Nicorandil, and ranolazine should only be used in accordance with the treatment of angina pathway

Nicorandil

• Tablets 10mg, 20mg (£2.22 = 20mg twice daily)

Indications

• Angina

Dose

• Initially 10mg twice daily (if susceptible to headache 5mg twice daily); usual dose 10–20mg twice daily; up to 30mg twice daily may be used

Notes

1. Nicorandil has similar efficacy to other anti-anginal drugs in controlling symptoms; it may produce additional symptomatic benefit in combination with other anti-anginal drugs.
2. MHRA Drug Safety Alert (January 2016)
   1. Use nicorandil for treatment of stable angina only in patients whose angina is inadequately controlled by first line anti-anginal therapies, or who have a contraindication or intolerance to first line anti-anginal therapies such as beta-blockers or calcium antagonists
   2. Nicorandil can cause serious skin, mucosal, and eye ulceration, including gastrointestinal ulcers which may progress to perforation, haemorrhage, fistula, or abscess
   3. Stop nicorandil treatment if ulceration occurs—consider the need for alternative treatment or specialist advice if angina symptoms worsen

Ivabradine

• Tablets 5mg, 7.5mg (£3.82 = 7.5mg twice daily)

Indications

• Angina
• Chronic heart failure

Dose

• Angina, initially 5mg twice daily, increased if necessary after 3–4 weeks to 7.5mg twice daily (if not tolerated reduce dose to 2.5–5mg twice daily); elderly initially 2.5mg twice daily. Do not initiate if heart rate is below 60bpm.
• Heart failure, initially 5mg twice daily, increased if necessary after 2 weeks to 7.5mg twice daily (if not tolerated reduce dose to 2.5mg twice daily)

Notes

1. Consultant initiated
2. Treatment of chronic heart failure in accordance with NICE TA267 Ivabradine for the treatment of chronic heart failure (November 2012).
3. MHRA Drug Safety Update (December 2014): When using ivabradine to treat the symptoms of chronic angina:
   1. only start ivabradine if the resting heart rate is at least 70 beats per minute
   2. do not prescribe ivabradine with other medicines that cause bradycardia, such as verapamil, diltiazem, or strong CYP3A4 inhibitors
   3. monitor patients regularly for atrial fibrillation. If atrial fibrillation occurs, carefully reconsider whether the benefits of continuing ivabradine treatment outweigh the risks
   4. consider stopping ivabradine if there is no or only limited symptom improvement after 3 months

Ranolazine

• Modified-release tablets 375mg, 500mg, 750mg (£16.73 = 500mg twice daily)

Indications

• Adjunctive therapy in the treatment of stable angina in patients inadequately controlled or intolerant of first-line anti-anginal therapies

Dose

• Initially 375mg twice daily, increased after 2–4 weeks to 500mg twice daily and then adjusted according to response to maximum 750mg twice daily (reduce dose to 375–500mg twice daily if not tolerated)

Notes

1. Consultant initiated