Approved: 4 Nov 2010. Last amended: 28 Nov 2019.

2.1 Positive inotropic drugs

2.1.1 Cardiac glycosides

Recommended

  • Digoxin
  • Specific Indication

  • DigiFab®

    reversal of life-threatening digoxin overdose

  • 2.1.2 Phosphodiesterase type-3 inhibitors

  • Enoximone

    for use in DCC and anaesthesia

  • Milrinone

    for use in DCC and anaesthesia

  • 2.2 Diuretics

    2.2.1 Thiazides and related diuretics

    Recommended

  • Indapamide (standard release)

    first line thiazide for hypertension

  • Alternative

  • Bendroflumethiazide

    2.5mg daily produces a near maximal blood pressure lowering effect, with very little biochemical disturbance.

  • Specific Indication

  • Chlortalidone

    Benign intracranial hypertension

  • Metolazone

    Severe heart failure and diuretic resistance – it is significantly more potent than bendroflumethiazide and will cause profound diuresis in combination with loop diuretics. Careful monitoring is required to avoid electrolyte disturbance and dehydration. Sometimes prescribed as a twice or three times weekly dose.

  • 2.2.2 Loop Diuretics

    Recommended

  • Furosemide
  • Specific Indication

  • Bumetanide

    when furosemide not tolerated or ineffective

  • 2.2.3 Potassium-sparing diuretics and aldosterone antagonists

    Recommended

  • Amiloride

    a weak diuretic, but is useful for potassium conservation and the most appropriate alternative to potassium supplements.

  • Spironolactone

    • Heart Failure
    • Oedema in liver cirrhosis
    • Conn’s Syndrome

    Spironolactone 25mg tablets are not scored. Ensure that patients have access to a tablet cutter if lower doses (e.g. 12.5mg) are required at home

  • Eplerenone

    Intolerance / adverse effects with spironolactone (heart failure patients only)

  • 2.2.4 Osmotic Diuretics

  • Mannitol Infusion 20%
  • 2.2.5 Mercurial diuretics

    None

    2.2.6 Carbonic anhydrase inhibitors

  • Acetazolamide 250mg tablets

    • Benign intracranial hypertension

    For use of acetazolamide in:

    • ophthalmology see section 11.6
    • epilepsy see section 4.8.1

  • 2.2.7 Diuretics with potassium

    None. Most patients on diuretics do not require potassium supplements. The amount of potassium in combined preparations (e.g. Burinex K®) is insufficient for those patients requiring supplementation, therefore the use of these products is discouraged. Potassium sparing diuretics are more effective for maintaining potassium levels.

    2.3 Anti-arrhythmic drugs

  • Digoxin
  • Verapamil
  • Amiodarone

    GHNHSFT Local Guidelines – Amiodarone Policy

    Amiodarone Shared Care Guideline

  • Disopyramide
  • Flecainide

    avoid if history of MI / heart failure / structural heart disease.

  • Propafenone
  • Sotalol

    can prolong QT interval, ECG required following dose change

  • Adenosine
  • Dronedarone

    As per NICE TA197

  • Lidocaine

    injection

  • Magnesium sulphate injection

    for documented long QT related ventricular arrhythmias (beware of risk of significant sinus node suppression, particularly when used with other antiarrhythmics such as amiodarone)

  • 2.4 Beta-adrenoceptor blocking drugs

  • Atenolol
  • Bisoprolol
  • Carvedilol

    Heart failure only

  • Labetalol

    • pregnancy
    • aortic dissection
    • anaesthesia

  • Metoprolol

    short-acting agent to establish if patient can tolerate beta blocker, and long term use in renal impairment

  • Propranolol

    • anxiety
    • portal hypertension
    • thyrotoxicosis

  • Esmolol
  • 2.5 Drugs affecting the renin-angiotensin system and some other antihypertensive drugs

    2.5.1 Vasodilator antihypertensive drugs

    Specific Indication

  • Hydralazine

    4th line adjunct

  • Minoxidil

    4th line adjunct

  • 2.5.2 Centrally acting antihypertensive drugs

    Specific Indication

  • Moxonidine

    4th line adjunct

  • Methyldopa

    • 4th line adjunct
    • 2nd line antihypertensive in pregnancy

  • 2.5.3 Adrenergic neurone blocking drugs

    None

    2.5.4 Alpha-adrenoceptor blocking drugs

    Hypertension

    Doxazosin or prazosin may be useful for treatment of hypertension in patients with benign prostatic hyperplasia.

    Recommended

  • Doxazosin

    4th line adjunct. Modified release doxazosin offers no pharmacokinetic benefit over the standard preparation and is significantly more expensive.

  • Alternative

  • Prazosin

    4th line adjunct

  • Specific Indication

  • Phentolamine

    anaesthesia and management of phaeochromocytoma

  • Phenoxybenzamine

    management of phaeochromocytoma

  • 2.5.5 Drugs affecting the renin-angiotensin system

    2.5.5.1 Angiotensin-converting enzyme inhibitors

  • Enalapril
  • Lisinopril
  • Perindopril

    2mg, 4mg, 8mg

  • Ramipril
  • 2.5.5.2 Angiotensin-II receptor antagonists

  • Candesartan
  • Losartan
  • Valsartan
  • 2.5.5.3 Angiotensin-II receptor antagonist with neprilysin inhibitor

    Specific Indication

  • Entresto® (valsartan / sacubitril)
  • 2.5.5.4 Renin inhibitors

  • Aliskiren

    4th line adjunct; for the treatment of resistant essential hypertension

    Aliskiren should not be prescribed in combination with an ACE inhibitor or ARB MHRA Drug Safety Advice

  • 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

    2.6.1 Nitrates

    Recommended

  • Isosorbide Mononitrate

    Standard release: asymmetrical dosing: (e.g. 0800 and 1400 for day-time angina; 1800 and 2200 for night-time angina).

    Modified release: more expensive - reserve for when standard release unsuitable

  • Glyceryl Trinitrate 400microgram

    Sublingual spray

  • Alternative

  • Glyceryl Trinitrate 500microgram

    tablets

  • Glyceryl Trinitrate 300microgram

    tablets (for patients unable to tolerate standard doses)

  • Glyceryl Trinitrate

    Patches – Distal to TPN infusion site (unlicensed)

  • Glyceryl Trinitrate
  • 2.6.2 Calcium-channel blockers

    2.6.2.1 Dihydropyridines

    Recommended

  • Amlodipine
  • Alternative

  • Lercanidipine
  • Specific Indication

  • Nifedipine capsules (non-m/r)

    Raynaud’s Phenomenon

  • Nifedipine capsules (non-m/r)

    Rapid control of blood pressure (e.g. DCC or cardiac catheter laboratory)

  • Nimodipine

    Subarachnoid haemorrhage only

  • 2.6.2.2 Non-dihydropyridines (not to be used concomitantly with beta blockers)

  • Diltiazem

    Modified Release (M/R) diltiazem preparations must be prescribed by brand name to avoid confusion.

  • Verapamil
  • 2.6.3 Other antianginal drugs

    Recommended

  • Nicorandil

    reserved for second or third line treatment as an adjunct.

  • Specific Indication

  • Ivabradine

    • stable angina in patients with intolerance or contraindications to beta blockers and where diltiazem / verapamil is not appropriate
    • chronic heart failure as per NICE TA267
    • MHRA Safety Warning: Risk of cardiac side effects

  • Ranolazine

    Cardiologist initiation only. Add-on treatment for angina where heart rate or blood pressure prevents up-titration of other agents. Shared Care Guideline

  • 2.6.4 Peripheral vasodilators and related drugs

    Specific Indication

  • Naftidrofuryl

    Peripheral arterial disease as per NICE TA223

  • 2.7 Sympathomimetics

    2.7.1 Inotropic sympathomimetics

  • Adrenaline

    • 1 in 1000
    • 1 in 10,000

  • Dobutamine
  • Dopamine
  • Dopexamine
  • Ephedrine
  • Isoprenaline
  • Noradrenaline
  • Specific Indication

  • Levosimendan

    Acute decompensated heart failure (unlicensed) - DCC consultant use only

  • 2.7.2 Vasoconstrictor sympathomimetics

  • Adrenaline

    • 1 in 1000
    • 1 in 10,000

  • Ephedrine
  • Metaraminol
  • Midodrine (Bramox®)

    second-line treatment of severe orthostatic hypotension due to autonomic dysfunction, as per Shared Care Guideline

  • Noradrenaline
  • Phenylephrine
  • 2.7.3 Cardiopulmonary resuscitation

  • Adrenaline

    1 in 10,000

  • Atropine
  • Amiodarone

    injection

  • 2.8 Anticoagulants and protamine

    2.8.1 Parenteral Anticoagulants

    GHNHSFT Local Guidelines – Fondaparinux for Acute Coronary Syndrome

    Recommended

  • Dalteparin

    for treatment and prophylaxis of venous thromboembolism

  • Fondaparinux

    Acute Coronary Syndrome

  • Specific Indication

  • Bivalirudin

    Percutaneous coronary intervention (PCI) NICE TA230

  • Danaparoid

    specialist use for patients with heparin induced platelet deficiency

  • Epoprostenol

    renal dialysis

  • 2.8.2 Oral Anticoagulants

    GHNHSFT Local Guidelines – Warfarin Initiation (intranet)

    GHNHSFT Local Guidelines – Warfarin bridging protocol (perioperative)

    Gloucestershire Direct Oral Anticoagulant (DOAC) Prescribing Guideline

    Recommended

  • Warfarin
  • Rivaroxaban

  • Specific Indication

  • Rivaroxaban

    • ACS treatment. Cardiologist initiation only NICE TA335
  • Rivaroxaban
    • VTE prophylaxis post knee or hip replacement surgery. Only for patients unsuitable for dalteparin (e.g. needle phobic) NICE TA170
  • Dabigatran

    • Non-valvular AF where rivaroxaban unsuitable NICE TA249
    • VTE treatment where rivaroxaban unsuitable (NB parenteral anticoagulant treatment is required for 5 days prior to starting dabigatran for this indication) NICE TA327

  • Dabigatran
    • VTE prophylaxis post knee or hip replacement surgery. Only for patients unsuitable for dalteparin (e.g. needle phobic) and where rivaroxaban is unsuitable NICE TA157
  • Apixaban

    • Non-valvular AF where rivaroxaban unsuitable NICE TA275
    • VTE treatment where rivaroxaban unsuitable NICE TA341
  • Apixaban
    • VTE prophylaxis post knee or hip replacement surgery. Only for patients unsuitable for dalteparin (e.g. needle phobic) and where rivaroxaban is unsuitable NICE TA245
  • Edoxaban

    • VTE treatment where rivaroxaban unsuitable (NB parenteral anticoagulant treatment is required for 5 days prior to starting edoxaban for this indication) NICE TA354
    • Non-valvular AF where rivaroxaban unsuitable NICE TA355

  • Phenindione

    Warfarin intolerance where other oral anticoagulants are unsuitable (e.g. mechanical heart valve)

  • 2.8.3 Protamine sulphate

  • Protamine

    Heparin reversal

  • 2.9 Antiplatelet drugs

  • Aspirin
  • Clopidogrel

    • True aspirin hypersensitivity (use aspirin plus PPI for aspirin-induced gastric symptoms)
    • Myocardial Infarction
    • Percutaneous coronary intervention (PCI)
    • Secondary prevention of Stroke / TIA (unlicensed)
    • Prevention of occlusive vascular events: NICE TA210

  • GHNHSFT Local guideline – Acute Coronary Syndrome (ACS)

    Gloucestershire guideline – Antiplatelets

    GHNHSFT Local guideline – Clopidogrel / PPI interaction

  • Asasantin Retard® (dipyridamole MR/aspirin)

    Secondary prevention of Stroke / TIA in patients who cannot take clopidogrel Local Guideline NICE TA210

  • Dipyridamole MR

    Secondary prevention of Stroke / TIA in patients who cannot take clopidogrel Local Guideline NICE TA210

  • Prasugrel

    Cardiologist initiation only: NICE TA317

  • GHNHSFT Local Protocol – Prasugrel

  • Ticagrelor

    Cardiologist initiation / advice only: NICE TA236, NICE TA420

  • GHNHSFT Local Protocol – Ticagrelor

    2.9.1 Glycoprotein IIb/IIIa Inhibitors

    GHNHSFT Local Protocol – Tirofiban

  • Tirofiban

    Acute coronary syndrome: NICE TA47

  • 2.10 Stable angina, acute coronary syndromes, and fibrinolysis

    2.10.1 Fibrinolytic drugs

    Primay PCI is now the first-line treatment for acute STEMI

    GHNHSFT Local Guideline: Massive pulmonary embolism (intranet)

  • Alteplase

    • Fibrinolytic treatment of acute ischaemic stroke NICE TA264
    • Massive pulmonary embolism
    • Thrombolysis of ST Elevation Myocardial Infarction where primary PCI unsuitable NICE TA52

  • 2.11 Antifibrinolytic drugs and haemostatics

  • Tranexamic Acid
  • Aprotinin

    management of life-threatening thrombolytic-induced haemorrhage

  • 2.12 Lipid-regulating drugs

    GHNHSFT Local Guideline: Statin Guidelines

    2.12.1 Statins

    Recommended

  • Atorvastatin
  • Alternative

  • Simvastatin
  • Pravastatin
  • Specific Indication

  • Rosuvastatin

    Rosuvastatin should only be considered in the following circumstances:

    1. Patients taking potent CYP3A4 inhibitors (see page 6) for whom pravastatin is not a clinically appropriate alternative (when total cholesterol >7.5mmol/L; LDL >4.5mmol/L).
    2. Patients who require a high-intensity statin who:

    • are intolerant to atorvastatin, or
    • have demonstrated an inadequate response to the maximum tolerated dose of atorvastatin, or
    • have undesirably low HDL (<1mmol/L in men; <1.2mmol/L in women); If HDL< 0.5mmol/L please refer to Lipid Clinic).

  • 2.12.2 Fibrates

    Recommended

  • Fenofibrate
  • Alternative

  • Bezafibrate
  • 2.12.3 Anion-exchange resins

  • Colestyramine
  • 2.12.4 Other

  • Ezetimibe

    Ezetimibe should only be considered in the following circumstances:

    1. Monotherapy in patients who have demonstrated intolerance to at least 3 different statins (including pravastatin & rosuvastatin); or because of contraindications to all initial statins.

    2. In combination with an initial statin only when an inadequate response to maximum tolerated doses of statin monotherapy (avoid simvastatin 80mg) has been demonstrated.

    When decision has been made to treat with ezetimibe co-administered with a statin, ezetimibe should be prescribed on the basis of lowest acquisition cost (i.e. avoid proprietary combination preparations).

    NICE TA385

  • 2.12.5 Omega-3 fatty acid compounds

  • None

    (exceptional use for resistant hypertriglyceridamia and only under the recommendation of a specialist)

  • 2.12.6 PCSK9 Inhibitors

  • Alirocumab

    Primary hypercholesterolaemia and mixed dyslipidaemia, as per NICE TA393

  • Evolocumab

    Primary hypercholesterolaemia and mixed dyslipidaemia, as per NICE TA394

  • 2.13 Local sclerosants

  • Ethanolamine Oleate
  • Sodium Tetradecyl Sulphate
  • BEST CARE FOR EVERYONE