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BNSSG Adult Joint Formulary

2.3 Blood clots

Last edited: 13-05-2024

2.3.1 Blocked catheters and lines

First line drugs Second line drugs Specialist drugs Secondary care drugs

 

Prostaglandins (Cardiovascular)

Epoprostenol (TLS Red)

 

2.3.2 Thromboembolism

 

Recommended: (TLS Green)

Aspirin

Clopidogrel

  • TIA - not recommended by NICE as they cannot recommend treatment outside licence. However clopidogrel post TIA is endorsed by AGWS Cardiac and Stroke Network
  • Peripheral Arterial Disease (PAD)
  • Multivascular disease
  • See 'BNSSG antiplatelet guidelines' for durations of treatment information, available on the Cardiovascular System Guidelines page

Specific indications: (TLS Blue)

Dipyridamole modified-release in combination with aspirin

Dipyridamole

  • NBT only as adjunct to oral anticoagulation in patients with prosthetic heart valves and to prevent access clotting in haemodialysis patients

 

Novel Oral Anticoagulants

Indication

Apixaban

Dabigatran

Edoxaban

Rivaroxaban

Prevention of VTE : elective hip or knee replacement surgery

TLS Red

within NBT and Weston only

NICE TA245

TLS Red

within NBT and Weston only

NICE TA157

 

TLS Red

NICE TA170

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)

TLS Green

NICE TA275

TLS Green

NICE TA249

TLS Green

NICE TA355

TLS Green

NICE TA256

Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt)

TLS Green

NICE TA341

 

TLS Green

NICE TA327

 

TLS Green

NICE TA354

 

TLS Green

NICE TA287

NICE TA261

 

 

 

 

Link to MHRA Prescribing medicines in renal impairment: using the appropriate estimate of renal function to avoid the risk of adverse drug reactions - applicable to DOACs

 

Factor Xa Inhibitors

Please see 'Anticoagulant Guidance' section of cardiovascular guidelines page for guidance such as  'Summary of Decisions when prescribing a DOAC' and 'DOAC decision aid tool' 

Note: there are different TLS colours for apixaban, rivaroxaban, edoxaban, dabigatran depending on the indication

Apixaban

  • TLS Green for the prevention of stroke and systemic embolism in patients with Atrial Fibrillation as per NICE TA275

Apixaban

  • TLS Green for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism as per NICE TA341

Apixaban (TLS Red)

  • For primary prevention of venous thromboembolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery as per NICE TA245

Rivaroxaban

  • TLS Green for the prevention of stroke and systemic embolism in patients with Atrial Fibrillation as per NICE TA256

Rivaroxaban

  • TLS Green, As an option for the treatment of DVT and secondary prevention of recurrent deep vein thrombosis and pulmonary embolism as per NICE TA261
  • TLS Green, As an option for the treatment of pulmonary embolism and prevention of recurrent venous thromboembolism as per NICE TA287 

Rivaroxaban (TLS Red)

  • For primary prevention of venous thromboembolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery as per NICE TA170
  • TLS Red for prophylaxis of DVT in patients placed in lower limb immobilisation.

Rivaroxaban

  • TLS Amber 1 month for preventing adverse outcomes after acute management of acute coronary syndrome as per NICE TA335 (SCP click here)
  • TLS Amber 3 months for preventing atherothrombotic events in people with coronary or peripheral artery disease as per NICE TA607. Click here for Shared Decision Making Tool and click here for Shared Care Protocol

Edoxaban

  • TLS Green for the treatment and secondary prevention of DVT or PE as per NICE TA354
  • TLS Green for preventing stroke and systemic embolism in patients with Atrial Fibrillation as per NICE TA355

Fondaparinux

  • Unstable angina and non ST- segment elevation acute MI undergoing early invasive <72 hours management or conservative but not including urgent invasive management <120 minutes
  • Also ST - segment elevation acute MI managed with thrombolytics, or initially no other form of reperfusion therapy.
  • Patients refusing animal products
  • Heparin induced thrombocytopenia
  • For systemic anticoagulation to prevent clotting in the extracorporeal circuit for patients with confirmed Type II Heparin Induced Thyrombocytopenia (HIT) who cannot achieve a satisfactory haemodialysis with anticoagulation free haemodialysis or with Citrasate® dialysate

 

Specific Reversal of Apixaban or Rivaroxaban Anticoagulation

Andexanet Alfa (TLS Red)

  • NICE TA697 Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban

 

Heparinoids

Danaparoid (TLS Red)

  • Restricted to heparin induced thrombocytopenia (HITS) and extra-corporeal circuit anticoagulation (dialysis) in patients who have had HITS

 

Heparins

For prophylaxis (TLS Amber)

Dalteparin

  • Restricted to Obstetrics.  For use where enoxaparin not appropriate for obstetric patients due to allergy/reaction.

Enoxaparin

  • Inhixa® is the preferred brand for new patients.
  • Specify brand when prescribing Inhixa®, Clexane®, Arovi®
  • Brands are not interchangeable. Patients should remain on the same brand post discharge

Tinzaparin

  • NBT only (renal use only)

For Treatment (TLS Green)

Dalteparin

  • Restricted to Obstetrics.  For use where enoxaparin not appropriate for obstetric patients due to allergy/reaction

Enoxaparin

  • Inhixa® is the preferred brand for new patients.
  • Specify brand when prescribing Inhixa®, Clexane®, Arovi®
  • Brands are not interchangeable. Patients should remain on the same brand post discharge

Tinzaparin

  • NBT only (renal use only)

Specific indication: (TLS Red)

Heparin Sodium

Heparin Calcium

  • Gastroenterology at UHB only

 

Protamine Sulphate

Recommended: (TLS Red)

Protamine

 

Fibrinolytics

Alteplase (TLS Red)

  • For treatment of adult patients with iliofemoral (proximal) deep vein thrombosis (DVT) with catheter-directed thrombolysis (CDT) at NBT

 Tenecteplase (TLS Red)

  • For thrombolysis of acute ischaemic stroke prior to thrombectomy on advice of stroke specialist. For patients who are eligible for thrombolysis and thrombectomy treatment only. For use at NBT only.

 

Thrombin Inhibitors

Argatroban

  • Restricted to heparin induced thrombocytopenia (HITS) and extracorporeal circuit anticoagulation (dialysis) in patients who have had HITS - TLS Red

Bivalirudin

  • For peri-procedure use in patients undergoing PCI for the treatment of an acute coronary syndrome, in place of Abciximab except in those very high risk patients (eg giant thrombus) after PCI.
  • See NICE NG185 ACS guideline

Note: there are different TLS colours for dabigatran depending on the indication

Dabigatran

  • TLS Green for the prevention of stroke and systemic embolism in patients with Atrial Fibrillation as per NICE TA249
  • TLS Green for the treatment and secondary prevention of DVT and PE as per NICE TA327 (SCP Click here)

Dabigatran

  • TLS Red within NBT and Weston only for primary prevention of venous thromboembolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery as per NICE TA157

Idarucizumab (TLS Red)

  • Specific reversal agent for dabigatran

Defibrotide (TLS Red)

 

Tissue Plasminogen Activators

Urokinase (TLS Red)

  • To restore patency of intravenous catheters and cannula blocked by fibrin clots.
  • For intrapleural instillation for relief of distressing dyspnoea due to malignant effusion resistant to simple drainage (on advice of respiratory consultant) NBT only
  • Management of blocked tunnelled intrapleural catheters which would otherwise need to be removed or replaced (on advice of respiratory consultant) NBT only

 

Vitamin K Antagonists

Recommended: (TLS Green)

Warfarin

  • If any new medication is initiated in a patient already taking warfarin please consider any potential drug interactions, and inform relevant warfarin clinic if appropriate as closer monitoring of INR may be required.

See BNSSG Guidance on the management of High INR in the community

Specific indications:

Phenindione

  • Where warfarin is inappropriate

 

IIa/IIIb Inhibitors

Eptifibatide (Integrellin®) (TLS Red)

  • For used in interventional radiology to treat thromboembolic events complicating interventional procedures and to prevent intracranial stent thrombosis

Others

Emicizumab (TLS Red)

  • As per NHS England Clinical Commissioning Policy: Emicizumab as prophylaxis in people with severe congenital haemophilia A without factor VIII inhibitors (all ages) Ref: 170134P

 

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