2: Cardiovascular system - Airedale NHS Foundation Trust€¦ · Cardiovascular system formulary BNF Section 2 Original Date of issue:28/11/07 Last Reviewed: 01/05/2011 Version:4

File name: Cardiovascular system formulary BNF Section 2

Original Date of issue:28/11/07 Last Reviewed: 01/05/2011 Version:4 Page 1 of 24

Department: Pharmacy Review Date:01/05/2013 Authorised: Drug and Therapeutics Committee

2: Cardiovascular system 2.1 Positive inotropic drugs 2.1.1 Cardiac glycosides Digoxin Tablets (62.5microgram, 125microgram, 250microgram) Digoxin Elixir (250microgram/5ml) Digoxin Injection (500microgram/2ml)

Formulary status

Product Restriction

R Digoxin specific antibody (Digibind) 38mg

For the treatment of digoxin toxicity. All stock is in A&E. Further stock can be obtained from BRI. Consult poisons centre for information.

2.1.2 Phosphodiesterase inhibitors Milrinone Injection (10mg in 10ml)

2.2 Diuretics 2.2.1 Thiazides and related diuretics Product Comments

First line Bendroflumethiazide Tablets (2.5mg, 5mg)

Second line Indapamide Tablets (1.5mg, 2.5mg) Metolazone Tablets (5mg)




2.2.2 Loop diuretics Product Comments

First line Furosemide Tablets (20mg, 40mg, 500mg) Furosemide SF Solution (5mg/5ml, 40mg/5ml) Furosemide Injection (20mg/2ml, 50mg/5ml, 250mg/25ml)

Second line Bumetanide Tablets 1mg Bumetanide Tablets 5mg Bumetanide Liquid 1mg/5ml Bumetanide Injection 2mg/4ml

Bumetanide is considerably more expensive than furosemide

2.2.3 Potassium-sparing diuretics and aldosterone antagonists

Product Comments

First line Amiloride Tablets (5mg) Amiloride SF Solution (5mg/5ml)

Second line Spironolactone Tablets (25mg, 50mg, 100mg) Spironolactone Suspension (10mg/5ml, 50mg/5ml)

Spironolactone would be first choice over amiloride in CHF

Formulary status

Product Restriction

C Eplerenone 25mg, 50mg Tablets

Only for patients who develop intolerable gynaecomastia with spironolactone under recommendation of Consultant Cardiologists only




2.2.4 Potassium-sparing diuretics with other diuretics

Formulary status

Product Restriction

R Co-amilozide Tablets (5/50) Prescribing of combination diuretics is restricted to patients in whom compliance is a problem.

R Co-amilofruse Tablets (2.5/20, 5/40)

2.2.5 Osmotic diuretics Mannitol Infusion (10% 500ml, 20% 500ml)

2.2.6 Mercurial diuretics NIL

2.2.7 Carbonic anhydrase inhibitors Formulary status

Product Restriction

R Acetazolamide Injection 500mg

This is usually used for treatment of glaucoma but is included in this section for use on ICU to uncouple metabolic compensation to chronic Type II respiratory failure under care of anaesthetists

2.2.8 Diuretics with potassium Nil

2.3 Anti-arrhythmic drugs 2.3.1 Management of arrhythmias See BNF




2.3.2 Drugs for arrhythmias Product Comments

First line Amiodarone Injection (150mg/3ml) Amiodarone Tablets (100mg, 200mg)

Should be initiated under hospital supervision only

Second line Disopyramide Capsules (100mg)

Adenosine Injection (6mg/2ml) Lidocaine Infusion (0.2% Glucose 5%) 500ml Lidocaine Injection 1% (2ml, 5ml,10ml, 20ml) Lidocaine Injection 2% (2ml, 5ml, 20ml)

Formulary status

Product Restriction

R Amiodarone Injection (300mg/10ml)

Restricted to crash trolleys and crash boxes only

C Dronedarone 400mg Tablets Consultant Cardiologist use only for patients per month with paroxysmal AF in whom first-line agents have been ineffective or not tolerated. Supported for use in-line with NICE TA197 (August 2010)

C Disopyramide Injection (50mg/5ml)

Consultant Cardiologist use only

C Flecainide 25mg/5ml Syrup

Consultant Cardiologist use only This is a named patient drug and therefore is NOT kept as stock in the pharmacy.

C Flecainide Injection (150mg/15ml) Flecainide Tablets (50mg, 100mg)

Consultant Cardiologist use only

http://www.nice.org.uk/guidance/TA197





2.4 Beta-adrenoceptor blocking drugs Product Comments

First line Atenolol Syrup (25mg/5ml) Atenolol Injection (5mg/10ml) Atenolol Tablets (25mg, 50mg, and 100mg) Bisoprolol Tablets (1.25mg, 2.5mg, 5mg, 10mg) Metoprolol Injection (5mg/5ml) Metoprolol Tablets (50mg, 200mg)

Atenolol Hypertension: 50 mg daily Angina: 100mg daily in 1 or 2 divided doses. Post MI: 25-50mg once daily Hypertension and angina usually 10mg once daily Heart failure see BNF Metoprolol Hypertension: 100 - 200mg daily Angina: 50-100mg 2-3 times a day. Post MI: 50 – 100mg 2-3 times daily

Propranolol MR Capsules (80mg, 160mg) Propranolol SF Solution (10mg/5ml) Propranolol Syrup (5mg/5ml) Propranolol Injection (1mg/1ml) Propranolol Tablets (10mg, 40mg)

Formulary status

Product Restriction

R Carvediol Tablets (3.125mg, 6.25mg, 12.5mg)

Restricted to Consultant cardiologist use only

R Labetalol Injection (100mg/20ml)

Restricted for use 1. In pregnant hypertensive

patients 2. In theatre for treatment of

intraoperative hypertension 3. In ICU for malignant

hypertension

R Labetalol Tablets (50mg, 100mg, 200mg)

Restricted for use in pregnant hypertensive patients

R Pindolol Tablets (5mg)

Restricted to patients who come in on it

R Sotalol Tablets (40mg, 80mg) Sotalol Injection (40mg/4ml)

Restricted to patients who come in on it







2.5 Drugs affecting the renin-angiotensin system and some other antihypertensive drugs

2.5.1 Vasodilator antihypertensive drugs Hydralazine Injections (20mg) Hydralazine Tablets (25mg, 50mg)

Formulary status

Product Restriction

S Sodium nitroprusside Injection 10mg/ml

Reserved for use in theatre and ICU

R Diazoxide Injection 300mg/20ml

Reserved for Consultant Cardiologist use only

2.5.2 Centrally acting antihypertensive drugs

Formulary status

Product Restriction

S Clonidine injection 150microgram/1ml

For use on ICU and theatre only

R Methyldopa tablets 250mg Methyldopa may be used for management of hypertension during pregnancy

R Moxonidine Tablets (200 microgram, 300 microgram)

Agreed for treatment of resistant hypertension only

2.5.3 Adrenergic neurone blocking drugs Formulary status

Product Restriction

C Guanethidine monosulphate Injection 10mg/ml

Consultant Anaesthetists use only




2.5.4 Alpha-adrenoceptor blocking drugs Product Comments

First line Doxazosin Tablets (1mg, 2mg, 4mg)

Second line Prazosin Tablets (500micrograms, 1mg, 2mg) Terazosin Tablets (2mg, 5mg)

Formulary status

Product Restriction

R Doxazosin Tablets 4mg MR Avoid the use of slow realease doxazosin as if offers no clinical benefit and is expensive. Available only for patients who come in on it.

R Phentolamine Injection (10mg/1ml)

Hypertensive episodes due to phaeochromocytoma

R Phenoxybenzamine Injection 50mg/ml Phenoxybenzamine Capsules 10mg

Hypertensive episodes due to phaeochromocytoma

2.5.5 Drugs affecting the renin-angiotensin system

2.5.5.1 Angiotensin-converting enzyme inhibitors Product Comments

First line Ramipril Tablets /Capsules (1.25mg, 2.5mg, 5mg, 10mg)

Hypertension: Initialy 1.25mg once daily increased at intervals of 1 – 2 weeks; usual range 2.5-5mg once daily. Heart failure: initially 1.25mg once daily under close medical supervision increased if necessary at intervals of 1-2 weeks; max. 10mg daily Prophylaxis after MI: (started in hospital 3-4 days after infarction) initially 2.5mg twice daily increase after 2 days to 5 mg twice daily: maintence 2.5-5mg twice daily. Note patient




should be started on a 1.25mg dose if initial dose is not tolerated and increase at normal rate, withdraw if 2.5mg daily is not tolerated Ramipril is sometimes prescribed twice daily during the titration phase

Second line Lisinopril Tablets (2.5mg, 5mg, 10mg, 20mg)

Hypertension: Initially 10mg daily: if used in addition to diuretic or in renal impairment, initially 2.5mg daily, usual maintenance dose is 20mg once daily; max. 80mg daily Heart failure: Initially 2.5mg daily under close medical supervision;usual maintence dose 5-20mg daily Prophylaxis after MI: systolic blood pressure over 120mmHg 5mg within 24 hours, followed by a further 5mg 24 hours , then 10mg 24hours later and continuing with 10 mg once daily for 6 weeks (or continued if heart failure); systolic blood pressure 100–120 mmHg, initially 2.5 mg, increasing to maintenance dose of 5 mg once daily.

Others Captopril Tablets (12.5mg, 25mg) Captopril Liquid 5mg/5ml) Enalapril Tablets (2.5mg, 5mg, 10mg, 20mg)

Formulary status

Product Restriction

R Fosinopril Tablets (10mg, 20mg)

Restricted to patients who come in on them

R Perindopril erbumine Tablets (2mg, 4mg, 8mg)

Restricted to patients who come in on them




2.5.5.2 Angiotensin- II receptor antagonists Angiotensin- II receptor antagonists are licensed for use in hypertension but should be restricted to patients who have intolerable dry cough with angiotensin converting enzyme inhibitors. Product Comments

First line Candesartan Tablets (2mg, 4mg, 8mg, 16mg)

Second line Irbesartan (75mg, 150mg, 300mg)

Irbesartan for renal protection in diabetes.

Formulary status

Product Restriction

R Losartan Tablets (25mg, 50mg, 100mg) Telmisartan Tablets (20mg, 40mg, 80mg) Micardis Plus 80/12.5 (Telmisartan 80mg +hydrochlorothiazide 12.5mg) Valsartan Tablets (40mg, 80mg) Olmesartan medoxomil Tablets (10mg, 20mg,40mg)

Reserved for patients who come in on them




2.6 Nitrates, calcium-channel blockers, and potassium-channel activators

2.6.1 Nitrates Product Comments

First line Isosorbide Mononitrate Tablets (10mg, 20mg)

Tolerance with reduced therapeutic effect can develop. To reduce this effect the second of the two daily doses should be given after 8 hours rather than after 12 hours (e.g 8.00am and 4.00pm) Slow or modified release preparations of isosorbide mononitrate are more costly than their short acting equivalents. In addition, there is little evidence to suggest that they are any more effective in treating the symptoms of angina.

Second line Isosorbide Mononitrate Capsules MR (25mg, 50mg) Isosorbide Mononitrate Tablets MR (40mg, 60mg)

These are given once daily and should be reserved for patients who have problems with compliance. Short-acting nitrates are therefore the formulation of choice when initiating treatment with nitrates. Take care when prescribing as some of the modified release products are once daily and some are twice daily.

Glyceryl Trinitrate Injection (10mg/10ml) Glyceryl Trinitrate Infusion (50mg/50ml) Glyceryl Trinitrate Spray (400 microgram) Glyceryl Trinitrate S/L Tablets (300 microgram, 500 microgram) Glyceryl Trinitrate Buccal Tablets (2mg, 3mg, 5mg) Glyceryl trinitrate Patches (5mg,10mg) Isosorbide Dinitrate Injection (10mg/10ml)

Formulary status

Product Restriction

R Isosorbide Dinitrate Tablets Restricted to patients who come in on




(10mg, 20mg)

them




2.6.2 Calcium-channel blockers Product Comments

Diltiazem Capsules (120mg, 180mg, 240mg, 300mg)

When prescribing long acting diltiazem for a new patient, please use either Diltiazem LA 180mg, 240mg or 300mg. This allows the pharmacy to dispense the brand of diltiazem, which is cost-effective across primary and secondary care. Patients who are admitted who are already taking LA diltiazem should be maintained on their current brand unless the dose is changed for other reasons. Diltiazem is effective in most forms of angina (section 2.6); the longer-acting formulation is also used for hypertension. It may be used in patients for whom beta-blockers are contra-indicated or ineffective. It has a less negative inotropic effect than verapamil and significant myocardial depression occurs rarely. Nevertheless because of the risk of bradycardia it should be used with caution in association with beta-blockers. Diltiazem Capsules 200mg Due to the complexities of diltiazem pricing, the LA 200mg formulation is more expensive than most of the other doses.

Verapamil Verapamil is used for the treatment of angina (section 2.6), hypertension, and arrhythmias (section 2.3.2). It is a highly negatively inotropic calcium channel-blocker and it reduces cardiac output, slows the heart rate, and may impair atrioventricular conduction. It may precipitate heart failure, exacerbate conduction disorders, and cause hypotension at high doses and should not be used with beta-blockers (see under VERAPAMIL). Constipation is the most common side-effect

Dihydropyridines

Amlodipine Tablets Nifedipine Capsules Nifedipine Tablets

Nifedipine relaxes vascular smooth muscle and dilates coronary and peripheral arteries. It has more influence on vessels and less on the myocardium than does verapamil, and unlike verapamil has no anti-arrhythmic activity. It rarely precipitates heart failure because any negative inotropic effect is offset by a reduction in left ventricular work. Short-acting formulations of nifedipine are not recommended for angina or long-term management of hypertension; their use may be associated with large variations in blood pressure and reflex tachycardia. Nicardipine has similar effects to those of nifedipine and may produce less reduction of myocardial contractility. Amlodipine and felodipine also resemble nifedipine and nicardipine in their effects and do not reduce myocardial contractility and they do not produce clinical deterioration in heart failure. They have a longer duration of action and can be given once daily. Nifedipine, nicardipine, amlodipine, and felodipine are used for the treatment of angina (section 2.6) or hypertension. All are valuable in forms of angina associated with coronary vasospasm. Side-effects associated with vasodilatation such as flushing and headache (which become less obtrusive after a few days), and ankle swelling (which may respond only partially to diuretics) are common.

http://www.bnf.org/bnf/bnf/current/doc/2614.htm



http://www.bnf.org/bnf/bnf/current/doc/2701.htm#_120502





Amlodipine Tablets (5mg, 10mg) Diltiazem MR Capsules (120mg, 180mg, 200mg, 240mg, 300mg) (various brands) Diltiazem Tablets (60mg, 90mg, 120mg) Nifedipine Capsules (5mg, 10mg) Nifedipine MR Tablets (10mg, 20mg, 30mg) Verapamil MR Capsules (120mg, 180mg, 240mg) Verapamil SF Solution (40mg/5ml) Verapamil Injection (5mg/2ml) Verapamil Tablets 40mg, 80mg, 120mg)

Formulary status

Product Restriction

C Felodipine MR Tablets (2.5mg, 5mg, 10mg)

Under recommendation of Consultant Cardiologist.

R Nimodipine Infusion (10mg/50ml) Nimodipine Tablets (30mg)

Prevention and treatment of ischaemic neurological defects following aneurismal subarachnoid haemorrhage

2.6.3 Other antianginal drugs Nicorandil Tablets (10mg, 20mg)

Formulary status

Product Restriction

C Ivabradine tablets (5mg, 7.5mg)

For Consultant Cardiologist use only for treatment of angina in patients intolerant of a beta-blocker and calcium channel blocker.

Ivabradine agreed for chronic heart failure in-line with NICE TA267 (November 2012). Treatment must be initiated by a heart failure specialist and dose titration and monitoring carried out by that specialist before responsibility for prescribing can be transferred to Primary Care under a shared care arrangement.

C Ranolazine 375mg tablets For Consultant Cardiologist use only for patients with stable angina who are inadequately controlled on intolerant to first line therapies

http://guidance.nice.org.uk/TA267







2.6.4 Peripheral and cerebral vasodilators 2.6.4.1 Peripheral vasodilators and related drugs Naftidrofuryl Capsules (100mg)

Formulary status

Product Restriction

C Pentoxifylline modified release tablets (400mg)

Consultant Gastroenterologist use only for the treatment of alcoholic liver disease in patients with contraindications to steroids (unlicensed indication)

2.6.4.2 Cerebral vasodilators NIL

2.7 Sympathomimetics 2.7.1 Inotropic sympathomimetics Dobutamine Injection (250mg/20ml) Dopamine Injection (200mg/5ml) Isoprenaline Injection (100 microgram /1ml, 100 microgram /10ml, 2mg/2ml)

Formulary status

Product Restriction

C Dopexamine 50mg/5ml Injection

Consultant Anaesthetists use on ICU

2.7.2 Vasoconstrictor sympathomimetics Adrenaline (Epinephrine) syringes 5mg in 50ml Ephedrine Injection (30mg/1ml) Noradrenaline Injection (4mg/4ml)

Formulary status

Product Restriction




S Metaraminol Injection 10mg/ml For use in theatre, ICU and A&E only

S Phenylephrine Injection 10mg/1ml

Use supported for the control of maternal hypotension during spinal caesarean section

2.7.3 Cardiopulmonary resuscitation Adrenaline (Epinephrine) Injection 1in 100,000 (10ml) Adrenaline (Epinephrine) Injection 1in 1,000 (10mg/10ml, 1mg/1ml, 1mg/1ml prefilled syringe, 100 microgram /1ml)




2.8 Anticoagulants and protamine

Link to thromboprophylaxis protocols 2.8.1 Parenteral anticoagulants Product Comments

First line Dalteparin Syringes (2,500units/0.2ml)

Prophylaxis of deep vein thrombosis in surgical patients with moderate risk

Dalteparin Syringes (5,000units/0.2ml)

Prophylaxis of deep vein thrombosis in surgical patients with high risk

Dalteparin Syringes (5,000units/0.2ml)

Prophylaxis of deep vein thrombosis in medical patients

Dalteparin Syringes Treatment of deep vein thrombosis and of pulmonary embolism by subcutaneous injection as a single daily dose depending on weight. Max 18,000units

Under 46kg 46-56kg 57-68kg 69-82kg 83kg and over

7,500units/0.3ml, 10,000units/0.4ml, 12,500units/0.5ml, 15,000units/0.6ml, 18,000units/0.72ml)

Dalteparin graduated syringes 10,000units/1ml,

Treatment of unstable coronary artery disease, by subcutaneous injection, 120units/kg every 12 hours Max 10,000units twice daily

Heparin calcium Injection (5000units/0.2ml) Heparin Sodium Injection (200units/2ml, 5,000units/1ml, 5,000units/5ml, 10,000units/10ml, 20,000units/20ml, 25,000units5ml)

Formulary status

Product Restriction

S Heparin Sodium 50units/5ml injection

Paediatric and neonatal use only e.g. For Hickman lines.

R Heparin Sodium 500units in 0.9% Sodium Chloride (500ml)

Restricted for use in CCU and theatre only

R Heparin Sodium 1000units in 0.9% Sodium Chloride (500ml)

Restricted for use in x-ray and cardiac catheter lab only

R Epoprostenol 500 microgram

http://sharepoint-srv2/C0/C5/VTE%20thromboprophylaxis/default.aspx




injection




2.8.2 Oral anticoagulants Product Comments

First line Warfarin Tablets (0.5mg, 1mg, 3mg, 5mg)

Warfarin Suspension 5mg/ 5mL (150mL)

For patients who are unable to swallow tablets

Second line Phenindione Tablets (10mg, 25mg, 50mg)

Formulary status

Product Restriction

R Dabigatran Tablets (150mg, 110mg)

Dabigatran use supported as a treatment option for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (AF) who meet the criteria of the West Yorkshire Cardiac Network. Use in-line with NICE TA249

R Rivaroxaban Tablets 20mg Use supported as a treatment option for the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation who are unable to tolerate warfarin, in-line with West Yorkshire Cardiac Network Clinical Advisory Group guidance. Use in-line with NICE TA256

R Rivaroxaban Tablets (15mg, 20mg)

Use supported as an option for the treatment of DVT and the prevention of recurrent DVT and PE in adult patients, in-line with NICE TA261 Use restricted to those patients unable to receive treatment dalteparin as a single agent or those unsuitable for treatment with warfarin.

2.8.3 Protamine Sulphate Protamine Sulphate Injection (50mg/5ml)

2.9 Antiplatelet drugs Product Comments

First line Aspirin Dispersible Tablets (75mg)








Formulary status

Product Restriction

R Aspirin EC Tablets 75mg Reserved for patients who come in on it.

R Clopidogrel Tablets (75mg, 300mg)

R Dipyridamole SF Suspension (50mg/5ml) Dipyridamole Tablets (25mg, 100mg) Dipyridamole MR Capsules (200mg) Asasantin MR Capsules (Dipyridamole 200mg/aspirin 25mg)

Supported for use in-line with NICE TA210 (December 2010)

R Asasantin MR Capsules (Dipyridamole 200mg/aspirin 25mg)

Where patients require aspirin and dipyridamole modified release the combination product Asasantin is the most economical.

R Ticagrelor Tablets 90mg Consultant Cardiologist use only, for the treatment of acute coronary syndromes in-line with West Yorkshire Cardiovascular Network Guidelines. Supported for use in-line with NICE TA236 (October 2011)

C Tirofiban Infusion (12.5mg/250ml)

Consultant cardiologists only

C Prasugrel Tablets 5mg

Consultant Cardiologist use only for patients returning from Leeds following PCI. Supported for use in-line with NICE TA182 (October 2009)

2.10 Myocardial infarction and fibrinolysis 2.10.1 Management of myocardial infarction NIL










2.10.2 Fibrinolytic drugs Streptokinase Injection (1.5million-unit) Urokinase Injection (25,000units)

Formulary status

Product Restriction

S Tenecteplase Injection 10,000units (50mg)

Restricted to CCU and A&E

S Tenecteplase Injection 8,000units (40mg)

Restricted to CCU and A&E

R Alteplase Injection (20mg, 50mg)

Available for stroke patients. Stock available in stoke kit in A&E. Supported for use in-line with NICE TA264 (September 2012)

2.11 Antifibrinolytic drugs and haemostatics Aprotinin Infusion (500,000units/50ml) Etamsylate Injection (250mg/2ml) Tranexamic Acid Injection (500mg/5ml) Tranexamic Acid Tablets (500mg)

Formulary status

Product Restriction

R Factor VIIa 1mg, 2mg, 5mg, 20mg

All stock kept in pathology Consultant Haematologist only

C Human Prothombin Complex (Octaplex) 500 units

All stock kept in pathology and issued by them

2.12 Lipid-regulating drugs Statins Product Comments

First line Simvastatin Tablets (10mg, 20mg, 40mg)

Simvastatin 20-40mg daily is the Formulary choice when initiating a patient on a statin






Second line Atorvastatin 10mg, 20mg, 40mg, 80mg Tablets

Reserved for patients who are resistant to simvastatin at a dose of 40mg

Formulary status

Product Restriction

R Pravastatin Tablets (10mg, 20mg, 40mg)

Reserved for patients who come in on it.

R Rosuvastatin Tablets (5mg, 10mg, 20mg)

To be used 3rd line for patients with resistant raised cholesterol. May be useful in patients with low HDL. Rosuvastatin should be reserved only for patients with resistant hypercholesterolaemia, unresponsive to other statins (at doses over 20mg). The starting dose is 10mg daily in all patients.

Bile acid sequestrants Colestyramine Sachets (4g)

Ezetimibe

Formulary status

Product Restriction

R Ezetimibe tablets (10mg) For use in combination with a statin for patients not achieving target cholesterol levels despite max. tolerated dose of a statin. Supported for use in-line with NICE TA132 Nov 2007






Fibrates Bezafibrate Tablets (200mg, 400mg) Ciprofibrate Tablets (100mg) Fenofibrate Tablets (160mg, 200mg, 267mg)

European Medicines Agency recommends fibrates as second line treatment with statins as first line

Omega-3 fatty acid compounds Formulary status

Product Restriction

R Omega-3-acid ethyl esters (Omacor)

Cardiology use only – routinely used post MI Treatment of hyperglyceridaemia in patients intolerant of other products

2.13 Local sclerosants Sodium Tetradecyl 3% Injection (2ml, 5ml) Sodium Tetradecyl 1% Injection 2ml

2: Cardiovascular system - Airedale NHS Foundation Trust€¦ · Cardiovascular system formulary BNF Section 2 Original Date of issue:28/11/07 Last Reviewed: 01/05/2011 Version:4

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