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 Formulary Chapter 2: Cardiovascular system - Full Chapter
02.08.02  Expand sub section  Oral anticoagulants
 note 
  • Warfarin is a competitive antagonist of vitamin K (phytomenadione), involved in the production of clotting factors. Its anticoagulant effect takes 36-48 hours to develop fully and is monitored using the international normalised ratio (INR). For treatment of VTE, heparin should continue for at least 5 days following warfarin initiation and not stopped until the INR has been in the therapeutic range for two consecutive tests.
  • Guidance on indications and target INRs are listed in the UHL Guidelines on Initiation of Oral Anticoagulation
  • The Anticoagulation (Warfarin) Induction Pack should be used for all new patients starting therapy with warfarin.
  • The Anticoagulation Initiation Pack for Oral Direct Factor Xa Inhibitors and Thrombin Inhibitors should be used for all new patients starting on either rivaroxaban, apixaban or dabigatran. 
  • The recommended inpatient dosing time for warfarin is 2pm and the INR should be measured between 8-10am the following morning.
  • Both vitamin K (phytomenadione) and prothrombin complex concentrate product are used for the emergency reversal of warfarin. Administration must not be delayed.
  • There is currently no product available for the emergency reversal of apixaban, dabigatran or rivaroxaban
  • All patients discharged from hospital on anticoagulants should be referred to the UHL anticoagulant clinic for counselling.
  • Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome is available for use by consultant cardiologists on request. Use only in line with NICE TA 335.  Decision added June 16. Traffic light status is red for this indication.
Warfarin
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Formulary
Green
Within UHL give 1mg tablets to all patients initiated on warfarin.
Patients already established on warfarin should receive the strengths of tablets they are used to. 
Link  MHRA Advice: Topical miconazole, including oral gel - reminder of potential for serious interactions with warfarin
Link  MHRA Advice: Warfarin: reports of calciphylaxis
   
Edoxaban
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Formulary
Green

For Atrial Fibrillation (AF) use inline with the Leicestershire Algorithms.

For patients with non-valvular AF, edoxaban is the preferred choice based on lower drug acquisition cost unless there is a specific clinical reason not to do so.

Date of entry of decision to formulary: November 2015

 
Link  Leicestershire Guidance: DOAC for Non-Valvular AF
Link  NICE TA 355: Edoxaban in AF
   
Rivaroxaban
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Formulary
Green
For Atrial Fibrillation (AF) use in line with the Leicestershire Algorithms.

Date of entry of decision to Formulary: August 2012
 
Link  Leicestershire Guidance:Direct Oral Anti-Coagulants for Non-Valvular Atrial Fibrillation
Link  UHL Prescriber Checklist
   
Apixaban
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Formulary
Green
For Atrial Fibrillation (AF) use inline with the Leicestershire Algorithms.

Date of entry of decision to Formulary: May 2013
 
Link  Leicestershire Guidance: DOAC for Non-Valvular AF
Link  UHL Prescriber Checklist
   
Dabigatran etexilate
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Formulary
Green
For Atrial Fibrillation (AF) use inline with the Leicestershire Algorithms. 
Link  Leicestershire Guidance: DOAC for Non-Valvular AF
Link  UHL Prescriber Checklist
   
Rivaroxaban
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Restricted Drug Restricted
Amber Simple
For DVT and PE use. Patients should be referred to the anticoagulant clinic for counselling.

Date of entry of decision to Formulary:
PE - September 2013
DVT - October 2012 
   
Apixaban
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Restricted Drug Restricted
Amber Simple
For DVT and /or PE use in line with NICE TA 341 only


Date of entry of decision to formulary: September 2015 
Link  NICE TA 341: Apixaban for DVT / PE
   
Dabigatran etexilate
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Restricted Drug Restricted
Amber SCA
Available DVT and PE in line with SCA.
Use in line with NICE TA 327

Date decision added to Formulary: February 2015 
Link  NICE TA 327: Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
   
Edoxaban
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Restricted Drug Restricted
Amber SCA
Available on request for treating and preventing DVT and PE in line with NICE: TA 354

Date of entry of decision to formulary: October 2015 
Link  NICE TA 354: Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism
Link  SCA: Dabigatran and Edoxaban DVT and PE
   
Rivaroxaban (2.5mg strength tablet only) (Xarelto)
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Restricted Drug Restricted
Red

Atherothrombotic events in coronary artery disease in conjunction with acetylsalicylic acid as per NICE TA 335 only

 
Link  NICE TA 335: Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome
   
Acenocoumarol
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Restricted Drug Restricted
Red
Red traffic light status for new patients but existing patients can continue to be supplied by primary care 
   
Fondaparinux Sodium
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Restricted Drug Restricted
Red
For HIT 
Link  Leicestershire Evaluation: Fondaparinux in HIT
   
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
 ....
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
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Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
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Link to SPCs
SMC
Scottish Medicines Consortium
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

Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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