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2.6 Nitrates and calcium-channel blockers

2.6.1 Nitrates

Glyceryl Trinitrate S/L tablets, spray, transdermal patches, ointment
Isosorbide mononitrate tablets, MR tablets (preferred brand: Monomil XL)
Isosorbide dinitrate tablets (see note)

Notes:

1. When instituting ORAL nitrates, it is recommend starting with a low dose and gradually increasing upwards. E.g. Isosorbide mononitrate 10mg bd. Asymmetrical dosing is recommended to provide a nitrate free interval, in order to reduce the risk of the development of nitrate tolerance.

2. Glyceryl trinitrate sublingual tablets will be supplied with an expiry date of eight weeks from the day of opening. Sublingual tablets are usually quite adequate for those patients experiencing frequent attacks. Sprays are more appropriate where their use is very occasional, or in patients who suffer from dry mouth.

3. Isosorbide dinitrate is for use with hydralazine for patients in chronic heart failure who are intolerant of Ace iInhibitors or angiotensin receptor antagonist. Cardiology Use Only.

 

2.6.2 Calcium-channel blockers

Amlodipine tablets
Nifedipine MR Capsules
Nifedipine IR capsules (for Raynaud's syndrome)
Diltiazem MR tablets/capsules
Felodipine tablets
Nimodipine tablets, intravenous infusion
Verapamil tablets, MR tablets
Nicardipine solution for injection – see note

Notes:

1. Coracten is the preferred form of nifedipine to be used in the Trust, patients coming in to the hospital on Adalat Retard may be switched to an equivalent dose of this preparation.

2. The administration of nifedipine by the sublingual route or by chewing in the management of severe hypertension is actively discouraged, as the reflex tachycardia produced is potentially fatal.

3. The Medicines Control Agency recommends prescribing diltiazem and verapamil  slow release preparations by brand name. This is to avoid patient confusion and because of potentially different side effect profiles.

4. Verapamil should not normally be prescribed to patients taking beta-blockers by any route. When used together they may precipitate profound bradycardia or hypotension.

5. There has been evidence of sudden cardiac death reported when erythromycin is co-administered with certain cytochrome P-450 3A enzyme inhibitors. Therefore if erythromycin is to be prescribed to a patient already recieving diltiazem or verapamil, then the calcium antagonist will be omitted for the duration of the erthromycin prescription.

6. IV nicardipine is available for acute life threatening hypertension / post-operative hypertension on ITU

 

2.6.3 Other Anti-anginal drugs

Ivabradine tablets
Nicorandil tablets – see note
Ranolazine tablets

Note:

1. Ivabradine is for treatment of angina patients with normal sinus rhythm where beta blockers or rate limiting calcium channel blockers (e.g. verapamil, diltiazem) are contraindicated or not tolerated. It is also a treatment option for chronic heart failure in patients who are in sinus rhythm and with a heart rate of 75bpm or more - see NICE TA 267.

Monitor the patient for bradycardia or its symptoms (dizziness, fatigue, hypotension). Dosage and monitoring advice is given in MHRA Drug Safety Update June 2014 and also MHRA Drug Safety Update December 2014

2. Nicorandil is a third line treatment of stable angina which is not adequately controlled despite combination therapy with beta-blockers and calcium antagonists. It is associated with a risk of serious skin, mucosal, and eye ulceration, including gastrointestinal ulceration, including perianal ulceration. Ulcers that result from nicorandil are refractory to treatment; they respond only to withdrawal of nicorandil. – see link to DSU

3. Ranolazine is available for 2nd line add-on therapy of stable angina when other agents are not tolerated or are contraindicated. There is no evidence for efficacy as part of a 3 or 4 day combination (NICE guidance).

 

2.6.4 Peripheral and cerebral vasodilators

Naftidrofuryl oxalate capsules 

Notes:

1. Naftidrofuryl is an option for the treatment of intermittant claudication in patients with peripheral arterial disease - see NICE TA 223.

2. Most serious peripheral disorders, such as intermittent claudication are now known to be due to occlusion of vessels, either by spasm or sclerotic plaques; use of vasodilators may increase blood flow at rest, but the few controlled studies carried out have shown little improvement in walking distance. Rest pain is rarely affected.

3. Iloprost (unlicensed/named-patient use) is available for specialist treatment of Raynaud's phenomenon where there is pre-gangrenous ischaemia of the digits.

 

For the link to the BNF section: 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs