2: Cardiovascular system
Please select a topic:
2.1 Positive inotropic drugs
2.2 Diuretics
2.3 Anti-arrhythmic drugs
2.4 Beta-adrenoceptor blocking drugs
2.5 Drugs affecting the renin-angiotensin
2.6 Nitrates, calcium-channel blockers, and
system and some other antihypertensive
other anti-antianginal drugs
drugs
2.7 Sympathomimetics
2.8 Anticoagulants and protamine
2.9 Antiplatelet drugs
2.10 Myocardial infarction and fibrinolysis
2.11 Antifibrinolytic drugs and
2.12 Lipid-regulating drugs
haemostatics
2.13 Local sclerosants
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 1 of 24
Date: 1.2.2012
2.1 Positive inotropic drugs

Digoxin 62.5, 125, 250 microgram tablets

Digoxin 250 micrograms/5ml elixir

Digoxin 250 micrograms/ml injection

Enoxamine 100mg/20ml injection (Emergency Drug Cupboard only)

Digibind 38mg injection (restricted)
Dose
- Digoxin tablets 62.5micrograms, 125micrograms, 250micrograms; elixir 50micrograms/mL:
rapid digitalisation, 1-1.5mg in divided doses over 24 hours; less urgent digitalisation, 250500micrograms daily (higher dose may be divided). Maintenance, 62.5-500micrograms daily.
- Digoxin injection 250micrograms/mL: according to local guidance.
- Enoxamine injection 100mg/20ml: see BNF
- Digibind injection 38mg: see BNF
Prescribing notes

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
intravenously or orally.

Regular measurements of plasma digoxin concentrations are not usually required except to
confirm toxic or sub-therapeutic levels, or to check compliance.

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, calcium channel blockers,
quinine, hydroxychloroquine.
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. 62.5-125 micrograms daily)
is usually adequate in older patients.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 2 of 24
Date: 1.2.2012
2.2 Diuretics
Thiazides and related diuretics

Bendroflumethazide/Bendrofluazide 2.5mg, 5mg tablet

Metolozone 5mg tablet

Chlorothiazide 250mg/5ml and 100mg/5ml suspension
Dose
- Bendroflumethiazide tablets 2.5mg, 5mg: hypertension, 2.5mg daily.
- Metolozone tablets 5mg: see BNF
- Chlorothiazide suspension 250mg/5ml, 100mg/5ml: see BNF for Children
Prescribing notes

Allow 4 weeks for maximal antihypertensive effect of bendroflumethiazide.

Bendroflumethiazide may be prescribed with furosemide (frusemide) for severe heart failure
under hospital supervision; this must be carefully monitored.
Loop diuretics

Furosemide 20mg, 40mg, 500mg tablet

Furosemide 20mg/5ml, 40mg/5ml liquid

Furosemide 50mg/5ml injection

Bumetanide 1mg, 5mg tablet

Bumetanide 1mg/5ml liquid

Bumetanide 1mg/2ml injection
Dose
- Furosemide tablets 20mg, 40mg, 500mg; liquid 20mg/5ml, 20mg/5ml: oedema, initially 40mg
daily then adjusted according to response.
- Furosemide injection 10mg/mL: slow intravenous injection, initially 20-50mg. Furosemide may be
given by intravenous infusion at a rate not exceeding 4mg/minute.
- Bumetanide tablets 1mg, 5mg; liquid 1mg/5ml: initially 1mg in the morning the adjusted
according to response
Prescribing notes

Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if
given intravenously; duration of action, 6 hours.

Furosemide 500mg tablets are scored and can be halved.

Bumetanide may be an option in those patients that are not responding to furosemide (1mg
bumetanide is equivalent to furosemide).
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 3 of 24
Date: 1.2.2012
Potassium-sparing diuretics

Amiloride 5mg tablet

Amiloride 5mg/5ml solution
Dose
- Amiloride tablets 5mg; oral solution 5mg/5ml: 5-20mg daily.
Prescribing notes

Amiloride is a weak diuretic with potassium-sparing properties, given with other diuretics if
hypokalaemia is a problem; may take 2-3 days for full effect.

Use with caution in renal impairment.

Potassium-sparing diuretics such as amiloride are usually only necessary if hypokalaemia
develops
Aldosterone antagonists

Eplerenone 25mg, 50mg tablet

Spironolactone 25mg, 100mg tablet

Spironolactone 50mg/5ml suspension
Dose
- Eplerenone tablets 25mg, 50mg: initially 25mg once daily, increased within 4 weeks to 50mg
once daily.
- Spironolactone tablets 25mg, 50mg, 100mg: heart failure in conjunction with ACE inhibitor,
25mg daily; higher doses may be needed in liver failure.
Prescribing notes

Spironolactone is an aldosterone antagonist used for oedema in hepatic cirrhosis or heart
failure, and primary hyperaldosteronism.

Spironolactone 25mg daily has been shown to reduce mortality in patients with severe heart
failure receiving standard therapy including ACE inhibitors; renal function and electrolytes
should be monitored.

Use with caution in renal impairment.

Eplerenone is to be used as an adjunct in stable patients with left ventricular dysfunction with
evidence of heart failure following myocardial infarction (start therapy within 3-14 days of
event).

Eplerenone is an alternative aldosterone antagonist which may be prescribed for patients who
develop gynaecomastia with spironolactone.
Osmotic diuretics

Mannitol 10%, 20% infusion polyfusor
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 4 of 24
Date: 1.2.2012
Older Patients - Diuretics
All diuretics have the propensity to cause postural hypotension and thus collapse and falls in older
patients.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 5 of 24
Date: 1.2.2012
2.3 Anti-arrhythmic drugs
Supraventricular arrhythmias

Adenosine 3mg/ml injection

Adenosine 30mg/10ml (Restricted/unlicensed)

Dronedarone 400mg tablet
Supraventricular and ventricular arrhythmias

Amiodarone 100mg, 200mg tablet

Amiodarone 150mg/3ml injection

Amiodarone 300mg in 10ml prefilled syringe

Atenolol 25mg, 50mg, 100mg tablets

Atenolol 25mg/5ml syrup

Atenolol 5mg/10ml injection

Disopyramide 100mg capsule

Disopyramide 50mg/5ml injection

Flecainide 100mg tablet

Flecainide 150mg/15ml injection

Propafenone 150mg tablet

Sotalol 40mg, 80mg, 160mg tablet
Ventricular arrhythmias

Lidocaine/Lignocaine 0.2% in 500ml infusion

Lidocaine/Lignocaine 1% 10ml minijet

Mexiletine 50mg capsules
Dose
Anti-arrhythmics are complex agents; intravenous injections or infusions should be given
according to specialist advice.
- Disopyramide capsules 100mg: orally 300-800mg daily in divided doses
- Lidocaine injection 10mg/mL (1%), 20mg/mL (2%); infusion 1mg/mL (0.1%) and 2mg/mL
(0.2%) in glucose 5%, 500mL.
- Flecainide tablets 50mg, 100mg; injection 10mg/mL: orally, ventricular arrhythmias, 100mg
twice daily; max 400mg daily, reduced after 3-5 days if possible; supraventricular arrhythmias,
50mg twice daily; max 300mg daily.
- Atenolol tablets 25mg, 50mg, 100mg; syrup 25mg/5mL; injection 500micrograms/mL: orally, 50100mg daily.
- Amiodarone tablets 100mg, 200mg; injection 50mg/mL: orally, 200mg 3 times daily for 1 week,
then 200mg twice daily for 1 week, then usually 100-200mg daily thereafter.
- Dronedarone tablets 400mg: orally, 400mg twice daily
- Sotalol (with ECG monitoring and measurement of corrected QT interval) tablets 40mg, 80mg,
160mg: orally, initially 80mg daily in 1-2 divided doses increased every 2-3 days to 160-320mg
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 6 of 24
Date: 1.2.2012
daily in 2 divided doses; 480-640mg daily for life-threatening ventricular arrhythmias.
- Verapamil tablets 40mg, 80mg, 120mg; m/r tablets 120mg, 240mg; m/r capsules 120mg,
180mg, 240mg; injection 2.5mg/mL: orally, supraventricular arrhythmias, 40-120mg 3 times daily
for standard preparation; m/r verapamil, dose according to brand. See BNF.
- Adenosine injection 3mg/mL.
- Atropine injection 100micrograms/mL, 200micrograms/mL, 300micrograms/mL,
600micrograms/mL.
- Digoxin tablets 62.5micrograms, 125micrograms and 250micrograms; elixir 50micrograms/mL;
injection 250micrograms/mL.
- Mexiletene capsules 50mg: see BNF
Prescribing notes

Amiodarone may cause corneal microdeposits, thyroid dysfunction, pneumonitis, peripheral
neuropathy and hepatotoxicity. Liver-function and thyroid-function tests should be performed
before treatment, and 6 monthly thereafter; chest X-ray should be done before treatment.

Patients receiving amiodarone should avoid exposure of the skin to direct sunlight or sun
lamps; a sunscreening product providing SPF 25 should be applied if amiodarone is
prescribed.

Amiodarone interacts with many drugs. There is a potential for drug interactions to occur for
several weeks (or even months) after treatment with it has been stopped.

Sotalol may cause atypical VT (torsades de pointes); it should be given with extreme caution
with drugs known to prolong the QT interval e.g. erythromycin, chloroquine, haloperidol,
lithium, tricyclic antidepressants, chlorpromazine. It should not be used for angina,
hypertension, thyrotoxicosis or secondary prevention after myocardial infarction. Sotalol
should be avoided in patients on diuretics or with hypokalaemia.

For patients prescribed dronedarone, liver function tests should be performed:
o Prior to treatment
o On a monthly basis for six months
o At months 9 and 12, and periodically thereafter

With dronedarone if alanine transaminase (ALT) levels are elevated to ≥3 x upper limited of
normal (ULN), levels should be re-measured within 48 to 72 hours. If ALT levels are
confirmed to be ≥3 x ULN after re-measurement, dronedarone treatment should be
withdrawn.

Patients on dronedarone should be advised to contact healthcare professionals immediately in
case of signs or symptoms of liver injury.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 7 of 24
Date: 1.2.2012
2.4 Beta-adrenoceptor blocking drugs

Atenolol 25mg, 50mg, 100mg tablets

Atenolol 25mg/5ml syrup

Atenolol 5mg/10ml injection

Bisoprolol 1.25mg, 2.5mg, 3.75mg, 5mg, 10mg tablet

Esmolol 100mg/10ml

Esmolol 2.5g/250ml (ITU only)

Labetolol 50mg, 100mg tablet

Labetolol 5mg/ml injection

Metoprolol 5mg/5ml injection

Metoprolol 25mg/5ml suspension

Metoprolol 50mg, 100mg tablet

Nebivolol 5mg tablet

Propranolol 10mg, 40mg tablet

Propranolol 10mg/5ml and 80mg/5ml SF solution

Propranolol 1mg/ml injection

Propranolol M/R 80mg, 160mg capsule

Sotalol 40mg, 80mg, 160mg tablet
(For use in the treatment of heart failure only)
Dose
- Atenolol tablets 25mg, 50mg, 100mg; syrup 25mg/5mL: 25-100mg daily according to response.
- Bisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg: stable, chronic heart failure,
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily
for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily
maintenance.
- Labetolol tablets 50mg, 100mg: see BNF
- Metoprolol tablets 50mg, 100mg, suspension 25mg/5ml: see BNF
- Propranolol tablets 10mg, 40mg, 80mg, 160mg: thyrotoxicosis (adjunct), anxiety tachycardia,
10-40mg 3-4 times daily. Anxiety with symptoms such as palpitations, sweating, tremor, 40mg once
daily increased to 40mg 3 times daily if necessary. Migraine prophylaxis, essential tremor: initially
40mg 2-3 times daily, maintenance 80-160mg daily.
Prescribing notes

Bisoprolol is second-line for patients intolerant of atenolol in hypertension.

Bisoprolol is first choice beta-blocker for stable, chronic heart failure initiated under specialist
supervision.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 8 of 24
Date: 1.2.2012

Beta-blockers may cause bronchospasm; avoid in patients suffering asthma. If a beta-blocker
is required, a cardioselective beta-blocker should be selected, initiated at a low dose and the
patient closely monitored.

Sotalol is only used as an anti-arrhythmic.

Propranolol is indicated for treatment of migraine, anxiety, thyrotoxicosis and essential
tremor.
2.5 Drugs affecting the renin-angiotensin system and other antihypertensive drugs
Vasodilator antihypertensive drugs

Hydralazine 25mg tablet

Hydralazine 20mg injection

Minoxidil 5mg tablet

Sodium nitroprusside 50mg/5ml injection
Centrally acting antihypertensive drugs

Methyldopa 125mg, 250mg, 500mg tablet

Moxonidine 200 microgram, 300 microgram, 400 microgram tablet

Clonidine 25 microgram and 100 microgram tablet

Clonidine 150 microgram/ml injection
Alpha-adrenoceptor blocking drugs
1st Choice

Doxazosin 1mg, 2mg, 4mg tablet

Doxazosin 4mg XL, 8mg XL tablet
Alternatives

Prazosin 1mg tablet

Terazosin 2mg, 5mg tablet
Dose
- see BNF
Prescribing notes

Doxazosin is a third-line agent in the treatment of hypertension. It should be used with
caution in patients with heart failure or impaired left ventricular function.

Doxazosin may cause postural hypotension and first dose hypotension. Treatment should be
initiated at the lowest dose possible.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 9 of 24
Date: 1.2.2012
Angiotensin-converting enzyme inhibitors

Captopril 12.5mg, 25mg tablet

Enalapril 2.5mg, 5mg, 10mg tablet

Lisinopril 2.5mg, 5mg, 10mg, 20mg tablet

Perindopril 2mg, 4mg tablet

Ramipril 1.25mg, 2.5mg, 5mg, 10mg capsule
Dose
- see BNF
Prescribing notes

ACE inhibitors are useful alternatives for hypertension when thiazides and beta-blockers are
contra-indicated, not tolerated or fail to control blood pressure.

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.

Urea and electrolytes should be checked within 1 week of commencing therapy.

Enalapril should be prescribed once daily for hypertension.

Ramipril should be prescribed as a once daily dose. Patients who have been initiated on twice
daily dosing should be switched to an equivalent once daily dose/
Angiotensin-II receptor antagonists

Candesartan 2mg, 4mg, 8mg, 16mg and 32mg tablets

Irbesartan 75mg, 150mg tablet

Valsartan 40mg, 80mg and 160mg capsules
Dose
- Candesartan tablets 2mg, 4mg, 8mg, 16mg, 32mg: recommended dose is 4-32 daily. See BNF.
- Irbesartan tablets 75mg, 150mg, 300mg: recommended dose is 150-300mg once daily (in
haemodialysis or in elderly over 75 years, initial dose of 75mg once daily may be used). See BNF.
- Valsartan capsules 80mg, 160mg: 40mg-160mg daily. See BNF
Prescribing notes

Angiotensin-II receptor antagonists should be reserved for patients who develop a persistent
cough with ACE inhibitors.

Urea and electrolytes should be checked within 2 weeks of commencing therapy and after
any change in dose.

Losartan is available as a generic product and is less expensive currently than the other
angiotensin-II receptor antagonists.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 10 of 24
Date: 1.2.2012
Miscellaneous

Phenoxybenzamine 10mg capsules

Phentolamine 10mg/ml injection

Guanethidine 10mg/ml injection (Theatres only)

Iloprost nebules 10microgram/ml (Critical Care Only)
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 11 of 24
Date: 1.2.2012
2.6 Nitrates, calcium-channel blockers, and other anti-anginal drugs
Nitrates

Glyceryl trinitrate 400 microgram/dose spray

Glyceryl trinitrate 2mg, 3mg, 5mg buccal m/r tablet

Glyceryl trinitrate 5mg, 10mg skin patch

Glyceryl trinitrate 5mg/5ml injection

Isosorbide mononitrate 10mg, 20mg tablet

Isosorbide dinitrate 10mg, 20mg tablet

Isosorbide dinitrate 25mg/50ml injection
Dose
- Glyceryl trinitrate spray 400micrograms per puff; sublingual tablets 300micrograms,
500micrograms: sublingually, 300microgram-1mg repeated as required.
- Glyceryl trinitrate buccal tablets m/r 2mg, 3mg, 5mg: treatment of angina, 2mg as required
(1mg in sensitive patients), increased to 3mg if necessary; prophylaxis 1-3mg 3 times daily; 5mg in
severe angina. Unstable angina (adjunct), up to 5mg with ECG monitoring. Congestive heart failure,
5mg 3 times daily, increased to 10mg 3 times daily in severe cases. Acute heart failure, 5mg
repeated until symptoms abate.
- Isosorbide mononitrate tablets 10mg, 20mg:: 20 - 40mg twice daily (10mg twice daily in those
who have not previously received nitrates); up to 120mg daily in divided doses if required.
- Isosorbide dinitrate tablets 10mg, 20mg: see BNF
Prescribing notes

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 cost-effective branded long-acting preparation should be prescribed
only for patients who have a problem with compliance.

Glyceryl trinitrate (GTN) intravenous injection may be given when sublingual or buccal GTN is
ineffective in patients with chest pain due to myocardial infarction or severe ischaemia, and
in treatment of acute left ventricular failure.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 12 of 24
Date: 1.2.2012
Calcium-channel blockers

Amlodipine 5mg, 10mg tablet

Diltiazem 60mg M/R tablets (Tildiem®

Diltiazem 120mg, 240mg, 180mg, 300mg and 360mg s/r capsule (Viazem XL®)

Diltiazem 200mg M/R capsules (Tildiem LA®)

Lercanidipine 10mg tablets

Nifedipine 5mg, 10mg capsule - Instant release formulation

Nifedipine 10mg, 20mg s/r tablet (Adalat retard®) - 12 hourly formulation

Nifedipine 10mg, 20mg m/r capsules (Coracten SR®) - 12 hourly formulation

Nifedipine 30mg and 60mg XL capsules (Coracten XL®) - 24 hourly formulation

Nimodipine 30mg tablet, 10mg/50ml injection

Verapamil 40mg, 80mg,120mg tablet

Verapamil 120mg s/r capsule

Verapamil 40mg/5ml SF solution

Verapamil 2.5mg/ml injection
Dose
- Amlodipine tablets 5mg, 10mg: hypertension or angina, initially 5mg once daily; max. 10mg
once daily.
- Diltiazem m/r tablets 60mg, 90mg, 120mg; m/r capsules 60mg, 90mg, 120mg, 180mg, 200mg,
240mg, 300mg, 360mg: dose according to brand. See BNF.
- Verapamil tablets 40mg, 80mg, 120mg; m/r capsules 120mg: dose according to brand. See BNF.
Prescribing notes

Nifedipine m/r is first choice calcium-channel blocker for hypertension. The brand of different
calcium-channel blockers should be specified since different formulations may have different
clinical effects. The most cost-effective brand should be prescribed.

Sudden withdrawal of calcium-channel blockers may exacerbate angina; withdraw if
ischaemic pain occurs or worsens after starting treatment.

Nifedipine should not be given without a beta-blocker for angina.

Short-acting formulations of nifedipine capsules have been associated with large variations in
blood pressure and reflex tachycardia; they are no longer recommended for angina or
hypertension.

Diltiazem is first choice calcium-channel blocker for angina if a beta-blocker cannot be used;
it is also given for hypertension. It has less negative inotropic effects than verapamil and
significant myocardial depression is rare. Use caution if given with beta-blockers due to risk
of bradycardia. The most cost-effective brand should be prescribed.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 13 of 24
Date: 1.2.2012

Verapamil is used for angina, hypertension and arrhythmia; it reduces cardiac output, slows
the heart rate and may affect atrioventricular conduction. It may produce heart failure,
exacerbate conduction disorders, and high doses may cause hypotension. It should not be
used with beta-blockers.
Other Anti-anginal drugs

Nicorandil 10mg, 20mg tablet

Ivabradine 5mg, 7.5mg tablets
Dose
- see BNF
Prescribing notes

Nicorandil is used when other anti-anginal drugs are insufficient; 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.

Ivabradine is approved for use, on the initiation of a cardiologist, chronic stable angina in
patients for whom heart rate control is desirable and also have a contra-indication or
intolerance of beta-blockers and rate limiting calcium channel blockers.
Peripheral vasodilators and related drugs

Cinnarizine 75mg capsules

Pentoxyfilline 400mg tablets

Naftidrofuryl 100mg capsules
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.

Peripheral vasodilators are of limited value.

Cilostazol, pentoxifylline and inositol are not recommended for the treatment of intermittent
claudication.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 14 of 24
Date: 1.2.2012
2.7 Sympathomimetics
Inotropic sympathomimetics

Dobutamine 250mg/20ml injection

Dopamine 200mg/5ml injection

Dopexamine 50mg/5ml injection

Isoprenaline 2.25mg/2ml injection (unlicensed)
Vasoconstrictor sympathomimetics

Ephedrine 30mg/ml injection

Metaraminol 10mg/ml injection

Noradrenaline/Norepinephrine 2mg/ml injection

Phenylephrine 10mg/ml injection (ITU only)
Cardiopulmonary resuscitation

Adrenaline/Epinephrine 100 micrograms/ml(1:10,000) minijet

Adrenaline/Epinephrine 100 micrograms/ml(1:10,000) injection
Dose
- See BNF for dosing recommendations.
- Adrenaline injection 100micrograms/mL: during cardiopulmonary resuscitation (CPR), 1mg
(10mL) intravenously flushed with saline, and repeated every 3 minutes.
- Dobutamine strong sterile solution,12.5mg/mL and 50mg/mL.
- Dopamine sterile concentrate, 40mg/mL and 160mg/mL; intravenous infusion, 400mg or 800mg
in 250mL glucose 5%.
- Noradrenaline acid tartrate injection 2mg/mL (equivalent to noradrenaline base 1mg/mL).
Prescribing notes

Low dose dopamine induces vasodilatation and increases renal perfusion; higher doses (more
than 5micrograms/kg/min) produce vasoconstriction and may exacerbate heart failure.

Inotropic and vasoconstrictor sympathomimetics should preferably be used only in the
intensive care setting with invasive haemodynamic monitoring.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 15 of 24
Date: 1.2.2012
2.8 Anticoagulants and protamine
Parenteral anticoagulants

Fondaparinux 2.5mg syringe (Haematology advice only)
Standard heparins

Heparin 20000units/20ml, 5000units/5ml injection

Heparin 5000 units/0.2ml (Calciparine®)

Heparin 50 units/5ml (Hepsal®)
Low molecular weight heparins

Enoxaparin 20mg, 40mg, 60mg, 80mg, 100mg and 150 mg pre-filled syringe

Tinzaparin 20000 units/ml (2ml) vial

Tinzaparin 20000 unit/ml pre-filled syringes (10000, 14000, 18000, 40000 units)

Tinzaparin 10000/ml pre-filled syringes (3500, 4500 units)
Dose
- See BNF for dosing recommendations.
- Standard heparin 1000units/mL, 20 000units/20mL.
- Enoxaparin 100mg/mL (0.2mL, 0.4mL, 0.6mL, 0.8mL and 1mL syringes); 150mg/mL (0.8mL,
1mL syringes).
- Tinzaparin 10,000 units/mL (0.25mL, 0.35mL, 0.45mL syringes or 2mL vial) or 20,000 units/mL
(0.5mL, 0.7mL, 0.9mL syringes or 2mL vial).
Prescribing notes

See Trust “Unfractionated Heparin Dosing Guidelines”.

See Trust Thrombophylaxis guidelines on use of LMWHs.

Treatment with standard heparin is continued until no longer required, or until warfarin takes
effect (at least 3 days).

Heparin is monitored using activated partial thromboplastin time (APTT) to give a
patient/control ratio of 1.5-2.5.

Low molecular weight heparin does not require APTT monitoring; if necessary, anti-factor Xa
can be monitored.

Heparins may induce two types of thrombocytopenia: the first, usually develops within 1-4
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 7-11 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.

Lepirudin injection will be discontinued in the UK from 1st April 2012.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 16 of 24
Date: 1.2.2012
Epoprostenol

Epoprostenol 500 microgram vial
Oral anticoagulants

Warfarin 1mg, 3mg and 5mg tablets

Phenindione 10mg, 25mg and 50mg tablets

Dabigatran 75mg capsules

Dabigatran 110mg and 150mg capsules
Dose
- Warfarin tablets 500micrograms (white), 1mg (brown), 3mg (blue), 5mg (pink): induction dose
10mg daily for 2 days, then adjusted according to INR. A lower induction dose may be required by
some patients; see BNF for details.
Prescribing notes

See Trust “GUIDELINES FOR WARFARIN- INDUCTION and MAINTENANCE DOSES”

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 BNF before prescribing.

Vitamin K (phytomenadione) can be given to reverse the effects of warfarin but takes 6-12
hours to become effective. Immediate reversal of the anticoagulant effect of warfarin may be
achieved with fresh frozen plasma or prothrombin complex concentrate; see BNF for details.
Specialist haematological advice should be sought.

Dabigatran is approved for use in hip and knee replacement surgery for prophylaxis of
venous thromboembolism.

Warfarin will continue to be the first line drug of choice for prevention of stroke in patients
with non-valvular AF but Dabigitran be considered for patients with a warfarin allergy or an
absolute contra-indication to warfarin (Dabigatran may also be contra-indicated in some of
these indications). Please note that a bleeding risk that would lead to a contraindication to warfarin would also contra-indicate to Dabigatran.
Older Patients - Warfarin
Warfarin should be used with caution in patients with confusion or a tendency to fall.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 17 of 24
Date: 1.2.2012
Protamine

Protamine 50mg/5ml injection
Prescribing notes

Protamine sulphate reverses the effects of standard heparin, but only partially reverses the
effects of low molecular weight heparins.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 18 of 24
Date: 1.2.2012
2.9 Antiplatelet drugs

Aspirin 75mg and 300mg dispersible tablets

Aspirin 75mg and 300mg e/c tablets

Aspirin 150mg suppositories

Clopidogrel 75mg tablets

Dipyridamole 50mg/5ml suspension

Dipyridamole 200mg s/r capsules

Prasuguel 5mg and 10mg tablets

Tirofiban 12.5mg/50ml injection
Dose
- Aspirin dispersible tablets 75mg, 300mg: prophylaxis of cerebrovascular disease or myocardial
infarction, initial loading dose of 150-300mg, then 75mg daily.
- Clopidogrel tablets 75mg: for acute coronary syndrome, 75mg once daily for up to 12 months in
combination with aspirin. An initial loading dose of clopidogrel 300mg is recommended.
- Dipyridamole SR capsules 200mg: for secondary prevention of ischaemic stroke and transient
ischaemic attacks (used alone or combination with aspirin) 200mg capsule twice daily.
- Prasugrel tablets 5mg, 10mg: (with aspirin) initially 60mg as a single dose then body-weight over
60kg, 10mg once daily or body-weight under 60kg or over 75 years, 5mg once daily.
- Tirofiban injection 12.5mg/50ml: see BNF
Prescribing notes

The e/c formulations of aspirin are not recommended.

Dipyridamole m/r or low dose aspirin may be used with warfarin for prophylaxis of
thromboembolism due to prosthetic heart valves.

Patients with proven intolerance to aspirin may be prescribed clopidogrel to prevent further
events in stroke, myocardial infarction or peripheral vascular disease.

Aspirin and clopidogrel may be prescribed concomitantly for acute coronary syndrome for up
to 12 months, after which clopidogrel is discontinued.

Hospital specialists may prescribe clopidogrel for up to 3 months to prevent coronary artery
stent occlusion.

The combination of dipyridamole and clopidogrel has not been adequately evaluated and is
therefore not recommended.

There is a clinically significant interaction between clopidogrel and omeprazole making
clopidogrel less effective. If concomitant use of clopidogrel and a proton pump is necessary,
then lansoprazole would be an appropriate choice.

Prasugel in combination with aspirin 75mg is an option for treatment acute coronary
syndrome undergoing PCI.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 19 of 24
Date: 1.2.2012
2.10 Myocardial infarction and fibrinolysis

Alteplase 20mg and 50mg injection

Streptokinase 1.5million and 250000 unit injection

Tenecteplase and 50mg injection
(a) acute myocardial infarction
First choice: tenecteplase
Prescribing notes

Thrombolysis is effective if given as soon as possible after acute myocardial infarction; urgent
transfer to hospital is essential.

Tenecteplase has the advantage of availability as a single, weight adjusted, intravenous bolus
injection. It can also be used in patients who have ever received streptokinase, suffered a
recent streptococcal infection or developed a hypersensitivity reaction to streptokinase.

If severe bleeding occurs, the fibrinolytic should be discontinued; coagulation factors and/or
tranexamic acid may be required.
(b) acute ischaemic stroke
First choice: alteplase
Prescribing notes

Alteplase must be used in strict accordance with detailed protocols in a specialist acute stroke
unit.

Treatment must be started within 3 hours of onset of symptoms and after exclusion of
intracranial haemorrhage by means of appropriate imaging techniques.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 20 of 24
Date: 1.2.2012
2.11 Antifibrinolytic drugs and haemostatics

Etamsylate 500mg tablets

Tranexamic acid 100mg/ml injection

Tranexamic acid 500mg tablets

Factor VIIa 1mg and 5mg injection (Novoseven®)

Prothrombin complex 250unit and 500unit injection (Beriplex®)
Dose
- Tranexamic acid tablets 500mg; injection 100mg/mL: orally, menorrhagia (initiated when heavy
bleeding has started), 1-1.5g 3-4 times daily for 3-4 days. Slow intravenous injection: local
fibrinolysis 0.5-1g 3 times daily.
- Other products: see BNF or product literature
Prescribing notes

The manufacturer recommends regular eye examinations and liver function tests when
tranexamic acid is used long-term for hereditary angioneurotic oedema; however, the BNF
states that the need for regular eye examinations during long-term treatment is based on
unsatisfactory evidence.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 21 of 24
Date: 1.2.2012
2.12 Lipid-regulating drugs
Anion-exchange resins

Colestyramine 4g sachets
Fibrates

Bezafibrate 200mg tablets

Bezafibrate 400mg m/r tablets

Ciprofibrate 100mg tablets

Fenofibrate MR 160mg tablets
Prescribing notes

Fibrates have been less well tested in clinical trials. They are mainly of benefit in those with
mixed hyperlipidaemia and low HDL cholesterol.
Statins

Atorvastatin 10mg, 20mg, 40mg and 80mg tablets

Pravastatin 10mg, 20mg and 40mg tablets

Simvastatin 10mg, 20mg and 40mg tablets

Rosuvastatin 5mg, 10mg and 20mg tablets
Dose
- Atorvastatin tablets 10mg, 20mg, 40mg, 80mg: hyperlipidaemia, 10-80mg at night
- Simvastatin tablets 10mg, 20mg, 40mg, 80mg: hyperlipidaemia, 10-80mg at night; coronary
heart disease, initially 20mg at night, max 80mg at night.
- Pravastatin tablets 10m, 20mg, 40mg: see BNF
- Rosuvastatin tablets 5mg, 10mg, 20mg: see BNF
Prescribing notes

Lowering cholesterol is associated with reduced mortality and morbidity in patients at high
and moderate risk of, or with established, cardiovascular and cerebrovascular disease.

Pravastatin is less likely to interact with other drugs than atorvastatin or simvastatin and
may be preferred in certain situations, such as in patients receiving warfarin, digoxin or
ciclosporin.

Generic simvastatin is substantially lower cost than other lipid lowering agents.

Caution should be exercised when prescribing other drugs with statins. Simvastatin and
atorvastatin interact with many drugs including azole antifungals, macrolide antibiotics,
amiodarone, verapamil, grapefruit juice and warfarin. See BNF for full list of interactions.

Caution should be exercised when prescribing simvastatin 80mg daily due to the increased
risk of adverse effects.
Other

Ezetimibe 10mg tablets

Omacor capsules
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 22 of 24
Date: 1.2.2012
Dose
- Ezetimibe tablets 10mg: 10mg once daily.
- Omacor capsules: see BNF
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 23 of 24
Date: 1.2.2012
2.13 Local sclerosants

Ethanolamine oleate 5% injection

Sodium tetradecyl sulphate 0.5%, 1% and 3% injection
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 24 of 24
Date: 1.2.2012