| Formulary Chapter 2: Cardiovascular system - Full Chapter
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| Chapter Links... |
 LSCMMG: Atrial Fibrillation |
| NG 196 - Atrial fibrillation: diagnosis and management |
| LSCMMG: Heart Failure - Primary Care Guideline for the Use of SGLT-2 Inhibitors in Reduced Ejection Fraction Heart Failure |
| NICE NG106: Chronic heart failure in adults: diagnosis and management |
| NICE NG187: Acute heart failure: diagnosis and management |
| LSCMMG: Lipid Management Pathway for Primary Prevention of Cardiovascular Disease |
| LSCMMG: Lipid Management Pathway for Secondary Prevention of Cardiovascular Disease |
| LSCMMG: Low Molecular Weight Heparins (LMWHs) Summary Prescribing Guide |
| MHRA: Clopidogrel and proton pump inhibitors: interaction—updated advice |
| NG 185 - Acute coronary syndromes |
| NICE NG136: Hypertension in adults: diagnosis and management |
| NICE NG203: Chronic kidney disease: assessment and management |
| NICE NG95: Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis |
| Enoxaparin Shared Care Guideline **FOR USE IN THE MORECAMBE BAY REGION ONLY** |
| Low Molecular Weight Heparins - Use in Primary care Best Practice Guideline *FOR USE IN PENNINE REGION ONLY* |
| Details... |
| 02.05 |
Drugs affecting the renin-angiotensin system and some other antihypertensive drugs |
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| 02.05.01 |
Vasodilator antihypertensive drugs |
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Hydralazine
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Formulary
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Tablets 25mg, 50mg
Hypertension
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Hydralazine
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Formulary
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Tablets 25mg, 50mg
Heart failure
Initiated in hospital or under specialist supervision.
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 NG106: Chronic heart failure in adults: diagnosis and management
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Sildenafil
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Formulary
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Tablets 20mg
Tertiary centre only.
Sildenafil and bosentan are licensed for use in pulmonary arterial hypertension (PAH). Treatment of this condition is commissioned nationally through a small number of PAH centres based in hospitals across the UK.
All patients should be referred to one of these centres, who carry out all prescribing of these therapies.
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MHRA Drug Safety Update Nov 18: 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
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Sodium Nitroprusside
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Formulary
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Injection 50mg vials
 unlicensed
For specialist use only.
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Hydralazine
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Formulary
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Injection 20mg/2mL
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| 02.05.02 |
Centrally acting antihypertensive drugs |
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Methyldopa
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Formulary
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Tablets 125mg, 250mg, 500mg
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NG133: Hypertension in pregnancy: diagnosis and management
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Moxonidine
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Formulary
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Tablets 200micrograms, 300micrograms, 400micrograms
Reserved for use in resistant hypertension, in line with NG 136
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Clonidine Hydrochloride
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Formulary
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Tablets 25 microgram
Clonidine is considered less suitable for prescribing in hypertension
Vasomotor symptoms (VMS) associated with menopause
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LSCMMG: Clonidine 25 mcg tablets - Vasomotor symptoms (VMS) associated with menopause
NICE NG136: Hypertension in adults: diagnosis and management
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| 02.05.04 |
Alpha-adrenoceptor blocking drugs |
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Doxazosin
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Formulary
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Tablets 1mg, 2mg, 4mg
Doxazosin MR do not prescribe
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LSCMMG: Doxazosin MR do not prescribe
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| 02.05.04 |
Phaeochromocytoma |
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Phenoxybenzamine Hydrochloride
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Formulary
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Capsules 10mg
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LSCMMG: Phenoxybenzamine hydrochloride
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Phentolamine
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Formulary
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Injection
unlicensed
For theatre/ICU use only.
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| 02.05.05 |
Drugs affecting the renin-angiotensin system |
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| 02.05.05 |
Heart Failure |
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Dapagliflozin (Forxiga®)
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Formulary
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Tablets 5mg, 10mg
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MHRA: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
MHRA: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
NICE TA679: Dapagliflozin for treating chronic heart failure with reduced ejection fraction
NICE TA902: Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction
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Empagliflozin
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Formulary
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Tablets 10mg, 25mg
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MHRA: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
MHRA: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
NICE TA773: Empagliflozin for treating chronic heart failure with reduced ejection fraction
NICE TA929: Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction
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| 02.05.05.01 |
Angiotensin-converting enzyme inhibitors (ACE inhibitors) |
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Ramipril
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Formulary
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Capsules 1.25mg, 2.5mg, 5mg, 10mg
First line
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Lisinopril
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Formulary
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Tablets 2.5mg, 5mg, 10mg, 20mg
First line
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Perindopril erbumine
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Formulary
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Tablets 2mg, 4mg, 8mg
Not first line
Perindopril ARGININE is considered ‘Not suitable for prescribing’ across the ICB.
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LSCMMG: Perindopril arginine
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Enalapril
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Formulary
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Tablets 2.5mg, 5mg, 10mg, 20mg
 Restricted to use in post natal women when used in line with NG133
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NG133: Hypertension in pregnancy: diagnosis and management
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| 02.05.05.02 |
Angiotensin-II receptor antagonists |
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Angiotensin-II receptor antagonists reserved for use when ACE inhibitors are not tolerated. |
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Losartan
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Formulary
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Tablets 12.5mg, 25mg, 50mg, 100mg
First line
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Candesartan
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Formulary
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Tablets 2mg, 4mg, 8mg, 16mg, 32mg
First line
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Irbesartan
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Formulary
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Tablets 75mg, 150mg, 300mg
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Sacubitril/valsartan (Entresto®)
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Formulary
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film-coated tablets
24.3 mg sacubitril and 25.7 mg valsartan (as sacubitril valsartan sodium salt complex).
48.6 mg sacubitril and 51.4 mg valsartan (as sacubitril valsartan sodium salt complex).
97.2 mg sacubitril and 102.8 mg valsartan (as sacubitril valsartan sodium salt complex).
Entresto® tablets and granules contain sacubitril and valsartan in the form x/y where x and y are the strength in milligrams of sacubitril and valsartan respectively. Doses in BNF Publications are expressed as the total of both drug strengths.
For Entresto® tablets, the 24/26 mg, 49/51 mg, 72/78 mg, and 97/103 mg strengths are referred to as 50 mg, 100 mg, 150 mg, and 200 mg, respectively.
See BNF for more detail.
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LSCMMG: Sacubitril valsartan
NICE TA388 Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
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Valsartan
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Formulary
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tablets and capsules
Existing patients only
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| 02.05.05.03 |
Renin inhibitors |
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Aliskiren
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Formulary
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LSCMMG: Aliskiren
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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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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Traffic Light Status Information
| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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