23 Blood clots - Milton Keynes Formulary

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2.3 Blood clots

Traffic light status (TLS) explained:

• Green: Routine prescribing within licensed indication
• Amber 1: specialist recommendation followed by GP initiation and continuation
• Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
• Amber 3: specialist initiation and stabilisation followed by GP continuation
• Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
• Red: Hospital or specialist prescribing only

2.3.1 Blocked catheters and lines 

Epoprostenol (Consultant request only)

• Flolan^® Infusion, powder for reconstitution 500 micrograms vial with diluent    

Other drugs used for blocked catheters and lines: Unfractionated Heparin and Urokinase (see below)

2.3.2 Thromboembolism  

Aspirin

• Dispersible tablets 75mg, 300mg
• Enteric coated tablets 75mg, 300mg

Clopidogrel

• Tablets 75mg
• Tablets 300mg (Hospital only)

Notes:

• Concomitant use of clopidogrel and omeprazole or esomeprazole is to be discouraged
• Dual anti-platelet therapy (aspirin plus clopidogrel) for longer than 12 months is unlicensed. 
• Use as per NICE guidelines CG94: Unstable angina and NSTEMI - early management (November 2013) 
• Use as per NICE guidelines CG172: Myocardial infarction - cardiac rehabilitation and prevention of further MI (November 2013)
• Use as per NICE TA210: Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events(December 2010) 

Dipyridamole

• Tablets 25mg, 100mg
• Modified release capsules 200mg (Persantin^® Retard)
• Suspension 50mg in 5mL

Note:

• The modified release capsules are licensed for secondary prevention of ischaemic stroke and transient ischaemic attacks, 1 capsule twice daily.
• Dipyridamole is far more expensive than Aspirin and is licensed only as adjunct to oral anticoagulation for prophylaxis of thromboembolism associated with prosthetic heart valves.
• It has not been shown to be effective alone post-infarction or for TIAs.
• Dipyridamole contributes little if anything to the anti-thrombotic action of Aspirin. This does not apply to Dipyridamole modified release preparation - Persantin^® Retard  

Fondaparinux sodium

• Arixtra^® Injection 2.5mg/0.5mL in pre-filled syringes

Notes:

• For treatment of unstable angina or non-ST segment elevation myocardial infarction in adults for whom urgent (< 120 mins) invasive management (PCI) is not indicated.
• For Hospital prescribing only and for a maximum of 8 days or till hospital discharge if that occurs earlier.

Heparins 

Heparin Sodium

• 1000 units/mL; 1mL amp, 5mL amp, 5mL vial, 10mL amp, 20mL amp 
• 5000 units/mL; 1mL amp, 5mL amp, 5mL vial 
• 25,000 units/mL; 0.2mL amp, 1mL amp, 5mL vial

Heparin flushes 

• 10 units/mL; 5mL amp for IV Flush 
• 100 units/mL; 2mL amp for IV Flush

Notes:

• Cannulae intended to be in place for less than 48 hours should be flushed with Sodium Chloride 0.9% solution.
• Heparin flush solution should be reserved for cannulae to be in place for longer than 48 hours.

Dalteparin Sodium (Fragmin^®) (Amber 1)

• Injection 2500 units in 0.2mL pre-filled syringe
• Injection 5000 units in 0.2mL pre-filled syringe
• Injection 7500 units in 0.3mL pre-filled syringe
• Injection 10000 units in 0.4mL pre-filled syringe
• Injection 12500 units in 0.5mL pre-filled syringe
• Injection 15000 units in 0.6mL pre-filled syringe
• Injection 18000 units in 0.72mL pre-filled syringe 
• Injection 10 000 units in 1mL pre-filled graduated syringe  

Notes:

• Discharge supplies - Patients with GPs in MK are supplied 14 days of dalteparin on discharge and GP is expected to continue therapy

Enoxaparin sodium - Inhixa® (Amber 1)

100mg/ml (equiv. to 10,000 iu anti-Factor Xa activity) soln in single dose pre-filled syringes

• Injection 20mg in 0.2mL pre-filled syringe
• Injection 40mg in 0.4mL pre-filled syringe
• Injection 60mg in 0.6mL pre-filled syringe
• Injection 80mg in 0.8mL pre-filled syringe
• Injection 100mg in 1mL pre-filled syringe

Notes:

• For use in Maternity patients only
• Discharge supplies - Patients with GPs in MK are supplied 14 days of enoxaparin on discharge and GP is expected to continue therapy

Protamine sulphate

Protamine sulphate

• Injection 1%, 10mg/mL

Tinzaparin sodium (Innohep)

Approved for use at the Oxford Renal Unit Only  

• Injection 10000 units in 0.5mL pre-filled syringe
• Injection 14000 units in 0.7mL pre-filled syringe
• Injection 18000 units in 0.9mL pre-filled syringe
• 10000 international units in 1mL injection
• 20000 international units in 1mL injection

Thrombin Inhibitors 

Bivalirudin

• Angiox^®Injection, powder for reconstitution 250mg vial

Notes:

• NICE TA230: Bivalirudin for the treatment of ST-segment-elevation myocardial infarction July 2011

• Bivalirudin in combination with aspirin and clopidogrel is recommended for the treatment of adults with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Idarucizumab

• Praxbind® Injection 2.5g/50mL

Notes:

• Specific reversal agent for Pradaxa® Dabigatran etexilate

Tissue Plasminogen Activators 

Urokinase

• Injection, powder for reconstitution 10 000-unit vial, 25 000-unit vial and 100 000-unit vial (available from manufacturers on named-patient basis)
• Use as per  NICE TA52: Myocardial infarction - thrombolysis (October 2002) 

Vitamin K antagonists

Warfarin

• Tablets 

500 microgrammes (white); 

1mg (brown); 

3mg (blue); 

5mg (pink). 

Notes:

• The following recommendations are based on those of the British Committee for Standards in Haematology (1998) and apply to patients taking warfarin:
• Vitamin K is very well absorbed orally. When partial correction is required it may be necessary to give intravenous vitamin K or alternatively give the intravenous preparation orally (Konakion^® MM Paediatric 10mg/mL 0.2mL amp).
• Vitamin K will usually lower the INR within 12 to 24 hours. Repeat doses may be needed after 24 hours if the INR is still too high. 

Direct Oral AntiCoagulants (DOACs)

Local Guideline

Advice to Prescribers & Decision Support for Anticoagulants (agreed at MKPAG, Jan 2019) can be found here

or

click on the following link: https://www.formularymk.nhs.uk/includes/documents/Anticoagulation-guidance-Jan-2019.pdf

Edoxaban (Amber 2)

Lixinia^® Tablets film-coated 15mg, 30mg, 60mg

Notes:

• Edoxaban represents the most cost-effective DOAC for many patients. Refer to the local guideline above before prescribing.
• Use as per NICE TA355: Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (September 2015)
• Use as per NICE TA354: Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism(August 2015)  

Apixaban (Amber 2) 

• Eliquis^® Tablets 2.5mg, 5mg

Notes:

• Refer to local guideline above
• Use as per NICE TA341: Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (June 2015)
• Use as per NICE TA275 Apixaban for the prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation with one or more risk factor for stroke or systemic embolism (February 2012) 
• Use as per NICE TA245: Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (January 2012)   

Dabigatran etexilate

• Pradaxa® Capsules 75mg, 110mg, 150mg

Notes:

• Approved for prophylaxis of venous thromboembolism in adults after total hip replacement or total knee replacement surgery.
• Use as per NICE TA327: Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (December 2014) 
• Use as per NICE TA249: Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation (March 2012)
• Use as per NICE TA157: Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults (September 2008) 

Rivaroxaban (Amber 2)

•  Xarelto® Tablets 2.5mg, 10mg, 15mg, 20mg

Notes:

• Refer to local guideline above before prescribing
• Drug Safety Update. Rivaroxaban (Xarelto▼) after transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in patients in a clinical trial (Oct 2018)  
• Use as per NICE TA335: Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome (March 2015)
• Use as per NICE TA287:Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (June 2013)
  
• Use as per NICE TA261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (July 2012)
  
• Use as per NICE TA256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation (May 2012)
  
• Use as per NICE TA170: Rivaroxaban for the prevention of venous thromboembolism after total hip or knee replacement in adults  (April 2009) 

Traffic light status (TLS) explained:

• Green: Routine prescribing within licensed indication
• Amber 1: specialist recommendation followed by GP initiation and continuation
• Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
• Amber 3: specialist initiation and stabilisation followed by GP continuation
• Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
• Red: Hospital or specialist prescribing only 

Return to Chapter: 2. Cardiovascular system

Last updated by: Dupe Fagbenro on 20-02-2019 16:51