2 Cardiovascular System Please Select A Topic 21

2: cardiovascular system ------------------------ please select a topic: 2.1 positive inotropic drugs 2.2 diuretics 2.3 anti-ar

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
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, 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
- 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.
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).
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
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)
*
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, 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.
- 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 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:
*
Prior to treatment
*
On a monthly basis for six months
*
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.
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
*
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
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
*
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.
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.
Miscellaneous
*
Phenoxybenzamine 10mg capsules
*
Phentolamine 10mg/ml injection
*
Guanethidine 10mg/ml injection (Theatres only)
*
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 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.
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.
*
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.
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.
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.
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 contra-indication 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.
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.
----------------------------------------------------------------
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.
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.
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.
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
Dose
- Ezetimibe tablets 10mg: 10mg once daily.
- Omacor capsules: see BNF
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 Page 24 of 24 Date: 1.2.2012
Drug Formulary
Drug & Therapeutics Committee