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

2.6 Nitrates, calcium-channel blockers and other antianginal drugs

2.6.1 Nitrates

Preferred list
GLYCERYL TRINITRATE (SUBLINGUAL SPRAY)

Prescribing Notes:

The patient should be fully aware of how to use a GTN spray prophylactically before angina-inducing activities. If symptoms persist following three uses of the spray within a 15 minute period, the patient should seek medical help.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2618.htm

ISOSORBIDE MONONITRATE (STANDARD RELEASE TABLETS)

Restrictions: Modified-release preparations are generally much more expensive and are restricted to use only in patients who fail to comply with standard-release tablets

Prescribing Notes:

Isosorbide mononitrate should be prescribed as asymmetric doses of standard-release products (e.g. 20mg at 8am and 20mg at 2pm). Nitrate-free periods (usually at night) are recommended to avoid the development of tolerance.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2656.htm

2.6.2 Calcium-channel blockers

The choice of therapeutic class for the management of hypertension is dependent on individual patient parameters. See the NHSGGC Guidelines for the Management of Hypertension, available on the Clinical Guidelines store on StaffNet. Calcium-channel blockers differ in their possible sites of action; therefore their therapeutic effects are disparate, with much greater variation than those of beta-blockers. There are important differences between verapamil/diltiazem and the dihydropyridine group of nifedipine/amlodipine. Within the dihydropyridine group, the efficacy and side effect profiles are similar, except that amlodipine has a much longer half-life.

Preferred list
AMLODIPINE

Restrictions: Excludes combination products

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2671.htm

DILTIAZEM

Prescribing Notes:

Prescribe by brand name. Diltiazem should not be prescribed in conjunction with beta-blockers because of the risk of severe bradycardia.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2673.htm

NIFEDIPINE

Restrictions: Short-acting formulations are not recommended for angina and hypertension.

Prescribing Notes:

Prescribe modified-release preparations by brand name.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2691.htm

Total Formulary
NIMODIPINE

Restrictions: Restricted to specialist initiation only.

Prescribing Notes:

Only licensed for the prevention and treatment of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2699.htm

VERAPAMIL

Prescribing Notes:

Modified release preparations should be prescribed by brand name.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2701.htm

2.6.3 Other antianginal drugs

Total Formulary
IVABRADINE

Restrictions: See prescribing notes below.

Prescribing Notes:

The following formulary restrictions apply:

  • Use for the symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm for whom heart rate control is desirable and who have a contra-indication or intolerance for beta-blockers and rate-limiting calcium-channel blockers is restricted to specialist initiation.
  • The use in chronic heart failure is restricted to those patients with New York Heart Association (NYHA) class II to IV with systolic dysfunction who are in sinus rhythm and whose heart rate is ≥75 beats per minute (bpm) in combination with standard therapy including beta-blocker therapy or when beta-blocker therapy is contra-indicated or not tolerated.  It is restricted to use in patients whose resting heart rate remains ≥75 beats per minute despite optimal standard therapy and should only be initiated by prescribers working within specialist heart failure teams.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129514.htm

NIFEDIPINE

Prescribing Notes:

Prescribe modified-release preparations by brand name.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2691.htm

2.6.4 Peripheral vasodilators and related drugs

Total Formulary
DEFIBROTIDE (intravenous infusion)

Restrictions: Use for the treatment of severe hepatic veno-occlusive disease (VOD) also known as sinusoidal obstruction syndrome (SOS) in haematopoietic stem-cell transplantation (HSCT) therapy is restricted to specialist use.

NAFTIDROFURYL OXALATE

Prescribing Notes:

Refer to SIGN 89 for the diagnosis and management of PVD. Treatment should be reassessed after three months and discontinued if of no benefit. There is poor evidence supporting vasodilator treatment and it is important that contributory risk factor treatments (such as antiplatelet and cholesterol-lowering therapies) are considered.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/2725.htm