NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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2 Cardiovascular system

2.8 Anticoagulants and protamine

2.8.1 Parenteral anticoagulants

Total Formulary
ARGATROBAN

Restrictions: Restricted to specialist use where other options are not suitable or available in accordance with local protocol (to be updated).

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP18455-argatroban-monohydrate.htm

DALTEPARIN

Restrictions: Restricted to specialist initiation only. For The treatment and prevention of VTE in patients with solid tumours use is restricted to initiation by healthcare professionals experienced in the treatment of VTE and use according to local protocol.

Prescribing Notes:

When dalteparin is used in the extended treatment of VTE and prevention of recurrence in patients with solid tumours, prescribers are reminded that a dose reduction is required following the first month of treatment, and where there is a transfer of care, the need for this dose reduction should be communicated clearly.  For further dosing information, see the product literature or BNF.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2773.htm

DANAPAROID SODIUM

Restrictions: Restricted to use in accordance with local protocols.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129019.htm

ENOXAPARIN

Restrictions: Restricted to specialist initiation only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2775.htm

EPOPROSTENOL

Restrictions: Restricted to specialist use only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2789.htm

FONDAPARINUX

Restrictions: Restricted to specialist initiation only. Restricted to use for the treatment of unstable angina or non-ST segment elevation myocardial infarction (NSTEMI) or ST segment elevation myocardial infarction (STEMI) in accordance with agreed local protocols.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/112795.htm

TINZAPARIN

Restrictions: Restricted to specialist initiation only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2777.htm

2.8.2 Oral anticoagulants

Preferred list
APIXABAN (tablets)

Prescribing Notes:

Apixaban is the preferred NOAC for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurring DVT and PE in adults.  

For other indications of apixaban, please refer to the Total Formulary

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP1508-apixaban.htm?q=apixaban&t=search&ss=text&p=2#_hit

Total Formulary
APIXABAN (tablets)

Restrictions: Restricted to use in accordance with the prescribing notes below

Prescribing Notes:

Prevention of stroke in atrial fibrillation

Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation, with one or more risk factors (see below), is restricted to:

  • newly diagnosed patients
  • those currently receiving warfarin who have poor INR control despite evidence that they are complying as described in NHSGGC Atrial Fibrillation guideline (NHS network access required)
  • patients with allergy or intolerable side effects from coumarin anticoagulants
  • patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate. 

Patients who are well controlled on warfarin should remain on warfarin therapy.

Risk factors may include: prior stroke or transient ischaemic attack (TIA); age ≥75 years; hypertension; diabetes mellitus; symptomatic heart failure (NYHA class ≥II)

Further supporting information for prescribers can be found in the Prescribing Resources section of this website

 

VTE prophylaxis in orthopaedic surgery

  • The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.

 

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP1508-apixaban.htm

DABIGATRAN ETEXILATE (tablets)

Restrictions: Restricted to use in accordance with the prescribing notes below

Prescribing Notes:

Prevention of stroke in atrial fibrillation

Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:

  • newly diagnosed patients
  • those currently receiving warfarin who have poor INR control despite evidence that they are complying
  • patients with allergy or intolerable side effects from coumarin anticoagulants
  • patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate

Risk factors include: 

  • previous stroke, transient ischaemic attack, or systemic embolism
  • left ventricular ejection fraction <40%
  • symptomatic heart failure, ≥ New York Heart Association (NYHA) Class 2
  • age ≥75 years
  • age ≥65 years associated with one of the following: diabetes mellitus, coronary artery disease or hypertension

Patients well controlled on warfarin should remain on warfarin therapy.

The National Consensus Statement was developed in April 2012 (click here) and may continue to provide useful advice in patients poorly controlled on warfarin and use in that patient group is described in the NHSGGC Atrial Fibrillation guideline (NHS network access required).

Further supporting information for prescribers can be found in the Prescribing Resources section of this website

A number of cases of serious and fatal haemorrhage have been reported in elderly patients with renal impairment who were receiving dabigatran. Renal function should be assessed in all patients before starting dabigatran and at least once a year in patients older than 75 years or those with a suspected decline in renal function.  Dabigatran is contraindicated in patients with severe renal impairment (creatinine clearance <30 mL/min). See Drug Safety Update December 2011 (click here)

Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE

Use is restricted to patients who fail to tolerate other therapeutic options or where other agents are not appropriate, where the intended duration of treatment is 3-6 months. Where indefinite duration is indicated, the treatment of choice should be or apixaban or low molecular weight heparin followed by warfarin.

VTE prophylaxis in orthopaedic surgery

  • The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201055.htm

EDOXABAN (tablets)

Restrictions: Restricted to use for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE and for the prevention of stroke in atrial fibrillation in accordance with the prescribing notes below.

Prescribing Notes:

Prevention of stroke in atrial fibrillation

Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).

RIVAROXABAN

Restrictions: Restricted to use in accordance with the prescribing notes below.

Prescribing Notes:

Prevention of stroke in atrial fibrillation

Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:

  • those currently receiving warfarin who have poor INR control despite evidence that they are complying
  • patients with allergy or intolerable side effects from coumarin anticoagulants
  • patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate

Risk factors may include: congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack. 

Patients well controlled on warfarin should remain on warfarin therapy.  Rivaroxaban is not included in the Formulary for use in newly diagnosed patients.

The National Consensus Statement was developed in April 2012 (click here) and may continue to provide useful advice in patients poorly controlled on warfarin and use in that patient group is described in the NHSGGC Atrial Fibrillation guideline (NHS network access required).

Further supporting information for prescribers can be found in the Prescribing Resources section of this website

Treatment of VTE

  • Rivaroxaban for the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) and prevention of further DVT and PE is restricted to use in accordance with local guidance for patients requiring anticoagulation where the intended duration of treatment is 3 to 6 months.  Where indefinite duration is indicated, then the treatment of choice should be apixaban or a low molecular weight heparin followed by warfarin.

VTE prophylaxis in orthopaedic surgery

  • The use in VTE prophylaxis in orthopaedic surgery is restricted to specialist use only in accordance with local protocol.

Acute Coronary Syndrome: The use of rivaroxaban for the prevention of atherothrombotic events in adult patients after an acute coronary syndrome (ACS) with elevated cardiac biomarkers is not recommended for use within NHS Scotland and is therefore non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201626.htm

2.8.3 Protamine sulphate

Total Formulary
PROTAMINE

Restrictions: Restricted to specialist use only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2800.htm

2.8.4 Reversal of anticoagulation

Total Formulary
IDARUCIZUMAB

Restrictions: See Prescribing Notes below.

Prescribing Notes:

Restricted to specialist use only when rapid reversal of anticoagulation effect of dabigatran is required for emergency surgery/ urgent procedures or in life-threatening or uncontrolled bleeding in line with national guidance.