Greater Glasgow and Clyde Medicines
Key to symbols The medicine should be initiated by, or on the advice of a specialist, but is suitable for continuation by a GP The medicine should only be used and prescribed by a specialist Indicates the preferred choice within a class or group of medicines
The medicine should be initiated by, or on the advice of a specialist, but is suitable for continuation by a GP
The medicine should only be used and prescribed by a specialist
Indicates the preferred choice within a class or group of medicines
2. Cardiovascular system

2.8. Anticoagulants and protamine

2.8.1. Parenteral anticoagulants

Total Formulary
Specialist Only
ARGATROBAN

Restrictions:

Restricted to specialist use where other options are not suitable or available in accordance with local protocol (to be updated).

BNF Link

Specialist and GP
DALTEPARIN (FRAGMIN)

Restrictions:

Restricted to specialist initiation only. For The treatment and prevention of VTE in patients with solid tumours use is restricted to initiation by healthcare professionals experienced in the treatment of VTE and use according to local protocol.

Prescribing Notes:

When dalteparin is used in the extended treatment of VTE and prevention of recurrence in patients with solid tumours, prescribers are reminded that a dose reduction is required following the first month of treatment, and where there is a transfer of care, the need for this dose reduction should be communicated clearly.  For further dosing information, see the product literature or BNF.

BNF Link

DANAPAROID SODIUM

Restrictions:

Restricted to use in accordance with local protocols.

BNF Link

Specialist and GP
ENOXAPARIN

Restrictions:

Restricted to specialist initiation only.

Prescribing Notes:

  • Enoxaparin is a biological medicine and should be prescribed by brand name
  • Inhixa® is the preparation of choice for pre-filled syringes 

BNF Link

Specialist Only
EPOPROSTENOL

Restrictions:

Restricted to specialist use only.

BNF Link

Specialist and GP
FONDAPARINUX

Restrictions:

Restricted to specialist initiation only. Restricted to use for the treatment of unstable angina or non-ST segment elevation myocardial infarction (NSTEMI) or ST segment elevation myocardial infarction (STEMI) in accordance with agreed local protocols.

BNF Link

HEPARIN
Specialist and GP
TINZAPARIN

Restrictions:

Restricted to specialist initiation only.

BNF Link

Specialist Only
TREPROSTINIL (subcutaneous infusion)

Restrictions:

Restricted to initiation and prescribing by specialists in the Scottish Pulmonary Vascular Unit or similar specialists for use in chronic thromboembolic pulmonary hypertension.

BNF Link

2.8.2. Oral anticoagulants

Preferred List
APIXABAN

Prescribing Notes:

Apixaban is the preferred DOAC

  • for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurring DVT and PE in adults.
  • for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).

Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website

VTE prophylaxis in orthopaedic surgery
The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.

BNF Link

WARFARIN
Total Formulary
DABIGATRAN ETEXILATE (tablets)

Restrictions:

Restricted to use in accordance with the prescribing notes below

Prescribing Notes:

Prevention of stroke in atrial fibrillation

Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:

  • newly diagnosed patients
  • those currently receiving warfarin who have poor INR control despite evidence that they are complying
  • patients with allergy or intolerable side effects from coumarin anticoagulants
  • patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate

Risk factors include: 

  • previous stroke, transient ischaemic attack, or systemic embolism
  • left ventricular ejection fraction <40%
  • symptomatic heart failure, ≥ New York Heart Association (NYHA) Class 2
  • age ≥75 years
  • age ≥65 years associated with one of the following: diabetes mellitus, coronary artery disease or hypertension

Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website

Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE

Use is restricted to patients who fail to tolerate other therapeutic options or where other agents are not appropriate, where the intended duration of treatment is 3-6 months. Where indefinite duration is indicated, the treatment of choice should be or apixaban or low molecular weight heparin followed by warfarin.

VTE prophylaxis in orthopaedic surgery

  • The use for the primary prevention of venous thromboembolic events (VTE) in adults undergoing elective hip or knee replacement surgery is non-formulary.

BNF Link

EDOXABAN

Prescribing Notes:

Second line DOAC for

  • the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).
  • the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE.

Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website

BNF Link

RIVAROXABAN

Restrictions:

Prevention of stroke in atrial fibrillation

Use for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation and with one or more risk factors is restricted to:

  • those currently receiving warfarin who have poor INR control despite evidence that they are complying
  • patients with allergy or intolerable side effects from coumarin anticoagulants
  • patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate

Risk factors may include: congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack. 

Further advice can be accessed via the NHSGGC Atrial Fibrillation guideline and the Prescribing Resources section of this website

Treatment of VTE

  • Rivaroxaban for the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) and prevention of further DVT and PE is restricted to use in patients requiring anticoagulation where the intended duration of treatment is 3 to 6 months and in whom apixaban is deemed unsuitable.

VTE prophylaxis in orthopaedic surgery

  • The use in VTE prophylaxis in orthopaedic surgery is restricted to specialist use only in accordance with local protocol.

Use in combination with aspirin in Coronary Artery Disease

  • Rivaroxaban co-administered with aspirin for the prevention of artherothrombotic events in adults is restricted to initiation by, or on the advice of a consultant only in patients with stable coronary artery disease that do not require dual antiplatelet therapy.

It should be noted that use of rivaroxaban in combination with aspirin for the prevention of atherothrombotic events in patients with peripheral artery disease (PAD) alone was not considered by SMC and the use in this setting is non-Formulary.

Prescribing Notes:

The following indications are not recommended for use by the SMC and are non-Formulary:

  • Acute Coronary Syndrome: The use of rivaroxaban for the prevention of atherothrombotic events in adult patients after an acute coronary syndrome (ACS) with elevated cardiac biomarkers is not recommended for use within NHS Scotland and is therefore non-Formulary.
  • Prevention of atherothrombotic events: use of rivaroxaban in combination with aspirin for the in patients with peripheral artery disease (PAD) alone was not considered by SMC and the use in this setting is non-Formulary.
  • Atrial fibrillation: rivaroxaban is not included in the Formulary for use in newly diagnosed patients.

BNF Link

2.8.3. Protamine sulphate

Total Formulary
Specialist Only
PROTAMINE

Restrictions:

Restricted to specialist use only.

BNF Link

2.8.4. Reversal of anticoagulation

Total Formulary
Specialist Only
ANDEXANET ALFA (ONDEXXYA) (infusion)

Restrictions:

Restricted to use only on the advice of a Consultant Haematologist for the reversal of anticoagulation in adults treated with a direct factor Xa inhibitor where there is life-threatening or uncontrolled bleeding.  In addition, use should be in accordance with the local protocol (in development).

BNF Link

Specialist Only
IDARUCIZUMAB

Restrictions:

See Prescribing Notes below.

Prescribing Notes:

Restricted to specialist use only when rapid reversal of anticoagulation effect of dabigatran is required for emergency surgery/ urgent procedures or in life-threatening or uncontrolled bleeding in line with national guidance.

BNF Link