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 Formulary Chapter 2: Cardiovascular system - Full Chapter
02.09  Expand sub section  Antiplatelet drugs
 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)
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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
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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)
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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®)
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Formulary
Green 3
Tablets

See information above, and GMMMG algorithms below.  
Link  NICE TA317: Acute coronary syndrome - prasugrel
   
Abciximab
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Formulary Injection 
Link  Adult Loading Doses Policy
   
Eptifibatide (Integrilin®)
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Formulary Injection
Infusion

 
Link  Adult Loading Doses Policy
   
Tirofiban (Aggrastat®)
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Formulary Concentrate for infusion 
Link  Adult Loading Doses Policy
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

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.   

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