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 Formulary Chapter 2: Cardiovascular system - Full Chapter
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02.08.02  Expand sub section  Oral anticoagulants
Warfarin
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First Choice
Green

Tablets 500mcg, 1mg, 3mg, 5mg
  • Potentially serious errors can occur if patients confuse the 500mcg and 5mg tablets
  • Use in accordance with NPSA Alert March 2007: Actions that can make anitcoagulant therapy safer
  •  
    Acenocoumarol (Sinthrome®)
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    Second Choice
    Blue

    Tablets
  • Alternative to Warfarin in true warfarin allergy. Consultant haematologist initiation
  •  
       
    Phenindione
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    Formulary
    Blue

    Tablets
  • Alternative to Warfarin in true warfarin allergy. Consultant haematologist initiation
  •  
       
    Apixaban (Eliquis®)
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    Formulary
    Green

    Tablets
  • Indication - Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) NICE TA275
  • Indication - Treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism NICE TA341

    Red
  • Indication - Venous thromboembolism (hip and knee surgery)NICE TA245
  • Apixaban is a recommended option to reduce thromboembolism after knee and hip replacement
  •  
    Link  Guidance on New Oral Anticoagulants
    Link  Atrial Fibrillation Management - Evidence Review - September 2014
    Link  HPSU Model Guidance - Anticoagulants for Stroke Prevention in Atrial Fibrilation
    Link  MHRA Drug Safety Update Jun 2019 Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Drug Safety Update Oct 2013 - risk of serious haemorrhage- clarified contraindications apply to all medicines
    Link  NICE TA245 - Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults
    Link  NICE TA275 - Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation
    Link  NICE TA341 Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
    Link  NOACs for DVT and PE - Policy Statement PCN 168-2015 - Oct 2015
    Link  Oral anticoagulants (warfarin,dabigatran, rivaroxaban, apixaban and edoxaban) for stroke prevention in atrial fibrillation (update) APC 420-2019
    Link  PCN Statement 176-2015 - NOACs for Stroke Prevention in Atrial Fibrillation
       
    Dabigatran (Pradaxa®)
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    Formulary
    Green

    Capsules
  • Indication - Atrial fibrilation (stroke prevention; in line with NICE)(NICE TA249)
  • Indication - Treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
    (NICE TA327)

    Red
  • Indication - VTE prophylaxis Post-THR/TKR only (NICETA157) 
  • Link  Atrial fibrillation: the management of atrial fibrillation
    Link  Dabigatran Conversions
    Link  Diagnosis & Management of Atrial Fibrillation in Primary Care
    Link  Evidence Review for Prescribing Clinical Network
    Link  Guidance on New Oral Anticoagulants
    Link  Guidelines for management of bleeding with dabigatran
    Link  Guidelines for perioperative management of dabigatran
    Link  HPSU Model Guidance - Anticoagulants for Stroke Prevention in Atrial Fibrilation
    Link  MHRA Drug Safety Update July 2012 Dabigatran: risk of serious haemorrhage - need for renal function testing
    Link  MHRA Drug Safety Update Jun 2019 Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Drug Safety Update Mar 2013 Dabigatran: contraindicated in patients with prosthetic heart valve(s) requiring anti-coagulant treatment - risk of thrombosis and haemorrhage
    Link  MHRA Drug Safety Update Oct 2013: risk of serious haemorrhage- clarified contraindications apply to all medicines
    Link  NICE Patient Decision Aid
    Link  NICE TA157 - Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults
    Link  NICE TA249 - Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation
    Link  NICE TA327 Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
    Link  NOACs for DVT and PE - Policy Statement PCN 168-2015 - Oct 2015
    Link  Oral anticoagulants (warfarin,dabigatran, rivaroxaban, apixaban and edoxaban) for stroke prevention in atrial fibrillation (update) APC 420-2019
    Link  PCN Statement 176-2015 - NOAC’s for stroke prevention in atrial fibrillation
       
    Edoxaban (Lixiana®)
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    Formulary
    Green

    Tablets
  • Indication - Treatment and prevention of deep vein thrombosis and pulmonary embolism (NICE TA354)
  • Indication - Prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation (NICE TA355) 
  • Link  Evidence review for Surrey PCN
    Link  MHRA Drug Safety Update Jun 2019 Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  NICE TA354 Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism
    Link  NOACs for DVT and PE - Policy Statement PCN 168-2015 - Oct 2015
    Link  Oral anticoagulants (warfarin,dabigatran, rivaroxaban, apixaban and edoxaban) for stroke prevention in atrial fibrillation (update) APC 420-2019
    Link  NICE TA355 Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation
    Link  PCN 176-2015- NOAC’s for Stroke prevention in Atrial Fibrillation
       
    Rivaroxaban (Xarelto®)
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    Formulary
    Green

    Tablets

    • Indications
    • Atrial fibrilation (stroke prevention; in line with NICE)- (TA256)
    • Deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (TA261)
    • Pulmonary embolism and recurrent venous thromboembolism (TA287)
    • Preventing adverse outcomes after acute management of acute coronary syndrome (TA335)

      Red
    • Indication - VTE prophylaxis Post THR only.(TA170)

      Rivaroxiban is a recommended option for thromboembolism prophylaxis arising from elective total hip or knee replacement surgery.

    **Rivaroxaban treatment in patients who undergo transcatheter aortic valve replacement (TAVR) should be stopped and switched to standard of care.

     
    Link  MHRA Drug Safety Update July 19 Rivaroxaban (Xarelto¥): reminder that 15 mg and 20 mg tablets should be taken with food
    Link  MHRA Drug Safety Update Jun 2019 Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome
    Link  MHRA Drug Safety Update Oct 2018: Rivaroxaban (Xarelto▼) after transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial
    Link  PCN 68-2013 - Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
    Link  Guidance on New Oral Anticoagulants
    Link  HPSU Model Guidance - Anticoagulants for Stroke Prevention in Atrial Fibrilation
    Link  MHRA Drug Safety Update Oct 2013: risk of serious haemorrhage-clarified contraindications applt to all medicines
    Link  NICE TA256 - Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation
    Link  NICE TA261 - Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism
    Link  NICE TA335 Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome
    Link  Oral anticoagulants (warfarin,dabigatran, rivaroxaban, apixaban and edoxaban) for stroke prevention in atrial fibrillation (update) APC 420-2019
    Link  PCN 162-2015 Rivaroxaban for prevention of atherothrombotic events in ACS
    Link  PCN 168-2015 NOACs for DVT and PE
    Link  Rivaroxaban for ACS - Evidence review - Jun 2015
    Link  NICE TA170 - Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults
    Link  NICE TA287 - Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism
    Link  PCN 176-2015 - NOACs for Stroke prevention in Atrial Fibrillation
       
    02.08.02  Expand sub section  Stroke prevention in AF
    02.08.02  Expand sub section  Atrial Fibrillation
    02.08.02  Expand sub section  VTE treatment
    02.08.02  Expand sub section  VTE prophylaxis in hip/knee surgery to top
    02.08.02  Expand sub section  VTE Prophylaxis
     ....
     Non Formulary Items
    INR self-testing device  (CoaguChek®)

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    Non Formulary
  • The routine use of self-testing with Coagucheck point of care testing (POCT) for INR monitoring is not supported.
    However if an individual patient is considered appropriate for self testing of INR levels, it is the responsibility of the clinician managing the patient’s INR and warfarin dose to agree how the governance is assured and how strips are supplied.
  • Link  Coagucheck point of care INR testing - Policy Statement PCN 71-2013 - Jul 2013
    Link  MHRA Device Alert Oct 2018 CoaguChek Test Strips for Point of Care and Home Use – risk of false high results (MDA/2018/033)
    Link  Surrey PCN guidance on Coagucheck
     
      
    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
    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

    Black

    Comment : Not to be routinely commissioned (prescribed) in any care setting (primary or secondary care). This may be due to a lack of good clinical evidence, cost effectiveness, concerns over safety or due to the availability of more suitable alternatives. As such, drugs classified as Black should be considered as non-formulary.   

    Red

    Initiation : Specialist only
    Repeat Prescribing : Specialist
    Monitoring : Specialist
    Comment : Prescribing must be in line with any specific treatment criteria outlined. In exceptional circumstances a GP may be asked to prescribe – the specialist must provide adequate information and support.   

    Amber

    Initiation : Specialist only
    Repeat Prescribing : Primary care OR specialist
    Monitoring : Primary care OR specialist
    Comment : Monitoring according to Effective Shared Care Agreement (ESCA) for stabilised patients only. GP agreement should be requested by specialist and confirmed/declined by GP on a patient-by-patient basis.   

    Blue

    Initiation/Recommendation : Specialist only
    Repeat Prescribing : Primary care
    Monitoring : Primary care
    Comment : Should be initiated or recommended by a specialist. Monitoring of either medicine or disease does not require specialist skills or equipment   

    Green

    Initiation : Primary care or specialist
    Repeat Prescribing : Primary care
    Monitoring : Primary care
    Comment : Suitable for non specialist initiation   

    OTC

    Patients should be advised to purchase if approriate.  

    netFormulary