pre-filled syringe
150mg/ml solution for injection in pre-filled syringe
See Letter Sent to Healthcare Professionals (June 2017) - Clexane (enoxaparin sodium):
50 units in 5ml & 200 units in 2ml – for flushing cannulae
Drug protocol: heparin in general medicine (CDDFT intranet access only)
Drug protocol: Unfractionated Heparin (treatment dose) for use in Vascular Surgery (CDDFT intranet access only)
1.5mg in 0.3ml injection, 2.5mg in 0.5ml injection,
5mg in 0.4ml injection, 7.5mg in 0.6ml injection &
10mg in 0.8ml injection in pre-filled syringes
Fondaparinux indication: for the treatment of unstable angina or non ST-elevation myocardial infarction. CDDFT Drug Protocol
750 units in 0.6ml injection (1,250 units/ml)
Danaparoid notes: for use on specific advice from haematologists in patients who develop thrombocytopaenia with heparins - cross reactivity with heparin antibodies is probably <10%
Epoprostenol (as sodium salt) 500 microgram & 1.5mg injection injection (Folan®)
Epoprostenol (as sodium) 500 microgram & 1.5mg injection injection (Veletri®)
CAUTION TWO BRANDS AVAILABLE
Epoprostenol PVD CDDFT Drug Protocol
Commissioner: NHS England - Policy - A11/PS/b
See Letter Sent to Healthcare Professionals (Sept 2016):
Flolan® (epoprostenol) – Introduction of new sterile solvent with different pH; temporary availability of two different formulations.
See Letter Sent to Healthcare Professionals (April 2017) - Floran (epoprostenol): reminder of replacement of Flolan (with Solvent pH 10.5) with Flolan (with Solvent pH 12)
Stroke Risk Stratification & Thromboprophylaxis Guideline
Primary Care Website or CDDFT Intranet
County Durham and Darlington DVT Pathway Information
Important Update to the County Durham and Darlington
County Durham Darlington DVT Investigation Proforma -Rivaroxaban
County Durham Darlington DVT Investigation Proforma -Enoxaparin
MHRA Warning: Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
Tablets - 500micrograms(white), 1mg (brown), 3mg(blue), 5mg(pink)
Warfarin and Rivaroxaban are First line choices for anticoagulation
CDDFT Intranet Oral anticoagulation with warfarin - adult patient management guidelines (including bleeding with NOACs)
MHRA Drug Safety Update (July 2016): Warfarin: reports of calciphylaxis
Tablets - 10mg, 15mg, 20mg
Warfarin and Rivaroxaban are First line choices for anticoagulation
MHRA Drug Safety Update (Oct 2013): Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
MHRA Drug Safety Update (Oct 2018): Rivaroxaban (Xarelto▼) after transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial
Indication: in the treatment of AF and DVT where patients can’t tolerate other treatment options and also in the fast track DVT pathway
Approved for use in accordance with the following NICE TAs
NOT RECOMMENDED: The Northern (NHS) Treatment Advisory Group does not recommend Rivaroxaban (Xarelto®▼) for acute coronary syndromes.
Tablets - 2.5mg, 5mg
When Rivaroxaban unsuitable for individual patient following shared decision discussion
Approved for use in accordance with the following NICE TAs
Tablets - 75mg, 110mg and 150mg
When Rivaroxaban unsuitable for individual patient following shared decision discussion
Approved indication: for prevention of stroke in non-valvular atrial fibrillation
NICE Guidance: NICE TA249, NICE TA157, NICE TA327
MHRA Drug Safety Update (March 2013): Dabigatran - contraindicated in patients with prosthetic heart valve(s) requiring anti-coagulant treatment, because of the risk of thrombosis and haemorrhage
MHRA Drug Safety Update (Oct 2013): Risk of serious haemorrhage with dabigatran, rivaroxaban & apixiban
Tablets - 15mg, 30mg, 60mg
When Rivaroxaban unsuitable for individual patient following shared decision discussion
Approved for use in accordance with the following NICE TAs:
Antiplatelet Drugs – Guidance for the use in Primary Care & NECVN Network Guidelines for Antiplatelet Use in STEMI, NSTEMI & Unstable Angina
Primary Care Website or CDDFT Intranet
NICE CG172: MI – Secondary Prevention
Tablets - 75mg
Aspirin dosage form restrictions: ONLY plain tablets. e/c tablets are not recommended for use.
Tablets - 75mg, 300mg
Clopidogrel: the APC recommends the use of generic 75mg clopidogrel tablets in all the approved indications for clopidogrel
300mg tablets also available for use in giving loading dose prior to percutaneous coronary interventions (PCI)
MHRA Drug Safety Update (December 2013): Clopidogrel - risk of acquired haemophilia with clopidogrel
Tablets - 5mg, 10mg
Prasugrel: NICE TA317 (review of TA182)
MHRA Drug Safety Update (January 2014): increased risk of bleeding – advice around timing of loading dose for prasugrel
200mg m/r capsules
Dipyridamole indication: as per guideline and NICE TA210
N.B. Primary Percutaneous Coronary Intervention (PCI) is now preferred to thrombolysis in patients with myocardial infarction with ST segment elevation (STEMI)
Alteplase indication: Acute Ischaemic Stroke NICE TA264
Drug protocol: alteplase (CDDFT intranet access only)
Prothrombin complex concentrate
For use in reversing the effects of oral anticoagulants in patients with life or limb threatening bleeding in accordance with a regional protocol – see CDDFT Intranet Oral anticoagulation with warfarin - adult patient management guidelines (including bleeding with NOACs)
Commissioner: NHS England - BCSH Guidelines
Guideline for lipid modification in primary and secondary prevention of CVD:
Primary Care Website or CDDFT Intranet
NICE CG172: MI – Secondary Prevention
FATS7 - A strategy for the use of cholesterol lowering drugs across the North East and North Cumbria
An MHRA (May 2014) summary of the risks and benefits of statins can be found here
Tablets - 10mg, 20mg, 40mg, 80mg
Tablets May be crushed and administered immediately in water
5mg, 10mg, 20mg & 40mg tablets
CD&D APC Grey List: Only to be considered as an option when patient has proven intolerance to, or lack of desired result from simvastatin, pravastatin and atorvastatin and in accordance with County Durham and Darlington PCTs Lipid Modification Guidelines OR as per FATS Guidelines.
Tablets - 10mg
Ezetimibe restrictions: see guideline
NICE guidance: NICE TA385
FATS7 Strategy for the Use of Cholesterol Lowering Drugs Primary Care Website
75mg/1ml & 150mg/1ml solution for injection in prefilled pen
See also NTAG recommendation