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 Formulary Chapter 2: Cardiovascular system - Full Chapter
02.05  Expand sub section  Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
02.05.01  Expand sub section  Vasodilator antihypertensive drugs
Hydralazine
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Formulary Tablets
Injection

Oral hydralazine may be used in combination with long-acting nitrates in patients with heart failure who are still symptomatic despite optimal therapy with ACE inhibitor and beta blocker or when ACE inhibitors and ARBs are contra-indicated or not tolerated.

Not to be used as monotherapy (causes tachycardia and fluid retention). (BNF)

 
Link  Adult Loading Doses Policy
   
Iloprost
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Formulary
Red
Injection

unlicensedunlicensed

For use in rheumatology patients, see attached guidelines. 
Link  Guideline for the use of intravenous iloprost in rheumatology patients
   
Sildenafil
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Formulary
Red
Tablets (Revatio®)
Suspension (paediatric use) unlicensedunlicensed

Formulary for treatment of pulmonary arterial hypertension.

For erectile dysfunction, see chapter 7.4.5.
 
   
Sodium Nitroprusside
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Formulary Intravenous infusion

unlicensedunlicensed 
   
02.05.02  Expand sub section  Centrally acting antihypertensive drugs
Methyldopa
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Formulary Tablets

Used in the management of hypertension in pregnancy 
Link  NICE CG107: Hypertension in Pregnancy
   
Clonidine Hydrochloride
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Formulary Tablets 
   
Moxonidine
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Formulary Tablets

Restricted Item Specialist initiation only

Moxonidine is considered a last-line management option for resistant hypertension.

 
   
02.05.03  Expand sub section  Adrenergic neurone blocking drugs
Guanethidine Monosulphate (Ismelin®)
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Formulary Intramuscular injection

Restricted Item Licensed for rapid control of blood pressure, however alternative agents are preferred (BNF).

 
   
02.05.04  Expand sub section  Alpha-adrenoceptor blocking drugs to top
Doxazosin
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Formulary Tablets

Doxazosin is a fourth-line hypertension management option.

note Modified release preparations of doxazosin are not approved by GMMMG. Consider converting any existing patients to standard release doxazosin, using the UKMi Medicines Q&A for guidance.  
Link  UKMI Q&A: How should conversion between doxazosin formulations be carried out?
   
02.05.04  Expand sub section  Phaeochromocytoma
Phenoxybenzamine Hydrochloride
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Formulary Capsules
(Injection is non-formulary) 
   
Phentolamine (Rogitine®)
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Formulary Injection

For hypertensive episodes due to phaeochromocytoma, e.g. during surgery (BNF).
 
   
02.05.05  Expand sub section  Drugs affecting the renin-angiotensin system
 note 

MHRA Safety Alert: Risk of potentially fatal hyperkalaemia

02.05.05.01  Expand sub section  Angiotensin-converting enzyme inhibitors (ACE inhibitors)
 note  In heart failure and post-MI, it is important that ACE inhibitors are titrated up to their target dose (or maximum tolerated) as advised by NICE.
Lisinopril
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First Choice Tablets 
Perindopril erbumine
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First Choice Tablets

Prescribers are reminded that perindopril should be prescribed generically. Perindopril arginine (Coversyl Arginate®) is not dose equivalent and is not included in the formulary.

 
Ramipril
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First Choice Capsules 
Enalapril
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Second Choice Tablets

 
   
Captopril
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Formulary Tablets
Oral solution unlicensedunlicensed. Restricted Item For paediatric use only

Not as per GMMMG for adults 
   
02.05.05.02  Expand sub section  Angiotensin-II receptor antagonists
 note  Angiotensin-II receptor antagonists (ARBs) are more expensive that ACE inhibitors. Their use should be reserved only for patients who suffer from unacceptable side effects using ACE inhibitors. However, if patients have suffered angioedema with an ACE inhibitor then an ARB is NOT recommended.

In heart failure, it is important that ARBs are titrated up to their target dose (or maximum tolerated) as advised by NICE.
Losartan
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First Choice Tablets


 
Candesartan
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First Choice Tablets 
Irbesartan
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Formulary Tablets

GMMMG endorse use for renal patients. 
   
Valsartan
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Formulary Tablets

GMMMG endorse use in post-myocardial infarction. 
   
Valsartan / Sacubitril (Entresto® )
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Formulary
Green 3
Tablets

Restricted ItemTo be initiated by Heart Failure team 
Link  PAT Guideline: Treatment of symptomatic chronic heart failure with reduced ejection fraction
   
02.05.05.03  Expand sub section  Renin inhibitors to top
 ....
 Non Formulary Items
Aliskiren

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Non Formulary
Green 3
Restricted Item Tablets

Restricted Item Specialist initiation only - requires approval on urgent clinical need basis from Medical D&T chair

Fourth-line agent after considering alpha-blockers, potassium sparing diuretics or aldosterone antagonists.

Link  GMMMG New Therapies Recommendation: Aliskiren
Link  MHRA: Aliskiren (Rasilez▼): risk of cardiovascular and renal adverse reactions—new contraindications and warnings
 
Ambrisentan

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Non Formulary
Red
 
Azilsartan

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Non Formulary
 
Bosentan  (Tracleer®)

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Non Formulary
Red
 
Captopril and Hydrochlorothiazide  (Capozide®)

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Non Formulary
 
Captopril and Hydrochlorothiazide  (Co-zidocapt®)

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Non Formulary
 
Cilazapril  (Vascace®)

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Non Formulary
 
Cozaar- Comp®

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Non Formulary
 
Diazoxide  (Eudemine®)

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Non Formulary Injection (discontinued)
Tablets - see section 6.1.4



 
Doxazosin M/R

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Non Formulary
Black
Modified release preparations of doxazosin are not approved by GMMMG. Consider converting any existing patients to standard release doxazosin, using the UKMi Medicines Q&A for guidance.
Link  UKMi Q&A: How should conversion between doxazosin formulations be carried out?
 
Enalapril Meleate and Hydrochlorothiazide  (Innozide®)

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Non Formulary
 
Eprosartan  (Teveten®)

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Non Formulary
 
Fosinopril Sodium

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Non Formulary Tablets

Not GMMMG
 
Iloprost nebules  (Vantavis®)

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Non Formulary
 
Indoramin  (Baratol®)

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Non Formulary
 
Indoramin  (Doralese®)

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Non Formulary
 
Lisinopril and Hydrochlorothiazide  (Carace® Plus)

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Non Formulary
 
Lisinopril and Hydrochlorothiazide  (Lisicostad®)

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Non Formulary
 
Lisinopril and Hydrochlorothiazide  (Zestoretic®)

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Non Formulary
 
Minioxidil  (Loniten®)

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Non Formulary
 
Minoxidil

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Non Formulary
 
Moexipril Hydrochloride  (Perdix®)

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Non Formulary
 
Olmesartan  (Sevikar®)

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Non Formulary
 
Perindopril Arginine  (Coversyl® Arginine)

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Non Formulary
 
Prazosin

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Non Formulary Not GMMMG
 
Quinapril

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Non Formulary Tablets

Not GMMMG
 
Quinapril and Hydrochlorothiazide  (Accuretic®)

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Non Formulary
 
Ramipril and Felodipine  (Triapin®)

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Non Formulary
 
Rasitro®

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Non Formulary
 
Sevikar HCT®

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Non Formulary
 
Sitaxentan Sodium  (Thelin®)

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Non Formulary
 
Tadalafil  (Adcirca®)

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Non Formulary
 
Telmisartan

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Non Formulary
 
Terazosin

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Non Formulary Not GMMMG
 
Tolazoline

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Non Formulary
 
Trandolapril  (Gopten®)

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Non Formulary Tablets

Not GMMMG
 
Trandolapril and Verapamil  (Tarka®)

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Non Formulary
 
  
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
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
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

Amber

Drugs designated amber are suitable for shared care arrangements under a shared care protocol. Prescribing may be transferred from secondary to primary care once the patient is stabilised and agreed shared care arrangements have been established. Alternatively primary care may initiate under the supervision of secondary care if this option is given in the shared care document. It is recommended that shared care arrangements should be drawn up following local discussion and agreement by prescribing parties.   

Black

These products have been reviewed by the GM Joint Formulary Group and have been deemed not suitable for prescribing for adults in primary or secondary care within Greater Manchester. These decisions have been made on the basis of safety, efficacy and cost-effectiveness of the products.  

Green

Not used   

Green 1

Drugs designated green1 are suitable for initiation and ongoing prescribing within primary care.   

Green 2

Drugs designated green2 can be initiated by primary care following written or verbal advice from a specialist and then be subsequently safely prescribed in primary care with little or no monitoring required.  

Green 3

Drugs designated green3 are suitable for on-going prescribing within primary care after specialist initiation and an initial review (unless specified) in secondary care. Little or no monitoring is required.  

Grey

Not suitable for routine prescribing but may be suitable for a defined patient population. Whilst prescribers should think very carefully before prescribing or recommending any of the products on the grey list, there may be exceptional instances when the use of one of these products is necessary for a particular patient.   

Red

Drugs designated red are considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in primary care. It is recommended that the supply of these specialist medicines should be organised via the hospital pharmacy, this may include arranging for supply via a home care company.   

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