• 62.5, 125 & 250 microgram tablets .
• 50 microgram per ml elixir .
• 500 microgram in 2ml injection .
• 100 microgram in 1ml injection unlicensed .

For the treatment of life threatening digoxin toxicity only, requests must be cleared by an appropriate clinician.

• As per licensed indication
• Injection given orally. Approved for the treatment of severe heart failure in adults and children to wean from IV milrinone as a bridge to transplant and to reduce the need for ventricular assist devices (VADs) unlicensed

• Current patients should continue on bendroflumethiazide
• Bendroflumethiazide 5mg tablets are available but not recommended for general use.

• PLEASE BE AWARE OF BIOAVAILABILITY COMPARED TO ORIGINATOR. REFER TO SPS BRIEFING DOCUMENT
  Differences between metolazone preparations and safety considerations

• Treatment should only be on advice from paediatric cardiology or nephrology specialists

• Approved as an option for treating stage 3 and 4 chronic kidney disease (with albuminuria) associated with type 2 diabetes in adults - in line with NICE TA877:
  • add-on to optimised standard care; this should include, unless they are unsuitable, the highest tolerated licensed doses of:
    • angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and
    • sodium–glucose cotransporter‑2 (SGLT2) inhibitors and
  • the person has an estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73 m² or more.

•  Resistant Hypertension - Step 4 NICE NG 136 - consider seeking expert advice
•  Post-acute myocardial infarction patients and patients with heart failure treatment should be initiated on instructions from a cardiologist or GP with a specialist interest in cardiology. Spironolactone is first choice (ahead of eplerenone) for severe heart failure.
• Spironolactone 10mg and 50mg in 5ml suspension is also approved unlicensed.
• 50mg/5ml - Recommended strength in children as per NPPG/RCPCH Position Statement: Using Standardised Strengths of Unlicensed Liquid Medicines in Children. 

• For use in post-acute myocardial infarction patients with left ventricular dysfunction and heart failure. Only to be used in patients who are unable to tolerate the estrogenic side effects of spironolactone. Treatment should only be on advice from a cardiologist.

• For use in paediatric cardiology. 
• Capsules are manufactured to have 1:10 ratio of spironolactone to chlorothiazide - formulations available include:
  
  • 1mg/10mg 
  • 2mg/20mg
  • 3mg/30mg
  • 5mg/50mg
  • 10mg/100mg
  
  

• 6mg in 2ml injection
• 25mg in 5ml injection unlicensed
• 30mg in 10ml injection for infusion - NHCT only
• 130mg in 130ml IV infusion unlicensed

• For radionuclide myocardial perfusion imaging in patients who are unable to undergo adequate exercise stress (e.g. COPD and asthma patients where dobutamine is indicated, and obese patients who require several vials of adenosine).

• 100mg & 200mg tablets 

• 50mg in 5ml suspension is also approved  unlicensed

• 150mg/3ml & 300mg/10ml injection 

NHS England (June 2019) advises that prescribers should not initiate amiodarone in primary care for any new patient.

in exceptional circumstances, where there is a clinical need for amiodarone to be prescribed, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional. Amiodarone has an important place in the treatment of severe cardiac rhythm disorders where other treatments either cannot be used or have failed. It has potential major toxicity and its use requires monitoring both clinically and via laboratory testing. 

MHRA Drug Safety Update (Mar 2022): Amiodarone (Cordarone X): reminder of risks of treatment and need for patient monitoring and supervision

• 50mg & 100mg tablets
• 5mg in 1ml liquid unlicensed. 

• Approved for patients who are unsuitable for or not tolerant of amiodarone. Treatment should be initiated by a cardiologist.

• Injection: 150ml/15ml 

• unlicensed


• ECG monitoring is required to be carried out by as part of the initiation process of mexiletine.

• For use as a diagnostic test of Brugada syndrome.

• 100mg injection, pre-filled syringes
• 1mg/ml (0.1%) & 2mg/ml (0.2%) IV infusions 500ml

• 5mg/10ml injection

• 50mg/10ml and 100mg/20ml

• Injection: 5mg/5ml 

• 5mg & 10mg tablets.
• 1.25mg, 2.5mg, 3.75mg & 7.5mg tablets - for use in the treatment of heart failure only. The 5mg and 10mg tablets should be used where possible - cheaper than other strengths.

• For use in the treatment of heart failure only.

• Tablets: 50mg, 100mg, 200mg, 400mg

• Tablets: 50mg, 100mg
• SR Tablets: 200mg 

• Treatment should only be intiated on the advice of a cardiologist. 

• For specialist use in the treatment of patients who cannot tolerate other beta-blockers. Treatment should only be intiated on the advice of a cardiologist. 

• Limited to use by cardiologists in patients with long QT syndrome/idiopathic ventricular fibrillation.
• Liquid formulations (unlicensed) can be obtained for use in children if necessary. Treatment should only be on the advice of a cardiologist.

• For specialist use in the treatment of patients who cannot tolerate other beta-blockers. Treatment should only be on the advice of a cardiologist.

• Tablets - 25mg, 50mg

• Treatment should only be on the advice of a cardiologist/nephrologist.

• unlicensed import

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy.
• Approved for systemic sclerosis with ongoing digital ulcer disease (to reduce number of new digital ulcers) - in accordance with NHS England Commissioning policy.

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 

• Ampoules: 20mg

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 

• Approved for Chronic Thromboembolic Pulmonary Hypertension - in accordance with NHS England Commissioning policy. 

• 20mg tablets
• 25mg, 50mg & 100mg tablets unlicensed indication
• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 
• Approved for systemic sclerosis with ongoing digital ulcer disease (to reduce number of new digital ulcers) - in accordance with NHS England Commissioning policy. 
• Approved for Raynaud's 

• Approved for pulmonary hypertension in adults for whom treatment with sildenafil is not tolerated or effective (in accordance with NHS England Commissioning policy).
• Approved for systemic sclerosis with ongoing digital ulcer disease (to reduce number of new digital ulcers) - in accordance with NHS England Commissioning policy.
• Approved for secondary Raynaud's.

• Approved for pulmonary hypertension - in accordance with NHS England Commissioning policy. 

• Treatment should be on the advice of a cardiologist/nephrologist.

• For use in paediatric cardiac ITU and in adult ITU patients with delerium and agitation, often around extubation unlicensed.

• 1mg, 2mg & 4mg tablets
• Doxazosin MR preparations are classified as BLACK - not approved

• For use in breastfeeding mothers only. Breastfeeding mothers should be converted to ramipril when they are no longer breastfeeding. 

• Perindopril is third line for all indications including prevention of stroke.

• Note: Perindopril arginine is classified as BLACK - not approved.

• Treatment should only be on the advice of a hospital paediatrician.
• 5mg in 5ml suspension are also approved for use.
• 2mg capsules are also approved for use unlicensed.

• Only to be used in the treatment of exisiting patients. 

• Only to be used in the treatment of existing patients.

• Only approved for use in accordance with NICE guidance. 

• 400 microgram/metered dose spray .   
  5mg & 10mg/day patches - for use in cardiothoracic critical care unit..

• 5mg in 5ml , 50mg in 10ml & 50mg in 50ml injections 

• 10mg, 20mg and 40mg tablets
• 60mg MR tablets - should only be used in patients when the non-modified release tablets are unsuitable . 

• M/R tablets: 2.5mg, 5mg, 10mg 

• 10mg in 50ml for IV infusion 

• Injection: 5mg/2ml (2.5mg/1ml) 

• For use as a second line calcium channel blocker where amlodipine is not tolerated. 

• Once daily formualtions are preferred
• 20mg controlled release tablets (Adalat LA), 30mg & 60mg m/r capsules (Coracten XL)
• 5mg & 10mg capsules
• 10mg & 20mg retard tablets
• 20mg in 1ml (1mg/drop) nifedipine oral solution is also approved for use unlicensed.

• Tablets - 40mg, 80mg, 120mg, 160mg
• MR Tablets - 240mg
• Oral Solution - 40mg/5ml

• 30mg tablets - treatment should be on the advice of the stroke team or a cardiologist.

• Approved as a second line agent for the treatment of aortic dissection and pre-eclampsia.

• Angina - for intiation on advice from a consultant cariologist in patients with contra-indications to or intolerance of beta-blockers.
• Heart failure  - approved for use in accordance with NICE guidelines.

• For use in the treatment of angina in those patients for whom other treatments have been unsuccesful.
• Initial prescribing should be by a consultant cardiologist only. 

• Approved for the treatment of intermittent claudication in people with peripheral arterial disease. 

• Approved for use in weaning paediatric and adult patients off extracorporeal membrane oxygenation (ECMO).
• Approved for use in paediatrics and adults where additional intravenous inotropic support is considered appropriate.

• 30mg in 1ml injection 
• 30mg in 10ml syringe unlicensed.
• 15mg tablets.

• For specialist initiation in treating symptomatic hypotension that has not responsed to conventional therapies. 

• 1 in 1,000 injections in 1ml syringes and 1ml & 10ml ampoules.
• 1 in 10,000 injections in 1ml & 10ml ampoules & syringes.

• Approved for use in severe veno-occlusive disease following stem cell transplant - in accordance with NHS England commissioning policy. 

• Approved for use as a rapid reversal agent for dabigatran.

• For use on advice of haematologists in patients with heparin induced thrombocytopenia.

•  Use during pregnancy and for pre-operative bridging therapy .

• Use during pregnancy and for pre-operative bridging therapy .

• For use on advice from haematologists in patients who develop thrombocytopenia with heparins - cross reactivity with heparin antibodies is thiought to be <10%. 

• Approved for preventing thrombosis in patients undergoing percutaneous coronary artery interventions.
• For use instead of abciximab in some low risk patients.
• Approved in combination with aspirin and clopidogrel for the treatment of adults with ST segment elevation MI undergoing percutaneous coronary intervention, in accordance with NICE guidance. 

• 50 units in 5ml & 200 units in 2ml – for flushing cannulae

• Approved for use in the prevention of central intravenous line infections
  in; haemodialysis patients, adult parenteral nutrition patients, patients with recurrent line infections, and immune deficiency unit patients.

• Approved for use in the prevention of central intravenous line infections in; haemodialysis patients, adult parenteral nutrition patients, patients with recurrent line infections, and immune deficiency unit patients.

• For pulmonary hypertension see section 2.5.1 

• Mainly for use in treating pulmonary hypertension - see secton 2.5.1 

• Approved for high risk orthopaedic surgery pateints and as an alternative to enoxaparin in accordance with NICE guidance.

• 500 microgram, 1mg, 3mg & 5mg tablets .
• 1mg/1ml oral suspension - - for use in paediatric patients on mechanical support using ventricular assistance devices, and for patients with mechanical heart valves or irregular heart rythms who have not been weaned .

• 1mg tablets

• 200mg powder for solution for infusion

• Approved for reversing anticoagulation from apixaban and rivaroxaban in adults with life-threatening or uncontrolled bleeding in line with NICE

• Only approved for use in accordance with NICE guidance. 
• In the absence of a specific clinical reason to select a particular DOAC, choose the most cost effective DOAC first. Rivaroxaban 'cost effective once daily choice for non-valvular AF' and Apixaban 'cost effective twice daily choice for non-valvular AF

• Only approved for use in accordance with NICE guidance. 

• In the absence of a specific clinical reason to select a particular DOAC, choose the most cost effective DOAC first. Rivaroxaban 'cost effective once daily choice for non-valvular AF' and Apixaban 'cost effective twice daily choice for non-valvular AF

• Only approved for use in accordance with NICE guidance. 

• In the absence of a specific clinical reason to select a particular DOAC, choose the most cost effective DOAC first. Rivaroxaban 'cost effective once daily choice for non-valvular AF' and Apixaban 'cost effective twice daily choice for non-valvular AF

• 2.5mg, 10mg, 15mg & 20mg tablets

• 1mg/1ml granules for oral suspension
  
  
  • approved for the treatment of VTE in children
  
  
  

• Only approved for use in accordance with NICE guidance. 

• In the absence of a specific clinical reason to select a particular DOAC, choose the most cost effective DOAC first. Rivaroxaban 'cost effective once daily choice for non-valvular AF' and Apixaban 'cost effective twice daily choice for non-valvular AF

• 2.5mg tablets

• Rivaroxaban co-administered with acetylsalicylic acid (ASA), is indicated for the prevention of atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischaemic events.

• Approved for use in accordance with NICE TA607

• 75mg dispersible tablets
• Note: 75mg e/c tablets – no longer recommended for use.

• 50mg powder for concentrate for solution for injection/infusion
  
  • Approved for bridging therapy in patients who have recently had a coronary stent but require urgent elective surgery
  
  
  

• Approved for use in cardiac patients being fitted with stents/acute coronary syndromes and where aspirin is contraindicated/not tolerated, despite its use in combination with acid suppressants e.g. omeprazole.
• Approved ischaemic stroke; in peripheral arterial/multivascular disease; or after MI only if aspirin not suitable in line with NICE.
• The North of Tyne APC recommends the use of generic 75mg clopidogrel tablets in all the approved indications for clopidogrel.
• Care should be taken to ensure that the brand supplied is suitable if it is to be packed into monitored dosage systems.

• Only approved for use in accordance with NICE guidance.
• 50mg in 5ml sugar free suspension alos avialable unlicensed.

• Only approved for use in accordance with NICE guidance.

• Only approved for use in accordance with NICE guidance. 

• For specialist use in the endovascular treatment of cerebral
  aneurysms

• Approved for use in paediatric patients with Berlin Heart devices.

• 10mg, 20mg, and 50mg injections.
• Also approved for stoke in accordance with NICE guidance. 
• 2mg in 2ml injection - approved for unblocking intravenous lines, mainly in paediatric dialysis patients.

• 5,000 units (25mg) powder and solvent for solution for injection
• 10,000 units (50mg) powder and solvent for solution for injection
• Approved or treating acute ischaemic stroke in adults in line with NICE

• Also available as a 500mg in 5ml syrup unlicensed.

• 100mg/ml Solution for Injection

• Approved for the use in paediatric patients undergoing extracorporeal membrane oxygenation (ECMO).

• For limited use in cardiothoracic surgery.

• Approved for reversing the effects of oral anticoagulants in patients with life or limb threatening bleeding in accordance with a regional protocol.

• Approved for treating moderately severe or severe haemophilia B in line with NICE

• Approved for patients with severe Haemophilia A and an inhibitor and in whom there is agreement to undertake immune tolerance induction with a plasma derived product. 

• Solution for infusion containing 45-75mg/ml human plasma proteins.

• Only approved for use in accordance with NICE guidance.

• Approved for use in accordance with NICE guidance for treating primary hypercholesterolaemia.
• Approved for the treatment of homozygous familial hypercholesterolaemia in line with NHS England Commissioning policy.

• 998mg capsules
• Icosapent ethyl is recommended as an option for reducing the risk of cardiovascular events in adults. It is recommended if they have a high risk of cardiovascular events and raised fasting triglycerides (1.7 mmol/litre or above) and are taking statins, but only if they have:
  • established cardiovascular disease (secondary prevention), defined as a history of any of the following:
    • acute coronary syndrome (such as myocardial infarction or unstable angina needing hospitalisation)
    • coronary or other arterial revascularisation procedures
    • coronary heart disease
    • ischaemic stroke
    • peripheral arterial disease, and
  • low-density lipoprotein cholesterol (LDL‑C) levels above 1.04 mmol/litre and below or equal to 2.60 mmol/litre

• 284mg/1.5ml solution for injection pre-filled syringes
  
  
  
  • Approved for the treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia as an adjunct to diet in adults in line with NICE. 
    
    
  
  
  
  

• For initiation in lipid clinic only in patients with familial hypercholesterolaemia and/or those with substantial cardiovascular risk and who are unable to tolerate existing treatments.
• Also approved for the treatment of leflunomide toxicity .

• For initiation in lipid clinic only in patients with familial hypercholesterolaemia and/or those with substantial cardiovascular risk and who are unable to tolerate existing treatments.

• 180mg tablets
• Approved for the treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia in adults in line with NICE and following the statin intensification pathway outlined in NEELI

• Bempedoic acid 180mg & ezetimibe 10mg tablets
• Approved for the treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia in adults in line with NICE and following the statin intensification pathway outlined in NEELI

• Only approved for use in accordance with NICE guidance.
• For further information refer to NEELI. 

•  5mg, 10mg, 20mg & 40mg tablets
• May be used as an alternative to atorvastatin for primary or secondary prevention in line with NEELI guidance 

• 10mg, 20mg. 40mg & 80mg tablets

• 10mg and 20mg chewable tablets
• Note: atorvastatin 10mg and 20mg chewable tablets should be used instead of simvastatin suspension where solid dosage forms cannot be used. 

• 10mg, 20mg & 40mg tablets

• Approved only for use when there is a supply problem with indometacin.

• 5mg and 10mg tablets
• Approved for treating chronic heart failure with reduced ejection fraction in line with NICE
• Approved for treating chronic heart failure with preserved or mildly reduced ejection fraction in adults in line with NICE

• 10mg and 25mg tablets
• Approved for the treatment of chronic heart failure with reduced ejection fraction in adults in line with NICE
• Approved for the treatment of chronic heart failure with preserved or mildly reduced ejection fraction in line with NICE

• Approved as an option for treating symptomatic obstructive hypertrophic cardiomyopathy in adults who have a New York Heart Association class of 2 to 3 in line with NICE and NHSE Specialised Commissioning guidance.
• It is recommended only if:
  • it is an add‑on to individually optimised standard care that includes beta‑blockers, non-dihydropyridine calcium-channel blockers or disopyramide, unless these are contraindicated.

The following providers are commissioned to provide this service:

• North Cumbria Integrated Care NHS Foundation Trust
• South Tees Hospitals NHS Foundation Trust
• The Newcastle upon Tyne Hospitals NHS Foundation Trust