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 Formulary Chapter 2: Cardiovascular system - Full Chapter
02.01  Positive inotropic drugs
02.01.01  Cardiac glycosides
Digoxin

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Formulary
  • Tablets

  • Liquid

  • Injection


  • When switching from oral to intravenous digoxin, the intravenous dose should be approximately 70% of the oral dose.

    GMMMG does not recommend digoxin as first-line for rate control of atrial fibrillation in ambulant patients.

    For plasma concentration monitoring, blood should be taken at least 6 hours after a dose.


    Link  PAHT Adult Loading Doses Policy  
    02.01.01  Digoxin-specific antibody
    Digoxin specific antibody fragments (Digifab®)

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    Formulary See link for SPC

    Link  DigiFab UKPAR (includes SPC)  
    02.01.02  Phosphodiesterase type-3 inhibitors
    Enoximone (Perfan®)

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    Formulary Intravenous Injection

    Link  PAT Loading Doses Policy  
    02.02  Diuretics to top
    02.02.01  Thiazides and related diuretics
    Indapamide

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    First Choice Tablets

    First choice for hypertension, where a thiazide is indicated (see NICE CG127: Hypertension).

    N.B. Modified release tablets are NON-formulary
     
    Bendroflumethiazide

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    Second Choice Tablets

    Not first line for hypertension (see NICE CG127: Hypertension). Patients with stable and controlled blood pressure currently taking bendroflumethiazide can continue treatment.

     
    Metolazone

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    Formulary
    Green 3
    Tablets

    unlicensedunlicensed
    UK licensed product discontinued in 2012. Unlicensed import product is available from Pharmacy.

     
    Chlorothiazide

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    Formulary Suspension

    unlicensedunlicensed


    Restricted Item Paediatric use only
     
    02.02.02  Loop diuretics
    Furosemide

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    First Choice Tablets
    Liquid
    Injection

     
    Bumetanide

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    Second Choice Tablets
    Liquid

    Injection has been discontinued

     
    Torasemide

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    Third Choice Tablets
     
    02.02.03  Potassium-sparing diuretics and aldosterone antagonists
    Amiloride

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    Formulary Tablets
    Liquid

     
    02.02.03  Aldosterone antagonists
    Spironolactone

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    Formulary Tablets
    Suspension

    Spironolactone is significantly cheaper than eplerenone but there is no data available to compare cost-effectivess in particular groups of patients.

    Link  MHRA Safety Alert: Risk of potentially fatal hyperkalaemia  
    Eplerenone

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    Formulary Tablets


    Link  Link to GMMMG IPNTS recommendation: Eplerenone
    Link  NICE CG172 MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction  
    02.02.04  Potassium-sparing diuretics with other diuretics to top
    Co-amilofruse (amiloride and furosemide)

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    Second Choice Tablets

    Although it is preferable to prescribe potassium-sparing diuretics and loop diuretics separately, the use of fixed combinations may be justified if compliance is a problem (BNF).
     
    Co-amilozide

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    Second Choice Tablets

    Although it is preferable to prescribe potassium-sparing diuretics and thiazide diuretics separately, the use of fixed combinations may be justified if compliance is a problem (BNF).
     
    02.02.05  Osmotic diuretics
    Mannitol

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    Formulary Intravenous Infusion
     
    02.02.06  Mercurial diuretics
    02.02.07  Carbonic anhydrase inhibitors
    02.02.08  Diuretics with potassium
    02.03  Anti-arrhythmic drugs to top
    02.03.01  Management of arrhythmias
    02.03.02  Drugs for arrhythmias
    02.03.02  Supraventricular arrhythmias
    Adenosine (Adenocor®)

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    Formulary Injection
    Infusion
     
    Dronedarone (Multaq®)

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    Restricted Drug Restricted
    Green 3
    Tablets

    Restricted Item  Cardiologist/stroke physician initiation only

    Dronedarone should only be initiated as a second line treatment option for non-permanent atrial fibrillation after:
  • standard NICE first line options are either cautioned/contraindicated or have failed

  • and if
  • amiodarone use is cautioned/intolerated

  • It should only be used in clinically stable patients, and is not recommended for those with NYHA Class III/IV heart failure.

    Dronedarone is not recommended for patients with permanent AF.

    See attached guidance for more information.

    Link  MHRA Safety Alert: Dronedarone cardiovascular, hepatic and pulmonary adverse events – new restrictions and monitoring requirements
    Link  NICE TA197: Atrial fibrillation - dronedarone  
    02.03.02  Supraventricular and ventricular arrhythmias
    Amiodarone

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    Formulary
    Green 3
    Tablets
    Infusion
    Injection (emergency use only)

    Restricted Item Specialist initiation only


    Link  Adult loading doses policy  
    Flecainide

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    Formulary
    Green 3
    Tablets
    Injection

    Restricted Item Specialist initiation only.

    Restricted Item Paediatric Use: Specialist initiation and secondary care management until stable.

    Link  Adult Loading Doses Policy  
    Disopyramide

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    Formulary Capsules
    (Injection discontinued)

     
    02.04  Beta-adrenoceptor blocking drugs to top
    Bisoprolol

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    First Choice Tablets
     
    Carvedilol

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    Formulary Tablets
     
    Labetalol

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    Formulary Tablets
    Injection
    Infusion

    Labetalol is a first line option for the management of hypertension in pregnancy (see NICE Guidance - Hypertension in Pregnancy).

    Link  NICE CG107: Hypertension in Pregnancy  
    Atenolol

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    Formulary Tablets
    Syrup
    Injection
     
    Metoprolol

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    Formulary Tablets (not a preferred GMMMG option)
    Injection

     
    Nebivolol (Nebilet®)

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    Formulary Tablets

    Highly cardio-selective. Can be considered in patients with severe COPD or asthma, when benefits of beta-blockade are thought to outweigh the respiratory risks, under specialist supervision with PEFR monitoring in hospital. Can also be tried in patients who develop wheeze with less cardioselective beta-blockers.

    Usual to start at 1.25mg and uptitrate. This will involve the use of quarter of a 5mg tablet.
     
    Sotalol

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    Formulary Tablets

    Restricted Item Specialist initiation

    Sotalol is an option for managing life-threatening arrhythmias.
     
    Esmolol

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    Formulary Intravenous Infusion

    Restricted Item Cardiologist/anaesthetist initiation only
     
    Propranolol
    (For non-cardiovascular indications)

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    Formulary Tablets
    Modified Release Capsules
    Liquid

     
    02.05  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
    02.05.01  Vasodilator antihypertensive drugs
    Hydralazine

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    Formulary Tablets
    Injection

    Oral hydralazine may be used in combination with long-acting nitrates in patients with heart failure who are still symptomatic despite optimal therapy with ACE inhibitor and beta blocker or when ACE inhibitors and ARBs are contra-indicated or not tolerated.

    Not to be used as monotherapy (causes tachycardia and fluid retention). (BNF)


    Link  Adult Loading Doses Policy  
    Iloprost

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    Formulary
    Red
    Injection

    unlicensedunlicensed

    For use in rheumatology patients, see attached guidelines.

    Link  Guideline for the use of intravenous iloprost in rheumatology patients  
    Sildenafil

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    Formulary
    Red
    Tablets (Revatio®)
    Suspension (paediatric use) unlicensedunlicensed

    Formulary for treatment of pulmonary arterial hypertension.

    For erectile dysfunction, see chapter 7.4.5.
     
    Sodium Nitroprusside

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    Formulary Intravenous infusion

    unlicensedunlicensed
     
    02.05.02  Centrally acting antihypertensive drugs
    Methyldopa

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    Formulary Tablets

    Used in the management of hypertension in pregnancy

    Link  NICE CG107: Hypertension in Pregnancy  
    Clonidine Hydrochloride

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    Formulary Tablets
     
    Moxonidine

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    Formulary Tablets

    Restricted Item Specialist initiation only

    Moxonidine is considered a last-line management option for resistant hypertension.

     
    02.05.03  Adrenergic neurone blocking drugs
    Guanethidine Monosulphate (Ismelin®)

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    Formulary Intramuscular injection

    Restricted Item Licensed for rapid control of blood pressure, however alternative agents are preferred (BNF).

     
    02.05.04  Alpha-adrenoceptor blocking drugs to top
    Doxazosin

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    Formulary Tablets

    Doxazosin is a fourth-line hypertension management option.

    note Modified release preparations of doxazosin are not approved by GMMMG. Consider converting any existing patients to standard release doxazosin, using the UKMi Medicines Q&A for guidance.

    Link  UKMI Q&A: How should conversion between doxazosin formulations be carried out?  
    02.05.04  Phaeochromocytoma
    Phenoxybenzamine Hydrochloride

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    Formulary Capsules
    (Injection is non-formulary)
     
    Phentolamine (Rogitine®)

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    Formulary Injection

    For hypertensive episodes due to phaeochromocytoma, e.g. during surgery (BNF).
     
    02.05.05  Drugs affecting the renin-angiotensin system
     note 

    MHRA Safety Alert: Risk of potentially fatal hyperkalaemia

    02.05.05.01  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
     note  In heart failure and post-MI, it is important that ACE inhibitors are titrated up to their target dose (or maximum tolerated) as advised by NICE.
    Lisinopril

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    First Choice Tablets
     
    Perindopril erbumine

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    First Choice Tablets

    Prescribers are reminded that perindopril should be prescribed generically. Perindopril arginine (Coversyl Arginate®) is not dose equivalent and is not included in the formulary.

     
    Ramipril

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    First Choice Capsules
     
    Enalapril

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    Second Choice Tablets

     
    Captopril

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    Formulary Tablets
    Oral solution unlicensedunlicensed. Restricted Item For paediatric use only

    Not as per GMMMG for adults
     
    02.05.05.02  Angiotensin-II receptor antagonists
     note  Angiotensin-II receptor antagonists (ARBs) are more expensive that ACE inhibitors. Their use should be reserved only for patients who suffer from unacceptable side effects using ACE inhibitors. However, if patients have suffered angioedema with an ACE inhibitor then an ARB is NOT recommended.

    In heart failure, it is important that ARBs are titrated up to their target dose (or maximum tolerated) as advised by NICE.
    Losartan

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    First Choice Tablets


     
    Candesartan

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    First Choice Tablets
     
    Irbesartan

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    Formulary Tablets

    GMMMG endorse use for renal patients.
     
    Valsartan

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    Formulary Tablets

    GMMMG endorse use in post-myocardial infarction.
     
    Valsartan / Sacubitril (Entresto® )

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    Formulary
    Green 3
    Tablets

    Restricted ItemTo be initiated by Heart Failure team

    Link  PAT Guideline: Treatment of symptomatic chronic heart failure with reduced ejection fraction  
    02.05.05.03  Renin inhibitors to top
    02.06  Nitrates, calcium-channel blockers, and potassium-channel activators
    02.06.01  Nitrates
    Glyceryl Trinitrate

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    Formulary Spray
    Sublingual Tablets
    Patches
    Injection


    Link  PAT Continuous Infusion Charts (cardiology)  
    Isosorbide Mononitrate

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    Formulary Modified release tablets
    Tablets

     
    Isosorbide Dinitrate

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    Formulary Injection

     
    02.06.02  Calcium-channel blockers
    Amlodipine

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    First Choice Tablets
     
    Diltiazem
    (angina)

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    First Choice Standard tablets (60mg)
    Modified release tablets
    Modified release capsules

    Specify the brand when prescribing a diltiazem preparation (except for 60mg tablet).

     
    Verapamil
    (rate controlled atrial fibrillation)

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    First Choice Standard tablets
    Modified release tablets
    Modified release capsules
    Injection


    Link  UKMI Q&A: Evidence for verapamil for cluster headache  
    Lercanidipine

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    Second Choice Tablets
     
    Nifedipine

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    Formulary Modified release capsules
    Standard release capsules Restricted Item Raynauds phenomenon. Not recommended for angina prophylaxis or hypertension

    Specify the brand when prescribing a modified release nifedipine preparation.

    Short-acting formulations of nifedipine are not recommended for angina or long-term management of hypertension; their use may be associated with large variations in blood pressure and reflex tachycardia. (BNF)
     
    Nimodipine (Nimotop®)

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    Formulary Tablets
    Intravenous Infusion

    Restricted ItemFor prevention (oral) and treatment (IV) of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage.
     
    02.06.03  Other antianginal drugs
    Ivabradine

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    Formulary
    Green 3
    Tablets


    Restricted Item Specialist initiation

    Ivabradine should only be initiated in people with NYHA class II to IV stable chronic heart failure with systolic dysfunction who:
  • are in sinus rhythm with a heart rate of 75 bpm or more

  • have a left ventricular ejection fraction of 35% or less, AND

  • who have been stable for 4 weeks on optimised standard therapy with ACE inhibitors, beta-blockers and aldosterone antagonists (or when beta-blockers are contra-indicated or not tolerated).


  • Link  NICE TA 267: Ivabradine  
    Ranolazine (Ranexa®)

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    Formulary
    Green 2
    Tablets

    Restricted Item Restricted to cardiac services (PAHT)

    For stable angina where patients are unsuitable for physical therapy or first and second line agents (PAHT).
     
    Nicorandil (Ikorel®)

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    Formulary Tablets

    Indicated for stable angina only in patients whose angina is inadequately controlled by first-line anti-anginal therapies, or who have a contra-indication or intolerance to first-line therapies, such as beta-blockers and/or calcium channel blockers.

    Link  MHRA Safety Alert: Risk of ulcer complications  
    02.06.04  Peripheral vasodilators and related drugs to top
    Naftidrofuryl Oxalate

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    Formulary Tablets

    Naftidrofuryl is an option for the treatment of intermittent claudication in people with peripheral arterial disease for whom vasodilator therapy is considered appropriate after taking into account other treatment options. See NICE TA223: Peripheral Arterial Disease.
     
    Pentoxifylline (Trental®)

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    Formulary Tablets

    Restricted Item For alcoholic liver disease.

    Not recommended for the treatment of intermittent claudication in patients with peripheral arterial disease, but patients currently taking pentoxifylline should have the option to continue until they and their clinican considers it appropriate to stop. (NICE TA223:Peripheral Arterial Disease)
     
    02.06.04  Other preparations used in peripheral vascular disease
    02.07  Sympathomimetics
    Midodrine

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    Formulary
    Green 3
    Tablets
    Restricted Item For hypotensive states. Not to be initiated in primary care.


     
    02.07.01  Inotropic sympathomimetics
    Dobutamine

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    Formulary Concentrate for intravenous infusion (dilute before use).


    Link  PAT Continuous Infusion Charts (cardiology)  
    Dopamine

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    Formulary Concentrate for intravenous infusion (dilute before use).
     
    Dopexamine

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    Formulary Concentrate for intravenous infusion (dilute before use).
     
    Isoprenaline

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    Formulary Concentrate for injection or infusion (dilute before use).
    unlicensedunlicensed


    Link  PAT Continuous Infusion Charts (cardiology)  
    02.07.02  Vasoconstrictor sympathomimetics
    Ephedrine

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    Formulary Intravenous injection
     
    Metaraminol

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    Formulary Injection

    unlicensedunlicensed
     
    Noradrenaline / Norepinephrine

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    Formulary Injection (for intravenous infusion; dilute before use).
     
    Phenylephrine

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    Formulary Injection
     
    02.07.03  Cardiopulmonary resuscitation to top
    Adrenaline / Epinephrine

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    Formulary Injection

    Link  PAT Resuscitation Policy  
    02.08  Anticoagulants and protamine
    02.08.01  Parenteral anticoagulants
    02.08.01  Heparin
    Heparin

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    Formulary Injection

     
    02.08.01  Low molecular weight heparins
     note  For details of GMMMG RAG list status for the Low Molecular Weight Heparins, see: http://gmmmg.nhs.uk/html/rag_adult.php
    Enoxaparin

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    First Choice
    Green
    Subcutaneous injection

    Green Traffic Light Green2 or Green3 depending on indication. See GMMMG RAG list for full details
     
    02.08.01  Heparinoids to top
    Danaparoid (Orgaran®)

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    Formulary Injection

    Restricted Item For prevention and treatment of thromboembolic disease in patients with a history of heparin-induced thrombocytopenia.
     
    02.08.01  Hirudins
    02.08.01  Heparin flushes
    Heparin

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    Formulary Flush solution

    note For maintaining patency of peripheral venous catheters, sodium chloride injection 0.9% is as effective as heparin flushes. The role of heparin flushes in maintaining patency of arterial and central venous catheters is unclear (BNF).

    All flush solutions must be prescribed. See NPSA Rapid Response Alert.

    Link  NPSA Rapid Response Report: Risks with Intravenous Heparin Flush Solutions  
    02.08.01  Epoprostenol
    Epoprostenol (Flolan®)

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    Formulary Infusion
     
    02.08.01  Fondaparinux
    Fondaparinux (Arixtra®)

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    Formulary
    Green
    Subcutaneous injection
    Green Traffic Light Depends on indication - see GMMMG website for further details
    Restricted Item Approved for prevention of venous thromboembolic events in orthopaedic surgery. Awaiting Trust-approved protocols for other indications.
     
    02.08.02  Oral anticoagulants to top
    02.08.02  Stroke Prevention in Atrial Fibrillation
    Warfarin

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    First Choice Tablets

    Link  Adult Loading Doses Policy
    Link  MHRA Safety Alert: Calciphylaxis with Warfarin
    Link  UKMI Q&A: IM injections in warfarin patients
    Link  UKMI Q&A: Warfarin and PPI interaction  
    Apixaban (Eliquis)

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    First Choice
    Green 1
    Tablets

    Link  PAT Guideline for the Management of Oral Anticoagulation in patients with Atrial Fibrillation
    Link  NICE TA275: Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) - apixaban (TA275)  
    Dabigatran (Pradaxa®)

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    Formulary
    Green 1
    Capsules

    Praxbind® (idarucizumab) is a specific reversal agent for dabigatran. This may be used on the advice of a haematologist only - see PAT guideline: Management of Bleeding in Patients Receiving Anti-thrombotic Agents.

    Link  PAT Guideline for the Management of Oral Anticoagulation in patients with Atrial Fibrillation
    Link  MHRA Drug Safety Update (dabigatran)
    Link  NICE TA249: Dabigatran for Stroke prevention in AF  
    Edoxaban (Lixiana®)

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    Formulary
    Green 1
    Tablets

    Link  NICE TA355: Edoxaban for stroke prevention in AF  
    Rivaroxaban (Xarelto®)

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    Formulary
    Green 1
    Tablets

    Link  PAT Guideline for the Management of Oral Anticoagulation in patients with Atrial Fibrillation
    Link  NICE TA256: Rivaroxaban for AF  
    Acenocoumarol (Sinthrome®)

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    Formulary Tablets

    Link  NICE CG144: Venous thromboembolic diseases  
    Phenindione

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    Formulary Tablets
     
    02.08.02  Treatment of DVT/PE
    Warfarin

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    First Choice Tablets

    Link  MHRA Safety Alert: Calciphylaxis with Warfarin
    Link  NICE CG144: Venous Thromboembolism  
    Apixaban (Eliquis)

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    First Choice
    Green 1
    Tablets

    Link  NICE TA341: Apixaban for the treatment and secondary prevention of DVT/PE  
    Dabigatran (Pradaxa®)

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    Formulary
    Green 1
    Capsules

    Praxbind® (idarucizumab) is a specific reversal agent for dabigatran. This may be used on the advice of a haematologist only - see PAT guideline: Management of Bleeding in Patients Receiving Anti-thrombotic Agents.

    Link  NICE TA327: Dabigatran for the treatment and secondary prevention of DVT/PE  
    Edoxaban (Lixiana®)

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    Formulary
    Green 1
    Tablets

    Link  NICE TA354: Edoxaban for treating and preventing DVT/PE  
    Rivaroxaban (Xarelto®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary
    Green 1
    Tablets

    Link  NICE TA261: Rivaroxaban for treatment of DVT
    Link  NICE TA287: Rivaroxaban for treating PE and preventing recurrent venous thromboembolism  
    Phenindione

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Tablets
     
    Acenocoumarol (Sinthrome®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Tablets

    Link  NICE CG144: Venous Thromboembolism  
    02.08.02  VTE prophylaxis in hip/knee surgery
    Dabigatran (Pradaxa®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary
    Green 1
    Capsules

    Praxbind® (idarucizumab) is a specific reversal agent for dabigatran. This may be used on the advice of a haematologist only - see PAT guideline: Management of Bleeding in Patients Receiving Anti-thrombotic Agents.

    Link  NICE TA157: Dabigatran for prophylaxis of VTE post hip or knee surgery  
    Rivaroxaban (Xarelto®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary
    Green 1
    Tablets

    Link  NICE TA170: Rivaroxaban for prevention of VTE post hip or knee surgery  
    02.08.03  Protamine sulphate
    Protamine Sulphate

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
    02.09  Antiplatelet drugs to top
     note 

    GMMMG Recommendations on prevention of occlusive vascular events

    Ischaemic stroke

    First-line - give Clopidogrel monotherapy.

    Give dipyridamole MR + Aspirin ONLY if:

    �� Clopidogrel is contraindicated (CI) or not tolerated, OR

    �� to continue treatment in patients already receiving this combination.

    Give dipyridamole MR monotherapy ONLY if Aspirin AND Clopidogrel are CI or not tolerated.

    TIA

    First-line - give dipyridamole MR + Aspirin.

    Give dipyridamole MR monotherapy ONLY if Aspirin is CI or not tolerated.

    Clopidogrel is not recommended for people who have had a TIA as it does not have UK marketing authorisation for this indication.

    PAD or multivascular disease

    First-line - give Clopidogrel monotherapy.

    MI

    Following initial acute management according to NICE CG94: Unstable angina and NSTEMI or NICE CG48: MI, Secondary Prevention :

    First-line - give Aspirin monotherapy.

    Give Clopidogrel monotherapy ONLY if Aspirin is CI or not tolerated.

    Although not discussed in this NICE guideline, Aspirin monotherapy would only be used if dipyridamole and/or Clopidogrel are contraindicated or not tolerated.

    Dual anti-platelet therapy (Aspirin plus Clopidogrel or Ticagrelor or Prasugrel) should be prescribed for up to 12 months after an acute MI (Usually 12 months will be recommended). Occasionally, consultant cardiologists may recommend a longer period of therapy (possibly lifelong/indefinitely) having taken account the risks and benefits at an individual patient level. This will usually be after a complex coronary stenting procedure of after recurrent events despite optimal therapy.

    A course length for clopidogrel, ticagrelor or prasugrel must be indicated on any communication with primary care.

    Early discontinuation of anti-platelets must be avoided especially in patients who have had intra-coronary stents, without prior discussion with cardiologists.

    In severe dyspepsia, low dose Aspirin should be initiated with gastro-protection (Omeprazole). Should the severe dyspepsia continue despite gastroprotection, substitute with Clopidogrel 75mg daily.

    Concomitant use of Clopidogrel and Omeprazole or Esomeprazole is discouraged unless considered essential. Consider Lansoprazole in patients who are taking Clopidogrel. Other gastrointestinal therapy such as H2 blockers (except cimetidine) or antacids may be suitable in some patients

    Aspirin (antiplatelet)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Dispersible tablets
    Gastro-resistant (enteric coated) tablets (only for patients established on this product)
    Tablets

    See information above.

    Low dose aspirin prophylaxis should not routinely be initiated for primary prevention.

    Enteric-coated aspirin tablets are not recommended. There is no convincing evidence that at a daily dose of 75mg using enteric coated rather than soluble aspirin reduces the risk of gastrointestinal bleeding. (Ref: Drug Ter Bull. Jan 1997, p7-8).
     
    Clopidogrel

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    Formulary Tablets

    See information above.

    Link  NICE TA210: Clopidogrel/dipyridamole MR prevention of occlusive vascular events.  
    Dipyridamole

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Tablets
    Modified Release Capsules
    Oral suspension

    See information above.

    Link  NICE TA 210: Clopidogrel/dipyridamole MR for prevention of occlusive vascular events  
    Dipyridamole and Aspirin (Asasantin® Retard)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Modified release capsules.

    See information above.

    Link  NICE TA210: Clopidogrel/dipyridamole MR for prevention of occlusive vascular events.  
    Ticagrelor (Brilique®)

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    Formulary
    Green 3
    Tablets

    See information above.

    Restricted Item Only to be prescribed on advice of cardiology

    Link  NICE TA236: Ticagrelor for the treatment of acute coronary syndromes  
    Prasugrel (Efient®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary
    Green 3
    Tablets

    See information above, and GMMMG algorithms below.

    Link  NICE TA317: Acute coronary syndrome - prasugrel  
    Abciximab

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection

    Link  Adult Loading Doses Policy  
    Eptifibatide (Integrilin®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
    Infusion


    Link  Adult Loading Doses Policy  
    Tirofiban (Aggrastat®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Concentrate for infusion

    Link  Adult Loading Doses Policy  
    02.10  Stable angina, acute coronary syndromes, and fibrinolysis
    02.10.01  Management of stable angina and acute coronary syndromes
    02.10.02  Fibrinolytic drugs
    Alteplase (Actilyse®)

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    Formulary
    Red
    Actilyse Injection

    Restricted ItemActilyse Cathflo 2mg (for thrombolytic treatment of occluded central venous access devices)is restricted to  NMGH Renal Unit only;

    Approved for pulmonary embolism, acute ischaemic stroke (FGH only) and thrombolysis in acute limb ischaemia.

    Alteplase is recommended for the treatment of acute ischaemic stroke in adults in accordance with its licensed indication if:
  • treatment is started as early as possible within 4.5 hoursof onset of stroke symptoms, AND

  • intracranial haemorrhage has been excluded by appropriate imaging techniques

  • See NICE TA264

    Link  Adult Loading Doses Policy
    Link  NICE TA264: Ischaemic stroke (acute) - alteplase  
    Streptokinase

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
    Tenecteplase (Metalyse®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
    Urokinase

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
    02.11  Antifibrinolytic drugs and haemostatics
    Tranexamic Acid

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Tablets
    Injection
     
    02.12  Lipid-regulating drugs to top
    02.12  Statins
     note 

    If intolerance to statins is a problem, this should be managed by dose reduction or the use of an alternative statin in preference to commencing alternative lipid lowering agents such as ezetimibe.

    Atorvastatin

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    First Choice Tablets
     
    Simvastatin

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    First Choice Tablets
     
    Pravastatin

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Tablets
     
    Rosuvastatin

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    Formulary Tablets

    Approved for use in PAHNT for patients who have not achieved target levels with other statins.
     
    02.12  Bile acid sequestrants
    Colestyramine

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    Formulary Powder
     
    02.12  Ezetimibe
    Ezetimibe (Ezetrol®)

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    Formulary Tablets

    Not licensed for primary or secondary prevention of cardiovascular disease.

    Link  NICE TA132: Hypercholesterolaemia - ezetimibe  
    02.12  Fibrates
    Fenofibrate

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    Formulary Capsules
    Tablets

    Fenofibrate has similar efficacy to bezafibrate in the reduction of triglycerides and is more potent in terms of LDL reduction and HDL elevation.

     
    02.12  Nicotinic acid group to top
    02.12  Omega-3 fatty acid compounds
    Omega-3-Acid Ethyl Esters

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    Formulary
    Grey
    Capsules

    Restricted Item Should only be used for the treatment of hypertriglyceridaemia under the care of a lipid management specialist.

    Omega-3-Acid Ethyl Esters are NOT recommended for the secondary prevention of Myocardial Infarction. See GMMMG IPNTS recommendation.

    Link  GMMMG IPNTS Recommendation: Omacor Capsules
    Link  NICE CG181: Lipid Modification
    Link  NICE Evidence Summary: schizophrenia - omega-3 fatty acid medicines  
    02.12  Other lipid modifying agents
    Evolocumab (Repatha®)

    View adult BNF  View SPC online  Track Changes
    First Choice
    High Cost Medicine
    Red
    Pre-filled syringe
    Pre-filled pen

    Only as per NICE TA394.
    Requires completion of Blueteq form prior to initiation.
    Available via Homecare providers.



    Link  NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
    Link  GMMMG Pathway: PCSK9 inhibitors in the treatment of hypercholesterolaemia  
    Alirocumab (Praluent®)

    View adult BNF  View SPC online  Track Changes
    Second Choice
    High Cost Medicine
    Red
    Pre-filled syringe
    Pre-filled pen

    Restricted Item For patients with latex allergy or intolerance to evolocumab

    Only as per NICE TA393.
    Requires completion of Blueteq form prior to initiation.
    Available via Homecare providers.



    Link  NICE TA393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia
    Link  GMMMG Pathway: PCSK9 inhibitors in the treatment of hypercholesterolaemia  
    02.13  Local sclerosants
    Ethanolamine Oleate

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
    Sodium Tetradecyl Sulphate (Fibro-Vein®)

    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Formulary Injection
     
     ....
     Non Formulary Items
    Acebutolol (Sectral®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Acipimox (Olbetam®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Aliskiren


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    Non Formulary
    Green 3
    Restricted Item Tablets

    Restricted Item Specialist initiation only - requires approval on urgent clinical need basis from Medical D&T chair

    Fourth-line agent after considering alpha-blockers, potassium sparing diuretics or aldosterone antagonists.


    Link  GMMMG New Therapies Recommendation: Aliskiren
    Link  MHRA: Aliskiren (Rasilez▼): risk of cardiovascular and renal adverse reactions—new contraindications and warnings  
    Ambrisentan


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Red

     
    Amlodipine and Valsartan (Exforge®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Aprotinin (Trasylol®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Argatroban (Exembol®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Atenolol and Co-amilozide (Kalten®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Atenolol and Nifedipine (Beta-Adalat®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Atenolol and Nifedipine (Tenif®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Azilsartan


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Bemiparin


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Bezafibrate


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Bivalirudin (Angiox®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary

    Link  NICE CG94: Unstable angina and NSTEMI
    Link  NICE TA230: Bivalirudin for the treatment of STEMI, 2011  
    Bosentan (Tracleer®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Red

     
    Burinex K®


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black

     
    Captopril and Hydrochlorothiazide (Capozide®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Captopril and Hydrochlorothiazide (Co-zidocapt®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Celiprolol Hydrochloride


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
     
    Centyl K®


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black

     
    Chlortalidone


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Cilazapril (Vascace®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Cilostazol (Pletal®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Not recommended for the treatment of intermittent claudication in patients with peripheral arterial disease. BUT, patients currently taking cilostazol should have the option to continue until they and their clinican consider it appropriate to stop. (NICE TA 223: Peripheral Arterial Disease)
     
    Ciprofibrate (Modalim®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Co-flumactone


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Colesevelam (Cholestagel®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Colestipol Hydrochoride (Colestid®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Co-tenidone (atenolol and chlortalidone)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
     
    Co-triamterzide


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Cozaar- Comp®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Cyclopenthiazide (Navidrex®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Dalteparin


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Subcutaneous injection
     
    Diazoxide (Eudemine®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Injection (discontinued)
    Tablets - see section 6.1.4



     
    Digitoxin


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
     
    Diumide-K Continus®


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black

     
    Doxazosin M/R


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black
    Modified release preparations of doxazosin are not approved by GMMMG. Consider converting any existing patients to standard release doxazosin, using the UKMi Medicines Q&A for guidance.

    Link  UKMi Q&A: How should conversion between doxazosin formulations be carried out?  
    Enalapril Meleate and Hydrochlorothiazide (Innozide®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Eprosartan (Teveten®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Etamsylate (Dicynene®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Felodipine


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Modified release tablets

    Not GMMMG
     
    Fluvastatin (Lescol® XL)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Fluvastatin (Lescol®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Fosinopril Sodium


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets

    Not GMMMG
     
    Frusene®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Gemifibrozil


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Hydrochlorothiazide


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Iloprost nebules (Vantavis®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Indapamide (Modified Release )


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Modified Release Tablets

     
    Indoramin (Baratol®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Indoramin (Doralese®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Inositol Nicotinate (Hexopal®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Not recommended for the treatment of intermittent claudication in patients with peripheral arterial disease. BUT, patients currently taking inositol nicotinate should have the option to continue until they and their clinican consider it appropriate to stop. (NICE TA223:Peripheral Arterial Disease)
     
    Isosorbide Dinitrate


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets
    MR Tablets
    Aerosol Spray
     
    Isradipine (Prescal®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Kalspare®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Lacidipine


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets

    Not GMMMG
     
    Lasikal®


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black

     
    Lepirudin (Refludan®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Lisinopril and Hydrochlorothiazide (Carace® Plus)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Lisinopril and Hydrochlorothiazide (Lisicostad®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Lisinopril and Hydrochlorothiazide (Zestoretic®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Milrinone (Primacor®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Intravenous Injection
     
    Minioxidil (Loniten®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Minoxidil


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Moexipril Hydrochloride (Perdix®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Moracizine


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Moxisylyte (Opilon®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Nadolol (Corgard®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Navispare®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Neo-NaClex-K®


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary
    Black

     
    Nicardipine


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets

    Not GMMMG
     
    Nicotinic Acid (Niaspan®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Nisoldipine (Syscor® MR)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Olmesartan (Sevikar®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Omega-3-Marine Triglycerides (Maxepa®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary

    Link  NICE: schizophrenia - omega-3 fatty acid medicines  
    Oxerutins (Paroven®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Oxprenolol Hydrochloride


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Oxprenolol Hydrochloride (Slow-Trasicor®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Oxprenolol Hydrochloride (Trasicor®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Oxprenolol Hydrochloride and Cyclopenthiazide (Trasidrex®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Perindopril Arginine  (Coversyl® Arginine)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Pindolol


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Pindolol and Clopamide (Viskaldix®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Prazosin


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Not GMMMG
     
    Procainamide


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Restricted Drug Unlicensed
     
    Propafenone


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Quinapril


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets

    Not GMMMG
     
    Quinapril and Hydrochlorothiazide (Accuretic®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Ramipril and Felodipine (Triapin®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Rasitro®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Reteplase (Rapilysin®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Sevikar HCT®


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Simvastatin and Ezetimibe (Inegy®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Sitaxentan Sodium (Thelin®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Tadalafil (Adcirca®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Telmisartan


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Terazosin


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Not GMMMG
     
    Timolol


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Timolol Maleate and Bendroflumethiazide (Prestim®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Timolol Maleate and Co-amilozide (Moducren®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Tinzaparin


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Tolazoline


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Trandolapril (Gopten®)


    View adult BNF  View SPC online  View childrens BNF  Track Changes
    Non Formulary Tablets

    Not GMMMG
     
    Trandolapril and Verapamil (Tarka®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Triamterene (Dytac®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
    Xipamide (Diurexan®)


    View adult BNF  View SPC online  View childrens BNF
    Non Formulary
     
      
    Key
    note Notes First Choice Item First Choice item
    Section Title Section Title (top level) Non Formulary Item Non Formulary section
    Section Title Section Title (sub level)
    Cytotoxic Drug
    Cytotoxic Drug
    Restricted Drug
    Restricted Drug
    CD
    Controlled Drug
    Unlicensed Drug
    Unlicensed
    High Cost Medicine
    High Cost Medicine
    click to search medicines.org.uk
    Link to SPCs
    click to search medicines.org.uk
    Link to adult BNF
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to children's BNF
    Cancer Drugs Fund
    Cancer Drugs Fund
       

     

    Traffic Light Status Information

    Status Description
      Amber   Drugs designated amber are suitable for shared care arrangements under a shared care protocol. Prescribing may be transferred from secondary to primary care once the patient is stabilised and agreed shared care arrangements have been established. Alternatively primary care may initiate under the supervision of secondary care if this option is given in the shared care document. It is recommended that shared care arrangements should be drawn up following local discussion and agreement by prescribing parties.   
      Black   These products have been reviewed by the GM Joint Formulary Group and have been deemed not suitable for prescribing for adults in primary or secondary care within Greater Manchester. These decisions have been made on the basis of safety, efficacy and cost-effectiveness of the products.  
      Green   Not used   
      Green 1   Drugs designated green1 are suitable for initiation and ongoing prescribing within primary care.   
      Green 2   Drugs designated green2 can be initiated by primary care following written or verbal advice from a specialist and then be subsequently safely prescribed in primary care with little or no monitoring required.  
      Green 3   Drugs designated green3 are suitable for on-going prescribing within primary care after specialist initiation and an initial review (unless specified) in secondary care. Little or no monitoring is required.  
      Grey   Not suitable for routine prescribing but may be suitable for a defined patient population. Whilst prescribers should think very carefully before prescribing or recommending any of the products on the grey list, there may be exceptional instances when the use of one of these products is necessary for a particular patient.   
      Red   Drugs designated red are considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in primary care. It is recommended that the supply of these specialist medicines should be organised via the hospital pharmacy, this may include arranging for supply via a home care company.   

    netFormulary