Carmarthenshire Joint Formulary

Chapter 2

Cardiovascular Drugs

2.1

POSITIVE INOTROPES

2.1.1

Cardiac glycosides

Digoxin

(generic)

Tablets 62.5mcg

125mcg, 250mcg

Elixir 50micrograms/ml

Injection 250micrograms/ml

Beware of potassium

interaction, particularly in

potassium lowering states

e.g. concomitant diuretics

2.2

DIURETICS

2.2.1

Thiazide and related diuretics

Bendrofluazide

(generic)

Tablets 2.5mg

2.5mg daily is the maximum

recommended dose for

hypertension

Metolazone

Tablets 5mg

Secondary care initiated

Monitor U+E s closely

Indapamide

Tablets 2.5 mg, tablets m/r 1.5mg

Isolated systolic hypertension.

in combination with

perindopril, post CVA

2.2.2

Loop diuretics

Furosemide

(frusemide)

Tablets 20mg, 40mg, 500mg

Injection 20mg/2ml, 50mg/5ml, 250mg/25ml

Liquid 40mg/5ml

First line - Monitor the

potassium within first 4

weeks of initiation or

dose change

Paediatric liquid 1mg/ml

Paediatric use

Bumetanide

Tablets 1mg, 5mg

Injection 0.5mg/ml

Generally second line in

severe CCF, gout

Liquid 1mg/5ml

Dysphagic patients

2.2.3

Potassium-sparing diuretics

Spironolactone

(generic)

Tablets 25mg

Tablets 50mg, 100mg

Congestive Heart Failure.

Oedema and ascites in cirrhosis of the liver

Nephrotic syndrome.

Primary hyper-aldosteronism

Monitor potassium within first

two weeks of initiation and then following each dose change

Eplerenone

Tablets 25mg

Left ventricular dysfunction with heart failure following myocardial infarction (started within 3 to 14 days of event) initiated by cardiologists only

Co-amilofruse

(generic)

Tablets

(5mg amiloride and 40mg frusemide)

Patients who require

amiloride to maintain

Their serum potassium

And are controlled on

Frusemide 40mg and

amiloride 5mg or

multiples thereof.

Caution in elderly, renal

dysfunction. Do not

use with ACE inhibitors.

2.3

ANTIARRHYTHMIC DRUGS

2.3.2

Drugs for arrhythmias

Amiodarone

(generic)

Tablets 100mg,200mg

Injection 30mg/ml

Hospital initiated. TFTs

need 6 monthly

monitoring.

See monitoring guidelines

Digoxin

(generic)

Tablets 62.5mcg,125mcg,

250 mcg

Injection 250mcg/ml

Disopyramide

Tablets 250mg S/R

Hospital initiated

Flecainide

Tablets 50mg, 100mg

Injection 10mg/ml

Hospital initiated

Sotalol

Tablets 40mg, 80mg,

160mg

Hospital initiated. Dose needs to be increased to at least 300mg to have a class III anti-arrhythmic effect.

Verapamil

Tablets 40mg,80mg,

120mg,240mg S/R

Injection 2.5mg/ml

Adenosine

Injection 3mg/ml

Atropine

Injection 600mcg/ml

Esmolol

Injection 10mg/ml

Lignocaine

Injection 10mg/ml

Magnesium Sulphate

Injection 50% (5g in 10ml)

Phenytoin

Injection 50mg/ml

2.4

BETA- ADRENOCEPTOR BLOCKING DRUGS

Combination products are not recommended

Atenolol

(generic)

Tablets 25mg, 50mg, 100mg

Injection 500mcg/ml

Initiate with a

low dose. Avoid in

asthmatic patients.

Consider BD dosage for angina

Bisoprolol

Tablets 5mg, 10mg

Reduce dose in hepatic

and renal impairment

Metoprolol

Tablets 50mg, 100mg

Shorter acting, may be used for initiation, then change to a longer acting drug.

Labetalol

Tablets 100mg, 200mg, 400mg

Pregnancy only

Propranolol

(generic)

Tablets 10mg, 40mg, 80mg. Modified-release tablets 80mg, 160mg

Anxiety states and

migraine only , thyrotoxic crisis.

Heart Failure

Bisoprolol (Cardicor)

Tablets 1.25mg,2.5mg,

3.75mg,5mg,7.5mg,10mg

Hospital initiation. Monitor

clinical status for 3-4 hours

after initiation. Ensure HF

Carvedilol (Eucardic)

Tablets 3.125mg,6.25mg, 12.5mg,25mg

not worsening before each

dose increase

Combination products for hypertension may be considered when patients are stable on treatment to reduce tablet burden.

2.5

DRUGS AFFECTING THE RENIN-ANGIOTENSIN SYSTEM AND SOME

OTHER ANTIHYPERTENSIVE DRUGS

2.5.1

Vasodilator antihypertensive drugs

Sodium Nitroprusside

Injection 10mg/ml

Emergency only

2.5.2

Centrally-acting antihypertensive drugs

Methyldopa

Injection

Tablets125mg,250mg,

500mg

Hospital initiated for

hypertension during

Pregnancy

Clonidine

Injection 150mcg/ml

I.T.U. only

2.5.4

Alpha-adrenoceptor blocking drugs

Doxazosin

Tablets 1mg, 2mg,

4mg XL

2.5.5.1

Angiotensin-converting enzyme inhibitors

Lisinopril

Tablets 2.5mg,5mg,

10mg, 20mg

Check U&Es 10 to 14 days after

each dose increase

Perindopril

Tablets 2mg, 4mg,8mg

Check U&Es 10 to 14 days after

each dose increase

Ramipril

Capsules 1.25mg, 2.5mg, 5mg, 10mg

Check U&Es 10 to 14 days after

each dose increase

2.5.5.2

Angiotensin II receptor antagonists- ONLY TO BE USED AFTER FAILURE OR INTOLERANCE OF AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR .

Valsartan

Capsules 40mg, 80mg, 160mg

Myocardial infarction with left ventricular failure or left ventricular systolic dysfunction ONLY

Irbesartan

Tablets 75mg, 150mg, 300mg

Renal disease in hypertensive type 2 diabetes mellitus.

Candesartan

Tablets 4mg, 8mg, 16mg, 32mg

Heart Failure ONLY

Olmesartan Tablets 10mg, 20mg, 40mg Hypertension

Telmisartan Tablets 20mg, 40mg, 80mg Hypertension

2.6

NITRATES AND OTHER VASODILATORS, AND CALCIUM CHANNEL

BLOCKERS

2.6.1

Nitrates

(OTC)

Glyceryl trinitrate

(generic)

Sublingual tablets 500mcg

Spray 400mcg/dose

(OTC)

Isosorbide mononitrate

Tablets 10, 20mg

Asymmetric dosing to avoid nitrate tolerance e.g. 8am and 2pm

Glyceryl trinitrate

injection 5mg/ml(hosp only)

2.6.2

Calcium-channel blockers

Diltiazem (generic)

Tablets 60mg

Use a long acting preparation. Prescribe by trade name.

Modified release diltiazem capsules , 120mg,180mg, 240mg,

200mg, 300mg

Only to be used with a beta blocker under specialist supervision.

Verapamil (generic)

Tablets 40mg, 80mg,

120mg, 160mg,240mg S/R

Only to be used with a beta blocker under specialist supervision

Amlodipine

Tablets 5mg, 10mg

Nimodipine

Tablets 30mg

Infusion 200mcg/ml

Subarachnoid haemorrhage only.

2.6.3

Other Antianginal Drugs

Nicorandilmmo Nicorandil

Tablets 10mg, 20mg

Prevention and long term

treatment of angina pectoris

Ivabradine

Tablets 5mg, 7.5mg

Consultant Cardiologist initiation only

2.6.4.1

Peripheral vasodilators and related drugs

None

2.6.4

Cerebral vasodilators

None

2.7

SYMPATHOMIMETICS

2.7.1

Inotropic sympathometics

Dobutamine Hydrochloride

Dopamine Hydrochloride

Dopexamine (ICU/Theatre)

Injection 12.5mg/ml

Injection 40mg/ml,160mg/ml

Injection 10mg/ml

2.7.2

Vaoconstrictor Sympathomimetics

Norepinephrine (Noradrenaline)

Injection 4mg/4ml

2.7.3

Cardiopulmonary Resuscitation

Epinephrine (adrenaline)

Injection

1 in 10,000, 1mg in 10ml

2.8

ANTICOAGULANTS AND PROTAMINE

2.8.1

Parenteral anticoagulants

Enoxaparin - (Unstable angina)

100mg/ml syringe - 6000units, 8000units, 10000units

Tinzaparin - (Treatment)

Syringes - 10,000units in 0.5ml,14,000units in 0.7ml, 18,000units in 0.9ml

Vial - 40,000 units in 2ml

Tinzaparin - (Prophylaxis)

Syringes -3,500 units, 4500 units.

Calcium Heparin (s/c)

Injection 25,000units/ml

Sodium Heparin

Injection 1000units/ml, 5000units/ml, 25,000units/ml

Fondaparinux

Orthopaedics only

2.8.2

Oral anticoagulants

Warfarin

(generic)

Tablets 0.5mg (white), 1mg (brown), 3mg (blue), 5mg(pink)

2.9

ANTIPLATELET DRUGS

(OTC)

Aspirin

(generic)

Dispersible tablets 75mg

Enteric coated not a proven

advantage

Dipyridamole

Capsules M/R 200mg

Cerebrovascular disease

Clopidogrel

Tablets 75mg

As an alternative to aspirin in true aspirin allergy only.

In combination with aspirin for a specificed duration :-

STEMI - 28 days

ACS (non-ST elevation) -12 months

Stents - as specified by consultant

TENTS

2.10

FIBRINOLYTIC DRUGS

Alteplase

Injection 50mg/vial

Tenecteplase

50mg Vial

Streptokinase

Injection 750000 units

Urokinase

Injection 5000 units

2.11

ANTI-FIBRINOLYTIC DRUGS + HAEMOSTATICS

Tranexamic Acid

Tablets 500mg

2.12

LIPID-LOWERING DRUGS

Advice on diet and exercise

Anion-Exchange Resins

Non-advised due to patient intolerance

Ezetimibe

Fibrate Group

Bezafibrate

Modified release tablets 400mg

Specialist initiation only

Fenofibrate

Capsules 67mg, 200mg

1^st choice of fibrates

HMG-CoA Reductase inhibitors - See also Guidelines for the Management of Hyperlipidaemia /Dyslipidaemia with statins.

Simvastatin

Tablets 20mg

40mg,

1^st line choice of statin

Monitor to ensure target is achieved.

Atorvastatin

Tablets

20mg, 40mg,80mg

2^nd line for patients not achieving target on Simvastatin 40mg

Atorvastatin 80mg only to be used in the acute phase post ACS, for 2 months only,then use statin as above to achieve target.

Rosuvastatin

5mg, 10mg, 20mg

2^nd line for patients not achieving target on Simvastatin 40mg.

OMEGA-3 Fatty Acid Compounds

Omega-3 acid ethyl esters (Omacor)

Secondary prevention after myocardial infarction.

High risk ACS patients initiated by consultant cardiologist only.

2.13

LOCAL SCLEROSANTS

Sodium Tetradecyl Sulphate

Injection 1%,3%