Section 2: Cardiovascular System

Section Description

BNF 2.1.1

Cardiac glycosides

BNF 2.1.2

Phosphodiesterase type-3 inhibitors

BNF 2.2.1

Thiazides and related diuretics

BNF 2.2.2

Loop diuretics

BNF 2.2.3

Potassium-sparing diuretics and aldosterone antagonists

BNF 2.2.4

Potassium-sparing diuretics with other diuretics

BNF 2.2.5

Osmotic diuretics

BNF 2.2.8

Diuretics with potassium

BNF 2.3.2

Drugs for Arrhythmias

BNF 2.4

Beta-adrenoreceptor blocking drugs

BNF 2.5

Hypertension and heart failure

BNF 2.5.1

Vasodilator antihypertensive drugs

BNF 2.5.2

Centrally acting antihypertensive drugs

BNF 2.5.4

Alpha-adrenoreceptor blocking drugs

BNF 2.5.5.1

Angiotensin-converting enzyme (ACE) inhibitors

BNF 2.5.5.2

Angiotensin-II receptor antagonists

BNF 2.5.5.3

Renin inhibitors

BNF 2.6.1

Nitrates

BNF 2.6.2

Calcium-channel blockers

BNF 2.6.3

Other antianginal drugs

BNF 2.6.4

Peripheral vasodilators and related drugs

BNF 2.7.1

Inotropic sympathomimetics

BNF 2.7.2

Vasoconstrictor sympathomimetics

BNF 2.7.3

Cardiopulmonary resuscitation

BNF 2.8.1

Parenteral anticoagulants

BNF 2.8.2

Oral anticoagulants

BNF 2.8.3

Protamine sulphate

BNF 2.8.4

Idarucizumab

BNF 2.9

Antiplatelet drugs

BNF 2.10.2

Fibrinolytic drugs

BNF 2.11

Antifibrinolytic drugs and haemostatics

BNF 2.12

Lipid-regulating drugs

BNF 2.13

Local sclerosants

BNF 2.1.1 Cardiac glycosides

Digoxin oral & injection

 

Sample 6 hours post-dose for digoxin levels.
Bioavailability of digoxin varies between its forms.
62.5mcg tablet is equivalent to 50mcg (1ml) elixir
62.5mcg tablet is equivalent to 42mcg(1ml) injection
Ref: The NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. North East Wales NHS Trust

BNF 2.1.2 Phosphodiesterase type-3 inhibitors

Enoximone injection

Restricted/ Specialist Prescribing Only

Milrinone injection

Restricted/ Specialist Prescribing Only

BNF 2.2.1 Thiazides and related diuretics

Chlortalidone oral

Step 3 for hypertension (see section 2.5)

Indapamide oral

Step 3 for hypertension (see section 2.5)

Metolazone oral

Specialist recommendation (unlicensed). Available from 'special-order' manufacturers or specialist importing companies.

Bendroflumethiazide oral

Hypertension: For existing patients only – offer chlorthalidone or indapamide to new patients.
Bendroflumethiazide 2.5mg daily produces a maximal or near-maximal blood pressure lowering effect, with very little biochemical disturbance. Higher doses cause more marked changes in plasma potassium, uric acid, glucose and lipids, with no advantage in blood pressure control. Reserve bendroflumethiazide 5mg for heart failure.

BNF 2.2.2 Loop diuretics

Bumetanide oral & injection

Furosemide oral & injection

BNF 2.2.3 Potassium-sparing diuretics and aldosterone antagonists

Amiloride oral

 

Eplerenone oral

For initiation and stabilisation by Cardiologist only, in patients for whom spironolactone is not appropriate, and then continuation in primary care.

See NICE CG108

Spironolactone oral

HEART FAILURE: Spironolactone 25mg daily has been shown to reduce symptoms and mortality in patients with severe heart failure who are already receiving an ACE inhibitor and a diuretic and possibly digoxin. Close monitoring of serum creatinine and potassium is necessary. Start at spironolactone 25 mg once daily. Check blood chemistry at: 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6/12 thereafter:
If K+ rises to between 5.5 and 5.9 mmol/litre or creatinine rises to 200 µmol/litre: reduce dose to 25 mg on alternate days and monitor blood chemistry closely
If K+ rises to > 6.0 mmol/litre or creatinine to > 200 µmol/litre: stop spironolactone and seek specialist advice
Also see NICE CG108

BNF 2.2.4 Potassium-sparing diuretics with other diuretics

Potassium-sparing diuretics are not usually necessary in the routine treatment of hypertension, unless hypokalaemia develops.

Co-amilofruse oral

Hospital prescribes amiloride and furosemide separately as required. Combination product may be prescribed in primary care to aid compliance.

BNF 2.2.5 Osmotic diuretics

Mannitol intravenous infusion

Restricted/ specialist prescribing only

BNF 2.2.8 Diuretics with potassium

The British National Formulary discourages the prescribing of these combined preparations.

BNF 2.3.2 Drugs for arrhythmias

Adenosine injection & infusion

Restricted / Specialist Prescribing Only 

Amiodarone injection

Restricted / Specialist Prescribing Only

Amiodarone oral

For initiation by hospital consultant and then continuation in primary care.

Amiodarone has a very long half-life and many weeks may be required to achieve steady-state plasma concentrations. This is particularly important when interactions with amiodarone are considered. Please see BNF for details of interactions. Patients should be advised to use a wide-spectrum sunscreen (to protect against both long ultraviolet and visible sunlight) because of the possibility of phototoxic reactions with amiodarone.

Chest X-ray, LFTs and TFTs before starting treatment.
Check LFTs and TFTs every six months.

Disopyramide injection

Restricted / Specialist Prescribing Only

Disopyramide oral

For initiation and stabilisation by Cardiologist and then continuation in primary care.

Dronedarone oral

For initiation by Cardiologist and then continuation in primary care.Shared Care Agreement
Dronedarone for the treatment of non-permanent atrial fibrillation NICE TA197
Monitoring:

    • ECG at 6 monthly intervals to identify those who revert back to AF. Discontinuation of dronedarone should be considered for these patients.
    • LFTs monthly to month 6, thereafter for the first 6 months of treatment, at month 9, at month 12 and periodically thereafter.
    • Creatinine levels should be measured before and 7 days after starting dronedarone. An increase in plasma creatinine (mean increase 10 micromole/L) has been observed with dronedarone 400 mg twice daily in healthy subjects and in patients. If an increase in creatininemia is observed, serum creatinine should be re-measured after a further 7 days. If no further increase in creatinaemia is observed, this value should be used as the new reference baseline. If serum creatinine continues to rise, then consideration should be given to further investigation and discontinuing treatment. An increase in creatininemia should not necessarily lead to the discontinuation of treatment with ACE inhibitors or angiotensin II receptor antagonists.

Lidocaine injection

For consultant cardiologist use only.

Mexiletine oral

Initiated by hospital consultant for treatment of life-threatening ventricular arrhythmias. Product can be obtained from specialist manufacturers or specialist importing companies e.g. Mawdsley Brooks (0800 5677412) or IDIS (01932 824000)

Propafenone oral

Initiated by hospital consultant only, then suitable for continuation in primary care.

BNF 2.4 Beta-adrenoreceptor blocking drugs

Angina

Atenolol oral & injection

 

Bisoprolol oral

 

Metoprolol oral

 

Anxiety

Propranolol oral

 

Arrhythmias

Atenolol oral & injection

 

Esmolol injection

Restricted / Specialist Prescribing Only: in accordance with RWT guidelines

Metoprolol oral

 

Sotalol oral

Initiation by Cardiologists only, then suitable for prescribing in primary care.

Heart Failure
(stable moderate to severe)

Bisoprolol oral

Initiation and titration by hospital consultant and/or specialist Heart Failure Service, then suitable for prescribing in primary care.

Carvedilol oral

Hypertension

(see section 2.5)

Atenolol oral & injection

Recommended max. daily dose for hypertension is 50mg

Bisoprolol oral

 

Metoprolol oral

 

Hypertension in Pregnancy

Labetalol injection & infusion

Restricted / Specialist Prescribing Only 

Labetalol oral

 

Migraine prophylaxis

Propranolol oral

 

Post-myocardial infarction

Atenolol oral & injection

 

Metoprolol oral

 

Thyrotoxicosis

Metoprolol oral

 

Propranolol oral

 

BNF 2.5 Hypertension and Heart Failure

Treatment of Hypertension

If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5 - 25.0 mg once daily) or indapamide (1.5mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

NICE CG127

BLOOD PRESSURE

Systolic

Diastolic

Standard target

<140mmHg

<90mmHg

Lower target e.g. established atherosclerotic CVD, diabetes or chronic renal failure

<130mmHg

<80mmHg

BNF 2.5.1 Vasodilator antihypertensive drugs

Diazoxide injection

Restricted / Specialist Prescribing Only

Hydralazine injection

Restricted / Specialist Prescribing Only
Profound hypotension may occur during first few days of treatment.

Minoxidil oral

Severe hypertension, in addition to diuretic + beta-blocker.

Sodium nitroprusside infusion

Restricted / Specialist Prescribing Only

BNF 2.5.2 Centrally acting antihypertensive drugs

Methyldopa oral

 

Moxonidine oral

3rd or 4th line antihypertensive (see section 2.5). Initiated by hospital consultant only, then suitable for continuation in primary care. 

BNF 2.5.4 Alpha-adrenoreceptor blocking drugs

Doxazosin oral

Caution – if susceptibility to heart failure
Use at Step 4 in the treatment of hypertension (see section 2.5)
Avoid use of expensive modified release (XL) preparation.

Converting between doxazosin formulations advice here


PHAEOCHROMOCYTOMA

Phenoxybenzamine injection

Restricted / Specialist Prescribing Only

Phentolamine injection

Restricted / Specialist Prescribing Only

BNF 2.5.5.1 Angiotensin-converting enzyme (ACE) inhibitors

ADULTS: FIRST CHOICE

Ramipril oral

 

ADULTS: SECOND-CHOICE

Enalapril oral

Existing patient only

Lisinopril oral

 

Perindopril erbumine oral

 

CHILDREN
No ACE Inhibitor is licensed for use in children or neonates

Captopril oral

See BNF for Children for further information.

MONITORING:

Check renal function before initiating treatment.
Check renal function 7 – 14 days after initiating treatment and every dose change
Check renal function once a year in patients with risk factors predisposing them to uraemia e.g.
  • old age
  • peripheral vascular disease
  • low cardiac output
  • concomitant treatment with NSAIDs
  • concomitant treatment with high-dose diuretics

BNF 2.5.5.2 Angiotensin-II receptor antagonists

Useful alternative for patients who have to discontinue an ACE inhibitor because of a persistent cough

Candesartan oral

 

Irbesartan oral

 

Losartan oral

 

Valsartan oral

 

For symptomatic chronic heart failure with reduced ejection fraction

Sacubitril valsartan oral

Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction NICE TA388. Not to be prescribed with an ACE inhibitor or angiotensin II receptor antagonist. RICaD

BNF 2.5.5.3 Renin Inhibitors

Aliskiren oral

For initiation by consultant nephrologists only, as fourth line for the treatment of hypertension, then suitable for continuation in primary care.

BNF 2.6.1 Nitrates

ACUTE ATTACK 

Glyceryl trinitrate sublingual spray 400mcg/dose

Glyceryl trinitrate IV

Restricted/ Specialist Prescribing Only

Glyceryl trinitrate buccal tablets

Restricted/ Specialist Prescribing Only (where no IV access)

PROPHYLAXIS

Isosorbide mononitrate oral

Asymmetric dosing: recommend second of two daily doses given after about 8 hours. Rather than after 12 hours e.g. 8am and 4pm (to avoid the development of nitrate tolerance).

Isosorbide mononitrate m/r oral

Prescribe by brand name

Glyceryl trinitrate patches

Prescribe by brand name

 

BNF 2.6.2 Calcium-channel blockers

What are the reported incidences of ankle oedema with different calcium channel blockers? UKMI Q&A

Rate Limiting Calcium-Channel Blockers

Diltiazem oral

Note once daily and twice daily preparations are available.
Prescribers should specifiy the brand to be dispensed

Verapamil oral & m/r oral

Licensed indications vary – please check product details before prescribing and prescribe by brand name.

Evidence for verapamil for cluster headache UKMI Q&A

Dihydropyridine Calcium-Channel Blockers

1st choice: Amlodipine oral

 

2nd choice: Felodipine oral

Metabolised via cytochrome P450 system – check BNF for interactions

Nifedipine m/r oral

Licensed indications vary – please check product details before prescribing and prescribe by brand name.

 

Raynaud’s Phenomenon

Nifedipine oral

5mg three times a day

Post-Aneurysmal Subarachnoid Haemorrhage

Nimodipine oral & infusion

Restricted / Specialist Prescribing Only

BNF 2.6.3 Other antianginal drugs

Nicorandil oral

Second line treatment for angina – risk of ulcers MHRA January 2016

Ivabradine oral

Initiated by hospital consultant only, then suitable for continuation in primary care.Second line.
NICE clinical guideline for management on stable angina NICE CG126
Ivabradine for treatment of heart failure NICE TA267

Ranolazine oral

Initiated by hospital consultant only, then suitable for continuation in primary care. As adjunctive therapy in the treatment of stable angina in patients inadequately controlled or intolerant to first-line antianginal therapies NICE CG126

BNF 2.6.4 Peripheral vasodilators and related drugs

PERIPHERAL VASCULAR DISORDERS

1st line: Naftidrofuryl oral

100mg-200mg three times a day. Assess for improvement after 3 to 6 months. See NICE TA223

2nd line: Cilostazol oral

For initiation by vascular surgeon, for patients not responding to or intolerant of naftidrofuryl. Assess for improvement after 3 to 6 months. Then suitable for prescribing in primary care.

RAYNAUD'S SYNDROME

Reduce frequency and severity of attacks

Nifedipine oral (see BNF 2.6.2)

Symptomatic improvement

Naftidrofuryl oral 100mg -200mg three times a day

BNF 2.7.1 Inotropic sympathomimetics

Dobutamine injection & infusion

Restricted/ Specialist Prescribing Only

Dopamine infusion

Restricted/ Specialist Prescribing Only

Dopexamine infusion

Restricted/ Specialist Prescribing Only

BNF 2.7.2 Vasoconstrictor sympathomimetics

Metaraminol injection

Restricted/ Specialist Prescribing Only

Norepinephrine (noradenaline) injection

Restricted/ Specialist Prescribing Only

Phenylephrine injection

Restricted/ Specialist Prescribing Only

BNF 2.7.3 Cardiopulmonary resuscitation

Resuscitation Council (UK) guidelines

Adrenaline injection

 

BNF 2.8.1 Parenteral anticoagulants

Heparin calcium injection

 

Heparin flushes

For maintaining patency of catheters, cannulas etc

LOW MOLECULAR WEIGHT HEPARINS

Enoxaparin injection

Suitable for prescribing in primary care after specialist initiation

Tinzaparin injection

Prevention of clotting in the extracorporeal circuit during haemodialysis in patients with chronic renal insufficiency - FOR RENAL USE ONLY. Suitable for prescribing in primary care after specialist initiation

Dalteparin sodium injection

Prevention of clotting in the extracorporeal circuit during haemodialysis in patients with chronic renal insufficiency - FOR RENAL USE ONLY. Suitable for prescribing in primary care after specialist initiation

HEPARINOIDS

Argatroban injection

Restricted / Specialist Prescribing Only (consultant only).
Thromboembolic disease in patients with heparin-induces thrombocytopenia.

Danaparoid injection

Restricted / Specialist Prescribing Only (consultant only).
Thromboembolic disease in patients with heparin-induces thrombocytopenia.

HIRUDINS

Bivalirudin injection

Restricted / Specialist Prescribing Only. Treatment of adult patients with unstable angina/non-ST segment elevation myocardial infarction planned for urgent or early intervention. NICE TA230

EPOPROSTENOL

Epoprostenol (Flolan®) infusion

Restricted / Specialist Prescribing Only (consultant only).

BNF 2.8.2 Oral anticoagulants

 
Apixaban oral

Wolverhampton Rationale for Initiation, Continuation and Discontinuation (RICaD) document for apixaban click here

For preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation NICE TA275

Venous thromboembolism - apixaban for hip and knee surgery NICE TA245

Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism NICE TA341

Dabigatran oral

Wolverhampton Rationale for Initiation, Continuation and Discontinuation (RICaD) document for dabigatran click here

For the prevention of stroke and systemic embolism in atrial fibrillation - for patients intolerant of warfarin only NICE TA249

Prophylaxis of venous thromembolism following total knee/hip replacement surgery NICE TA157

For the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism NICE TA327

Edoxaban oral

Wolverhampton Rationale for Initiation, Continuation and Discontinuation (RICaD) document for edoxaban click here 

Edoxaban for treating and preventing deep vein thrombosis and/or pulmonary embolism NICE TA354

Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation NICE TA355  

Rivaroxaban oral 

Wolverhampton Rationale for Initiation, Continuation and Discontinuation (RICaD) document for rivaroxaban click here

Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome NICE TA335

Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism NICE TA287

Rivaroxaban for the treatment of deep-vein thrombosis and prevention of recurrent deep-vein thrombosis and pulmonary embolism NICE TA261

Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation NICE TA256

Rivaroxaban for the prevention of venous thromboembolism NICE TA170 

Warfarin oral

Details of interactions can be found in Appendix 1 of the British National Formulary. Warfarin tablets are colour coded - 500mcg (white), 1mg (brown), 3mg (blue) and 5mg (pink). Tablets may be crushed and mixed with water if patient unable to swallow tablet whole.
A warfarin suspension can be ordered - please prescribe warfarin oral suspension 1mg in 1ml (5mg in 5ml) to avoid any confusion and enable changes in dose to be made safely. 

NPSA Patient Safety Alert for Anticoagulants
NPSA information Booklet for Patients

Also available in other languages: Arabic, Bengali, Cantonese, French , Gujarati, Polish, Punjabi, Somalian, Tamil, Welsh & Urdu

UKMI Q&A: IM injections in warfarin patients click here

UKMI Q&A: warfarin and PPI interactions click here

SECOND-LINE ORAL ANTICOAGULANTS

Acenocoumarol oral

Suitable for prescribing in primary care after specialist initiation

Phenindione oral

Suitable for prescribing in primary care after specialist initiation

SELF-MONITORING

Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor) NICE Diagnostic Guidance 14

BNF 2.8.3 Protamine sulphate

Protamine sulphate injection

Restricted/ Specialist Prescribing Only

BNF 2.8.4 Idarucizumab

Idarucizumab injection

Restricted/ Specialist Prescribing Only

BNF 2.9 Antiplatelet drugs

Abciximab injection

Restricted / Specialist Prescribing Only
Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes NICE TA47

Aspirin oral dispersible

Aspirin soluble cannot be included in medication dosage systems (dossets, trays), aspirin enteric-coated tablets 75mg may be used for this purpose.

Can a person with low dose aspirin take gingko? UKMI Q&A
Is there evidence to support the use of EC coated aspirin to reduce GI side effects? UKMI Q&A

Bivalirudin injection

Restricted / Specialist Prescribing Only
Treatment of adult patients with unstable angina/non-ST segment elevation myocardial infarction planned for urgent or early intervention (see BNF 2.8.1)

Clopidogrel oral

Use in combination with aspirin in acute coronary syndrome and following cardiac surgery for the period specified by the cardiologist (not usually more than 12 months). If dyspepsia experienced with clopidogrel, add lansoprazole (interaction with omeprazole) or ranitidine (interaction with cimetidine).

Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes NICE TA47

Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events  NICE TA210

Myocardial infarction: cardiac rehabilitation and prevention of further MI  NICE CG172

Dipyridamole with aspirin m/r capsules

To avoid severe headaches with dipyridamole, start with 25mg three times a day increasing over 1-2 weeks to 100mg three times a day. If dipyridamole tolerated, change to twice daily 200mg m/r preparation

Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes  NICE TA47

Dipyridamole oral

Eptifibatide injection & infusion

Restricted / Specialist Prescribing Only

Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes NICE TA47 

Unstable angina and NSTEMI NICE CG94 first line

Prasugrel oral

Use in combination with aspirin to prevent atherothrombotic events in patients with acute coronary syndrome having percutaneous coronary intervention (PCI), only when:

  • immediate primary PCI for STEMI is necessary or
  • stent thrombosis has ocurred during clopidogrel treatment or
  • patient has diabetes mellitus.

Prescribed in combination with aspirin; initiated and prescribed for one month by hospital then continued by primary care until stop date (12 months from date of initiation).

NICE guidance - Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal 182) NICE TA317

Ticagrelor oral

 

Use in combination with low-dose aspirin for up to 12 months, as a treatment option in adults with acute coronary syndrome, when:

  • STEMI, defined as ST elevation or new left bundle branch block on ECG, that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or
  • non-ST-segment-elevation myocardial infarction (NSTEMI) or
  • hospital admission with unstable angina, defined as ST or T wave changes on ECG suggestive of ischaemia. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideallly by a cardiologist.

Ticagrelor for the treatment of acute coronary syndrome NICE TA236

In place of Prasugrel for those patients who present for primary percutaneous coronary intervention (PPCI) following a diagnosis of ST-elevation myocardial infarction (STEMI) and also for diabetic non ST-elevation myocardial infarction (NSTEMI) patients who undergo coronary artery stent implantation.

For those patient intolerant of Clopidogrel and/or prasugrel due to hypersensitivity as per MHRA recommendation.

Ticagrelor, in combination with aspirin, for preventing atherothrombotic events after myocardial infarction NICE TA420 

Tirofiban infusion

Restricted / Specialist Prescribing Only

Unstable angina and NSTEMI: early management NICE CG94

BNF 2.10.2 Fibrinolytic drugs

NICE Guidance (Myocardial infarction - thrombolysis) NICE TA52

Alteplase injection

Restricted / Specialist Prescribing Only

Alteplase for treating acute ischamic stroke NICE TA264

Streptokinase injection

Restricted / Specialist Prescribing Only

Tenecteplase injection

Restricted / Specialist Prescribing Only

Urokinase injection

Restricted / Specialist Prescribing Only. Syner-KINASE®

BNF 2.11 Antifibrinolytic drugs and haemostatics

Etamsylate oral

 

Tranexamic acid injection

Restricted / Specialist Prescribing Only

Tranexamic acid oral

 

BNF 2.12 Lipid-regulating drugs

Wolverhampton Guideline for the prescribing in adults of Lipid Regulating Drugs Local Lipid Lowering Guidelines 2016

Lipid Management (Adult Patients) Secondary prevention or primary prevention with CVD risk > 20% Local Lipid Lowering Algorithm 2016

 

1st Line

Atorvastatin oral

For patients unable to tolerate atorvastatin
Simvastatin oral Simvastatin 40mg once daily taken at night.
Reduce dose to 20mg if patient is taking amiodarone or verapamil concurrently (increased risk or possible increased risk of myopathy). See BNF for other interactions
Patients should be advised not to drink grapefruit juice  

2nd Line

Ezetimibe oral

Ezetimibe 10mg daily may be added to maximum tolerated dose of the most potent statin in patients who fail to achieve target levels on maximum statin therapy.  

Ezetimibe for treating primary heterozygous-familial and non-famial hypercholesterolaemia NICE TA385

3rd Line

If targets are still not achieved with a statin plus ezetimibe, refer patient to specialist care for the addition of a fibrate as this increases risk of muscle toxicity (including rhabdomyolysis) and should be used with caution.  

Monitoring Statin Therapy

  1. Monitor liver function tests (LFTs) at beginning of treatment and at 1-3 months, 6 months, 12 months, then annually.
  2. Check baseline creatinine kinase (CK) and re-check if patient complains of musculoskeletal symptoms.
  3. Discontinue statins if:
  • strong suspicion of myopathy, if CK exceeds 5 times upper limit of normal range
  • alanine transaminase (ALT) persists above 3 times upper limit of normal range.

Patients Intolerant of Statins
Patients who do not tolerate statins at all may be prescribed:

 

Ezetimibe oral

10mg daily

or

Fenofibrate oral

Lipantil® and Supralip®  

or

Colestyramine oral

12-24g daily in divided doses. Other drugs should be taken at least 1 hour before or 4-6 hours after colestyramine (cholestyramine) to reduce possible interference with absorption.

Lipid Lowering Therapy for the Management of Moderate to Severe Hypertriglyceridaemia

Local Lipid Lowering Guidelines 2016 include as treatment options: Fish oil capsules, which contain omega-3 long chain fatty acids, and nicotinic acid.

Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia NICE TA393

Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia NICE TA934 

BNF 2.13 Local sclerosants

Sodium tetradecyl sulphate injection

Restricted / Specialist Prescribing Only