Acute coronary syndrome
SIGN 148: Acute coronary syndrome NICE NG185: Acute coronary syndromes
For 6 months (in most patients) then change to single drug, see prescribing notes on duration of anti-platelet therapy.
Initially loading dose of 300mg, then 75mg daily.
Initial loading dose of 300mg ,then 75mg once daily.
In acute coronary syndrome, prasugrel may be considered in high risk patients with consideration given to the balance of benefit (prevention of recurrent MI) and harm (major bleeding).
Initially loading dose of 300mg, then 75mg daily.
Loading dose 60mg for 1 dose then 10mg once daily, see prescribing notes.
Ticagrelor is considered to be an alternative to prasugrel in patients with a past medical history of stroke or TIA or >75years.
Initially loading dose of 300mg, then 75mg daily.
Initially 180mg for one dose, then 90mg twice daily.
Initially 180mg for one dose, then 90mg twice daily.
Prescribing Notes:
- Patients with acute coronary syndrome should receive dual antiplatelet therapy for six months. Longer durations may be used where the risks of atherothrombotic events outweigh the risk of bleeding. Shorter durations may be used where the risks of bleeding outweigh the risk of artherothrombotic events. SIGN 148.
- The co-prescribing of clopidogrel with omeprazole or esomeprazole should be avoided due to the potential antagonism of the anti-platelet effect. If concomitant use of clopidogrel and a PPI is necessary, then lansoprazole would be an appropriate choice.
- Prasugel may be used in patients less than 75 years old, weight greater than 60kg who have a proven intolerance to clopidogrel or who present with stent thrombosis whilst taking clopidogrel. The 5mg dose is not recommended in NHS Scotland.
History Notes
16/02/2022
East Region Formulary content agreed.
40-80mg to be taken in the morning.
40-80mg to be taken in the morning.
40-80mg to be taken in the morning.
40-80mg to be taken in the morning.
Initially 5-10mg once daily, then increased up to 20mg once daily at intervals of at least four weeks. See BNF for further details.
Initially 5-10mg once daily, then increased up to 20mg once daily at intervals of at least four weeks. See BNF for further details.
Initially 5-10mg once daily, then increased up to 20mg once daily at intervals of at least four weeks. See BNF for further details.
Prescribing Notes:
- See SIGN guideline 149 and NICE Clinical Guideline 181.
- Lowering cholesterol is associated with reduced mortality and morbidity in patients at high and moderate risk of, or with established, cardiovascular and cerebrovascular disease.
- Chewable atorvastatin tablets can be prescribed for those patients with swallowing difficulties.
- Fibrates have been less well tested in clinical trials. They are mainly of benefit in those with mixed hyperlipidaemia and low HDL cholesterol.
- Caution should be exercised when prescribing other drugs with statins. Statins interact with many drugs. See BNF for full details of drug interactions.
- The MHRA has produced recommendations for dose restrictions when used with some other drugs as interactions may increase the risk of adverse effects, or reduce the effectiveness of statin treatment.
- Ezetimibe may be considered in combination with a statin for patients who have failed to reach target cholesterol levels despite treatment with titrated/optimised statins alone.
History Notes
07/03/2024
Prescribing information updated, ERFC Feb 2024
16/02/2022
East Region Formulary content agreed.
Statins are more effective than any other lipid lowering option. See prescribing notes.
Ezetimibe may be considered as monotherapy where statins are inappropriate or poorly tolerated
10mg daily.
Prescribing Notes:
- If someone reports adverse effects when taking statins discuss:
- stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin;
- reducing the dose within the same intensity group; or
- changing the statin to a lower intensity group.
- There may be a role for ezetimibe in secondary prevention in patients who are statin intolerant (intolerance to ≥3 agents) or those who fail to achieve target LDL on maximum tolerated dose of statin. Consider referral for specialist advice.
History Notes
07/03/2024
Specialist initiation flag removed for ezetimibe, ERFC Feb 2024
16/02/2022
East Region Formulary content agreed.
As per specialist. Maximum 8 days.
Prescribing Notes:
- In STEMI first dose is given intravenously, and subsequent doses are given subcutaneously. Treatment is for a minimum of 2 days, up to a maximum of 8 days; In NSTEMI/Unstable angina, doses are given subcutaneously. Treatment is for a minimum of 2 days and a maximum of 8 days.
- Benefits and risks of treatment with fondaparinux should be assessed for patients with eGFR between 20 and 30ml/min: Avoid if eGFR less than 20ml/min.
- For NHS Lothian patients, the Edinburgh renal unit (Edren) website may contain helpful information.
History Notes
16/02/2022
East Region Formulary content agreed.
For 6 months (in most patients) then change to single drug, see prescribing notes on duration of anti-platelet therapy.
Initially loading dose of 150mg-300mg, then 75mg daily.
Initial loading dose of 300mg ,then 75mg once daily.
In acute coronary syndrome, ticagrelor or prasugrel may be considered in high risk patients with consideration given to the balance of benefit (prevention of recurrent MI) and harm (major bleeding).
Initially loading dose of 150mg-300mg, then 75mg daily.
Loading dose 60mg for 1 dose then 10mg once daily, see prescribing notes.
Ticagrelor is considered to be an alternative to prasugrel in patients with a past medical history of stroke or TIA or >75years.
Initially loading dose of 300mg, then 75mg daily.
Initially 180mg for one dose, then 90mg twice daily.
Initially 180mg for one dose, then 90mg twice daily.
Prescribing Notes:
- Patients with acute coronary syndrome should receive dual antiplatelet therapy for six months. Longer durations may be used where the risks of atherothrombotic events outweigh the risk of bleeding. Shorter durations may be used where the risks of bleeding outweigh the risk of artherothrombotic events. SIGN 148.
- The co-prescribing of clopidogrel with omeprazole or esomeprazole should be avoided due to the potential antagonism of the anti-platelet effect. If concomitant use of clopidogrel and a PPI is necessary, then lansoprazole would be an appropriate choice.
- Ticagrelor (or prasugrel) are recommended in SIGN 148.
- Prasugel may be used in patients less than 75 years old, weight greater than 60kg who have a proven intolerance to clopidogrel or who present with stent thrombosis whilst taking clopidogrel. The 5mg dose is not recommended in NHS Scotland.
History Notes
16/02/2022
East Region Formulary content agreed.