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2.6 Nitrates, calcium-channel blockers & other antianginal drugs

2.6 Nitrates, calium-channel blockers & other                    antianginal drugs
                    GREEN         Glyceryl trinitrate 
                                         tablets sublingual 500 microgram 
                                         buccal tablets 2mg, 5mg
                                         aerosol spray 400micrograms/dose  
                                         patches 5mg/24hr, 10mg/24hr
                    RED          Glyceryl trinitrate injection 25mg/5ml, 50mg/50mL 
                    Isosorbide mononitrate M/R
                    Standard release preparations have been replaced with the following modified release (M/R) products. These should be
                    prescribed generically. A guide detailing how to switch from standard formulation to modified release preparations can
                    be found here
                    GREEN      Isosorbide mononitrate XL 60mg tablets,
                                        Isosorbide mononitrate LA 25mg, 50mg capsules
      2.6.2 Calcium Channel Blockers
                    Amlodipine is for angina and hypertension, has a longer duration of action and can be given once a day. 
                    It should be prescribed generically as amlodipine.  The besilate salt should not be prescribed as this is more expensive.
                    GREEN       Amlodipine (as maleate/mesilate salt only) tablets 5mg, 10mg
                    Lercanidipine or Lacidipine can be used as a  second line calcium channel blocker when amlodipine is not tolerated
                    (e.g. where patients develop significant ankle oedema).
                    GREEN      Lercanidipine tablets 10mg, 20mg
                    GREEN      Lacidipine tablets 2mg, 4mg
                    Diltiazem is indicated for angina and hypertension. Prescribe modified-release diltiazem by brand name to avoid 
                    confusion between different formulations.
                    Diltiazem (once daily preparations)
                    GREEN     Zemtard XL (Prescribe by brand name) capsules 120mg, 180mg, 240mg, 300mg  
Slozem capsules 120mg, 180mg, 240mg, 300mg (1st line in hospital)
                                       Viazem® XL (prescribe by brand name) 120mg, 180mg, 240mg, 300mg, 360mg (3rd line and in-case of  
                                       supply disruption)
                    GREEN      Diltiazem MR 60mg tablets [to support dose titration options in CCU]
                   Nimodipine is licensed only for subarachnoid haemorrhage.
                   RED           Nimodipine tablets 30mg
                   RED           Nimodipine intravenous infusion 10mg/50mL
                   Verapamil is for angina, hypertension and arrhythmias, it reduces cardiac output, slows the heart rate and may  
                   precipitate heart failure.
                   GREEN      Verapamil
                                        tablets 40mg, 80mg, 120mg
                                        tablets m/r 120mg, 240mg
                   RED          Verapamil injection 5mg/2mL
                   Nicardipine IV for use on Critical Care Unit ELHT only, where beta-blockers not tolerated
                   RED           Nicardipine IV
                   Nifedipine MR - Hypertension during pregnancy and post-natal only
                   AMBER    Nifedipine MR tablets 10mg, 20mg
        2.6.3 Other antianginal drugs
                   Nicorandil, a potassium channel activator with a nitrate component, has both arterial and venous dilating properties
                   and is licensed for the prevention and  long-term treatment of chronic stable angina pectoris. It is usually prescribed in
                   addition to isosorbide mononitrate if symptoms remain uncontrolled.  Patients already receiving MAXIMAL therapy
                  with two antianginal medications (e.g. calcium channel blocker and nitrates) should be referred to a specialist for
                   further assessment.
                   GREEN      Nicorandil tablets 10mg, 20mg
                   Ivabradine [See Prescribing Guidance for GP's]
                   Chronic Stable Angina
                     °   Ivabradine should only be initiated by specialists in the treatment of chronic stable angina.
                     °   Ivabradine has not demonstrated any increased benefits in terms of efficacy and safety over other available 
                          treatments for angina, and is considerably more expensive.
                     °   It is recommended for symptomatic treatment of chronic stable angina pectoris in patients with normal sinus
                          rhythm for whom heart rate control is desirable and for whom beta-blockers and calcium-channel blockers are
                          inappropriate or not tolerated. Long-term protection against cardiovascular events, however, has not been 
                     °   Therefore patients already receiving MAXIMAL therapy with two antianginal medications (e.g. calcium channel  
                          blocker and nitrates) should be referred to a specialist for further assessment.
                     °   There is no evidence that addition of a third drug improves symptom control.  If a third drug (e.g. nicorandil) is 
                         introduced while awaiting an outpatient appointment, its effects should be monitored and if it has no effect it should 
                         be stopped.
                  AMBER    Ivabradine tablets 5mg, 7.5mg  [See Prescribing Guidance for GP's]
                   Chronic Heart Failure
                   Ivabradine should only be initiated by specialists in the treatment of chronic heart failure
                   AMBER    Ivabradine tablets 5mg, 7.5mg see prescribing information sheet
                  Ivabradine prior to Cardiac CT if required to lower the heart rate
                  RED         Ivabradine for use prior to cardiac CT when the heart rate is raised
                  Ranolazine is recommended as add on therapy for symptomatic treatment of patients with stable angina 
                  whose symptoms are inadequately controlled or intolerant  of first-line anti-anginal therapies, nitrates and/or , 
                  nicorandil and third line  ivabradine.
                     >    Ranolazine is recommended as add on therapy for symptomatic treatment of patients with stable angina whose
                           symptoms are inadequately controlled or intolerant of first-line antianginal therapies, nitrates and/orNicorandil, 
                           and third line
                     >    Ivabradine and when there are no re-vascularisation options available to the patient
                     >    Patients who experience a satisfactory response (reviewed by cardiologist after 3 months) may have their care
                           transferred to primary care
                 See Guidance for Prescribers/ quick reference guide for ranolazine
                 AMBER     Ranolazine m/r tablets 375mg, 500mg, 750mg
        2.6.4 Peripheral vasodilators and related drugs
                  Nifedipine may be useful for reducing the frequency and severity of vasospastic attacks in Raynaud’s syndrome.
                  [Nifedipine immediate release capsules have been discontinued and the use of MR 10mg, 20mg  BD has been approved for use]
                  Nifedipine is no longer recommended for the treatment of hypertension and angina.
                  GREEN      Nifedipine MR 10mg, 20mg
                  Post-natal hypertenion only
                  AMBER      Nifedipine MR 10mg, 20mg
                  Sildenafil, as an option in severe primary or secondary Raynaud’s resistant to initial therapies (calcium channel blockers).
                  Unlicensed Use
                  RED           Sildenafil tablets 25mg
                  NICE guidance for peripheral arterial disease (TAG 223)
                  Naftidrofuryl oxalate is recommended as an option for the treatment of intermittent claudication in people with
                  peripheral arterial disease for whom vasodilator therapy is considered appropriate after taking into account 
                  other treatment. Treatment with naftidrofuryl oxalate should be started with the least costly licensed preparation i.e.  
                  generic prescribing only.
                  GREEN      Naftidrofuryl oxalate capsules 100mg
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