Changes to the Formulary Since Previous Version

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 system and some other antihypertensive drugs / 2.6 Nitrates, calcium-channel blockers, and other anti-antianginal drugs
2.7 Sympathomimetics / 2.8 Anticoagulants and protamine
2.9 Antiplatelet drugs / 2.10 Myocardial infarction and fibrinolysis
2.11 Antifibrinolytic drugs and haemostatics / 2.12 Lipid-regulating drugs
2.13 Local sclerosants

Changes to the Formulary since previous version

(20.12.2013)

Section / Change / Reason for change
2.6 / REMOVED: GTN buccal tablets / Product discontinued
2.12 / REMOVED: Omacor / Gateshead Medicines Management Committee Approval

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)

·  Digifab 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, 250-500micrograms 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

- Digifab injection: see product literature

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.

2.2 Diuretics

Thiazides and related diuretics

·  Bendroflumethazide/Bendrofluazide 2.5mg, 5mg tablet

·  Chlorothiazide 250mg/5ml and 100mg/5ml suspension (unlicensed)

Dose

- Bendroflumethiazide tablets 2.5mg, 5mg: hypertension, 2.5mg daily.

- 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, 40mg/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 40mg furosemide).

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, 50mg, 100mg tablet

·  Spironolactone 50mg/5ml suspension (unlicensed)

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

Older Patients - Diuretics
All diuretics have the propensity to cause postural hypotension and thus collapse and falls in older patients.

2.3 Anti-arrhythmic drugs

Supraventricular arrhythmias

·  Adenosine 3mg/ml injection

·  Adenosine 30mg/10ml (Restricted/unlicensed)

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 50mg, 100mg tablet

·  Flecainide 150mg/15ml injection

·  Propafenone 150mg tablet

·  Sotalol 40mg, 80mg, 160mg tablet

·  Verapamil tablets

·  Verapamil 5mg/2ml injection

Ventricular arrhythmias

·  Lidocaine/Lignocaine 0.2% in 500ml infusion

·  Lidocaine/Lignocaine 1% injection

·  Mexiletine 50mg capsules (unlicensed)

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, 50-100mg 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.

- 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 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.

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.

·  Amiodarone and Sotalol may cause atypical VT (torsades de pointes); they should be given with extreme caution with drugs known to prolong the QT interval e.g. erythromycin, chloroquine, haloperidol, lithium, tricyclic antidepressants, chlorpromazine.

·  Sotalol 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.

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 (For use in the treatment of heart failure only)

·  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 (unlicensed)

·  Metoprolol 50mg, 100mg tablet

·  Nebivolol 5mg tablet

·  Propranolol 10mg, 40mg tablet

·  Propranolol 10mg/5ml solution

·  Propranolol M/R 80mg, 160mg capsule

·  Sotalol 40mg, 80mg, 160mg tablet

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.

·  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

Centrally acting antihypertensive drugs

·  Methyldopa 125mg, 250mg, 500mg tablet

·  Moxonidine 200 microgram, 300 microgram, 400 microgram tablet

·  Clonidine 100 microgram tablet

·  Clonidine 150 microgram/ml injection

Alpha-adrenoceptor blocking drugs

1st Choice

·  Doxazosin 1mg, 2mg, 4mg 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.

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

·  Ramipril 2.5mg/5ml oral solution

Dose

- see BNF

Prescribing notes

·  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 2 week of commencing therapy and after any dose change.

·  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.

·  Ramipril 2.5mg/5ml oral solution is approved for use in patients with short-term swallowing difficulties or enteral feeding tubes only. If required long-term then clinical need for patient to remain on therapy should be reconsidered.

Angiotensin-II receptor antagonists

·  Candesartan 2mg, 4mg, 8mg, 16mg and 32mg tablets

·  Irbesartan 75mg, 150mg tablet

·  Losartan 25mg, 50mg 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.

Miscellaneous

·  Phenoxybenzamine 10mg capsules

·  Phentolamine 10mg/ml injection

·  Guanethidine 10mg/ml injection (Theatres only) (Unlicensed)

·  Iloprost nebules 10microgram/ml (Critical Care Only)

2.6 Nitrates, calcium-channel blockers, and other anti-anginal drugs

Nitrates

·  Glyceryl trinitrate 400 microgram/dose spray

·  Glyceryl trinitrate 300microgram, 500microgram sublingual tablets

·  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.
- 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.

Calcium-channel blockers

·  Amlodipine 5mg, 10mg tablet

·  Diltiazem 60mg M/R tablets (Tildiem®