BNF.for.Children.2011-2012-ublog.tk


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facturerslistedinBNFPublicationsareshowninthe
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2011–2012
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Contents
..................................................................................................................................
Acknowledgements
................................................................................................................
BNFStaff
...............................................................................................................................
BNFforChildren
isconstructed
....................................................................................
Howtouse
BNFforChildren
.................................................................................................
Changesforthisedition
....................................................................................................
Generalguidance
...................................................................................................................
Prescriptionwriting
................................................................................................................
Supplyofmedicines
..............................................................................................................
Emergencysupplyofmedicines
............................................................................................
PrescribingControlledDrugs
.................................................................................................
Adversereactionstodrugs
.................................................................................................
Prescribinginhepaticimpairment
......................................................................................
Prescribinginrenalimpairment
.........................................................................................
Prescribinginpregnancy
....................................................................................................
Prescribinginbreast-feeding
..............................................................................................
Prescribinginpalliativecare
..............................................................................................
Prescribingindentalpractice
.............................................................................................
Drugsandsport
..................................................................................................................
Emergencytreatmentofpoisoning
....................................................................................
NotesondrugsandPreparations
Gastro-intestinalsystem
........................................................................................
Cardiovascularsystem
...........................................................................................
Respiratorysystem
..............................................................................................
Centralnervoussystem
.......................................................................................
Infections
.............................................................................................................
Endocrinesystem
.................................................................................................
Preface
BNFforChildren
aimstoprovideprescribers,pharma-
cistsandotherhealthcareprofessionalswithsoundup-
to-dateinformationontheuseofmedicinesfortreating
AjointpublicationoftheBritishMedicalAssociation,
Acknowledgements
ThePaediatricFormularyCommitteeisgratefulto
individualsandorganisationsthathaveprovidedadvice
andinformationtothe
BNFforChildren
Theprincipalcontributorsforthiseditionwere:
I.H.Ahmed-Jushuf,M.N.Badminton,S.Bailey,T.G.
BNFStaff
ManagingEditor:KnowledgeCreation
JohnMartin
BPharm,PhD,MRPharmS
AssistantEditors
Leigh-AnneClaase
BSc,PhD
BryonyJordan
BSc,DipPharmPract,MRPharmS
ColinR.Macfarlane
BPharm,MSc,MRPharmS
PaulS.Maycock
MPharm,DipPharmPract,
MRPharmS
ClaireL.Preston
BPharm,PGDipMedMan,
MRPharmS
RachelS.M.Ryan
BPharm,MRPharmS
ShamaM.S.Wagle
BPharm,DipPharmPract,
MRPharmS
StaffEditors
SejalAmin
BPharm,MSc
CristinaLopez-Bueno
SeniorBNFAdministrator
HeidiHomar
ManagingEditor:DigitalDevelopmentandDelivery
CorneliaSchnelle
MPhil
DigitalDevelopmentEditor
PhilipD.Lee
BSc,PhD
DigitalDevelopmentAssistants
RobertC.Buckingham
MichelleCartwright
JenniferL.Palmer
FdSc
Terminologist
SarahPeck
HeadofProduction
JohnWilson
SeniorProductionEditor
LindaPaulus
BNFPublishingDirector
DuncanS.T.Enright
MA,PGCE,MInstP,FIDM
ManagingDirector,PharmaceuticalPress
RobertBolick
BA,MA
SeniorMedicalAdviser
MartinJ.Kendall
OBE,MB,ChB,MD,FRCP,FFPM
BNFC2011–
PaediatricFormulary
Committee
WarrenLenney
MD,FRCP,FRCPCH,DCH
CommitteeMembers
JeffreyK.Aronson
MA,MBChB,DPhil,FRCP,FBPharmacolS,FFPM
NeilA.Caldwell
BSc,MSc,MRPharmS
IanCostello
BPharm,MSc,MRPharmS
MartinG.Duerden
BMedSci,MBBS,DRCOG,
MRCGP,DipTher,DPH
SimonKeady
BSc,MRPharmS,SP
MartinJ.Kendall
OBE,MB,ChB,MD,FRCP,FFPM
(Chair,Content
StrategyCommittee)
JamesH.Larcombe
MB,ChB,FRCGP,DipAdvGP
E.DavidG.McIntosh
MBBS,MPH,PhD,FAFPHM,FRACP,FRCPCH,
FFPM,DRCOG,DCH,DipPharmMed
NeenaModi
MB,ChB,MD,FRCP,FRCPCH
MatthewJ.Thatcher
MBBS,FRCS,DRCOG,DMRD
DavidTuthill
MB,BCh,FRCPCH
WilliamG.van’tHoff
BSc,MB,MD,FRCPCH,FRCP
EdwardR.Wozniak
BSc,MBBS,FRCP,FRCPCH,DCH
NursePrescribers’
AdvisoryGroup
NickyA.Cullum(untilNovember2010)
PhD,RGN
MollyCourtenay(fromDecember2010)
PhD,MSc,CertEd,BSc,RGN
CommitteeMembers
FionaCulley
LLM,RN,BSc,CertEd
DuncanS.T.Enright
MA,PGCE,MInstP,FIDM
PennyM.Franklin
RN,RCN,RSCPHN(HV),MA,PGCE
nGranellVillen
BSc,PGDipClinPharm
BNFforChildren
isconstructed
BNFforChildren
incorporatingtheinformationintoBNFCusing
establishedcriteriaforthepresentationandinclu-
sionofthedata;
Howtouse
BNFforChildren
BNFforChildren
(BNFC)providesinformationon
theuseofmedicinesinchildrenrangingfromneo-
prescribingnotesifappropriate.SummariesofNICE
technologyappraisals,andrelevantshortguidelines,
areincludedinpinkpanels.BNFCalsoincludesadvice
issuedbytheScottishMedicinesConsortium(SMC)
whenamedicineisrestrictedornotrecommendedfor
usewithinNHSScotland.
Inordertoselectsafeandeffectivemedicinesfor
individualchildren,informationintheprescribing
notesmustbeusedinconjunctionwithotherpre-
Figure1Illustratesthetypicallayoutofadrugmonographandpreparation
recordsinBNFC
HowtouseBNFC
DRUGNAME
HowtouseBNFC
BNFC2011–
Abriefdescriptionoftheclinicalusesofadrugcan
usuallybefoundintheIndicationandDosesectionofits
monograph(e.g.ibuprofen,p.503);across-referenceis
providedtoanyindicationsforthatdrugthatarecov-
eredinothersectionsofBNFC.
Thesymbol
isusedtodenotepreparationsthatare
consideredbytheJointFormularyCommitteetobeless
suitableforprescribing.Althoughsuchpreparations
maynotbeconsideredasdrugsofrstchoice,their
usemaybejustiableincertaincircumstances.
Drugmanagementofmedical
emergencies
Guidanceonthedrugmanagementofmedicalemer-
genciescanbefoundintherelevantBNFCchapters(e.g.
treatmentofanaphylaxisisincludedinsection3.4.3).A
summaryofdrugdosesusedforMedicalEmergencies
intheCommunitycanbefoundintheglossypagesat
thebackofBNFC.AlgorithmsforNewborn,Paediatric
Basic,andPaediatricAdvancedLifeSupportcanalsobe
foundwithinthesepages.
Minimisingharminchildrenwithco-
Thedrugchosentotreataparticularconditionshould
mentsshouldbemade,andthechildshouldbemon-
itoredadequately.Thegeneralprinciplesforprescribing
areoutlinedunder
PrescribinginHepaticImpairment
(p.14)and
PrescribinginRenalImpairment
(p.14).
Informationaboutdrugsthatshouldbeavoidedor
usedwithcautioninhepaticdiseaseorrenalimpair-
mentcanbefoundindrugmonographsunder
Hepatic
Impairment
RenalImpairment
(e.g.uconazole,
Selectingthedose
Thedrugdoseisusuallylocatedinpinkpanelswithin
IndicationandDose
sectionofthedrugmonograph
orwithinthe
sectionofthepreparationrecord.
Dosesarelinkedtospecicindicationsandroutesof
administration.Thedoseofadrugmayvaryaccording
todifferentindications,routesofadministration,age,
body-weight,andbody-surfacearea.Whenthedoseofa
drugvariesaccordingtodifferentindications,each
indicationanditsaccompanyingdoseisincludedina
separatepinkpanel(e.g.aciclovir,p.322).Thedoseis
locatedwithinthepreparationrecordwhenthedose
variesaccordingtodifferentformulationsofthatdrug
(e.g.amphotericin,p.305)orwhenapreparationhasa
dosedifferenttothatinitsmonograph.Occasionally,
drugdosesmaybeincludedintheprescribingnotesfor
practicalreasons(e.g.dosesofdrugsin
Helicobacter
pylori
eradicationregimens,p.42).Therightdose
shouldbeselectedfortherightageandbody-weight
(orbodysurfacearea)ofthechild,aswellasfortheright
indication,routeofadministration,andpreparation.
DosesinBNFCareusuallyassignedtospecicage
ranges;neonataldosesareprecededbytheword
,allotherdosesareprecededbytheword
.AgerangesinBNFCaredescribedasshown
inthefollowingexample:
Child1month–4years
referstoachildfrom1
montholduptotheir4
birthday;
Child4–10years
referstoachildfromthedayof
their4
birthdayuptotheir10
birthday.
However,apragmaticapproachshouldbeappliedto
thesecut-offpointsdependingonthechild’sphysio-
logicaldevelopment,condition,andifweightis
appropriateforthechild’sage.
Forsomedrugs(e.g.gentamicin,p.278)theneonatal
dosevariesaccordingtothe
postmenstrual
ageofthe
neonate.Postmenstrualageistheneonate’stotalage
expressedinweeksfromthestartofthemother’slast
menstrualperiod.Forexample,a3weekoldbabyborn
at27weeksgestationistreatedashavingapostmenstr-
ualageof30weeks.Atermbabyhasapostmenstrual
ageof37–42weekswhenborn.Formostotherdrugs,
thedosecanbebasedonthechild’sactualdateofbirth
irrespectiveofpostmenstrualage.However,thedegree
ofprematurity,thematurityofrenalandhepaticfunc-
tion,andtheclinicalpropertiesofthedrugneedtobe
consideredonanindividualbasis.
Manychildren’sdosesinBNFCarestandardisedby
body-weight
.Tocalculatethedoseforagivenchild
theweight-standardiseddoseismultipliedbythechild’s
weight(oroccasionallybythechild’sidealweightfor
height).Thecalculateddoseshouldnotnormally
exceedthemaximumrecommendeddoseforanadult.
Forexample,ifthedoseis8mg/kg(max.300mg),a
childof10kgbody-weightshouldreceive80mg,buta
childof40kgbody-weightshouldreceive300mg
(ratherthan320mg).Calculationbybody-weightin
theoverweightchildmayresultinmuchhigherdoses
beingadministeredthannecessary;insuchcases,the
doseshouldbecalculatedfromanidealweightfor
Occasionally,somedosesinBNFCarestandardisedby
bodysurfacearea
becausemanyphysiologicalphe-
bodysurfacearea-standardiseddoseismultipliedbythe
child’sbodysurfacearea.Thechild’sbodysurfacearea
canbeestimatedfromhisorherweightusingthetables
forBodySurfaceAreainChildrenlocatedintheglossy
pagesatthebackoftheprintversionofBNFC.
Thedosesofsomedrugsmayneedtobeadjustedif
theireffectsarealteredbyconcomitantusewithother
drugs,orinpatientswithhepaticorrenalimpairment
(seeMinimisingDrugInteractions,andPrescribingfor
ChildrenwithHepaticorRenalImpairment).
Whereverpossible,dosesareexpressedintermsofa
denitefrequency(e.g.ifthedoseis1mg/kgtwice
daily,achildofbody-weight9kgwouldreceive9mg
twicedaily).Occasionally,itisnecessarytoinclude
dosesinthetotaldailydoseformat(e.g.10mg/kg
dailyin3divideddoses);inthesecasesthetotaldaily
doseshouldbedividedintoindividualdoses(inthis
exampleachildofbody-weight9kgwouldreceive
30mg3timesdaily).
Mostdrugscanbeadministeredatslightlyirregular
intervalsduringtheday.Somedrugs,e.g.antimicrobials,
arebestgivenatregularintervals.Someexibility
shouldbeallowedinchildrentoavoidwakingthem
duringthenight.Forexample,thenight-timedosemay
begivenatthechild’sbedtime.
Specialcareshouldbetakenwhenconvertingdoses
ventcaries.Sugar-freepreparationsshouldbeused
wheneverpossible.
Whereadrughasseveralpreparations,thoseofa
FindingsigniÞcantchangesinanew
BNFCispublishedinJulyeachyearandincludeslistsof
changesinaneweditionthatarerelevanttoclinical
Theprintversionincludesan
thatsum-
marisesthebackgroundtoseveralkeychanges.A
copyoftheInsertcanalsobefoundatbnfc.orgin
thesectiononUpdatesunder‘What’snewin
Changesforthisedition
(p.xvii),providesalistof
signicantchanges,dosechanges,classication
changes,newnames,andnewpreparationsthat
havebeenincorporatedintoanewedition,aswell
asalistofpreparationsthathavebeendiscontinued
sincethelastedition.Foreaseofidentication,the
marginsofthesepagesaremarkedinpink;
areapplicabletoEnglandandWales,Scotland,and
NorthernIreland;pricesinthedifferenttariffsmayvary.
ExtraresourcesontheBNFCwebsite
WhiletheBNFCwebsite(bnfc.org)hoststhedigital
contentofBNFCproper,italsoprovidesadditional
resourcessuchas
FrequentlyAskedQuestions
onlinecalculators.
BNFC2011–
Changesforthis
SigniÞcantchanges
BNFforChildren
isrevisedyearlyandnumerous
EpilimChronosphere
,p.228
Fersamal
,p.444
Flucloxacillin[staphylococcallunginfectionincystic
brosis],p.259
NotconsideredsuitableforinclusionbythePaediatric
FormularyCommittee
BNFC2011–
TearsNaturale
SingleDose
[hypromellose],p.531
Tevagrastim
[lgrastim],p.456
Tobravisc
[tobramycin],p.520
[sodiumhyaluronate],p.531
Vivadex
[tacrolimus],p.438
[velaglucerasealfa],p.491
Wellvone
[atovaquone],p.343
[orlistat],p.191
Zerocream
,p.553
Zeroguent
,p.553
Zerolatum
,p.555
Zerolatum
Plus
,p.556
Zeroneum
,p.555
Zerozole
,p.556
BNFC2011–
Generalguidance
Medicinesshouldbegiventochildrenonlywhenthey
arenecessary,andinallcasesthepotentialbeneÞtof
administeringthemedicineshouldbeconsideredin
relationtotheriskinvolved.Thisisparticularlyimpor-
tantduringpregnancy,whentherisktobothmotherand
Generalguidance
painfultothechild.Certaindrugs,e.g.somevaccines,
areonlyadministeredintramuscularly.
Theintrathecal,epiduralandintraosseousroutesshould
beused
bystaffspeciallytrainedtoadminister
medicinesbytheseroutes.Localprotocolsforthe
managementofintrathecalinjectionsmustbeinplace
(section8.1).
Managingmedicinesinschool
Administrationofa
medicineduringschooltimeshouldbeavoidedifpossi-
ble;medicinesshouldbeprescribedforonceortwice-
dailyadministrationwheneverpracticable.Ifthemed-
icineneedstobetakeninschool,thisshouldbedis-
cussedwithparentsorcarersandthenecessary
arrangementsmadeinadvance;whereappropriate,
involvementofaschoolnurseshouldbesought.
gingMedicinesinSchoolsandEarlyYearsSettings
producedbytheDepartmentofHealthprovidesgui-
danceonusingmedicinesinschools(
www.dh.gov.uk
listimportingcompanies,seep.809.
Asfaraspossible,medicinesshouldbeprescribedwith-
Generalguidance
medicinescontainingcariogenicsugars,ortheircarers,
shouldbeadvisedofdentalhygienemeasurestopre-
ventcaries.Sugar-freepreparationsshouldbeused
wheneverpossible,particularlyiftreatmentisrequired
foralongperiod.
Whereinformationonthepresenceof
aspar-
tame,gluten
sulphites
tartrazine
arachis(peanut)oil
sesameoil
isavailable,thisisindicatedin
BNFfor
Children
againsttherelevantpreparation.
Informationisprovidedon
selectedexcipients
inskin
preparations(section13.1.3),invaccines(section14.1),
andon
selectedpreservatives
excipients
ineye
dropsandinjections.
Thepresenceof
benzylalcohol
polyoxylcastoroil
prescription,thepharmacistshouldcontacttheprescri-
ber.Ifthisisdonebytelephone,thenumbershouldbe
obtainedfromthedirectoryratherthanrelyingonthe
informationontheprescriptionform,whichmaybe
false.
Patientgroupdirection(PGD)
Inmostcases,the
mostappropriateclinicalcarewillbeprovidedonan
individualbasisbyaprescribertoaspeciÞcchild.
However,aPatientGroupDirectionforsupplyand
administrationofmedicinesbyotherhealthcareprofes-
sionalscanbeusedwhereitwouldbeneÞtthechildÕs
www.nice.org.uk
www.scottishmedicines.org
BNFC2011–
Generalguidance
Generalguidance
Prescriptionwriting
Sharedcare
Initsguidelinesonresponsibilityforprescribing
Theserecommendationsareacceptablefor
prescription-
onlymedicines
).Foritemsmarked
,seealsoPrescribingControlledDrugs,p.9.
ItispermissibletoissuecarboncopiesofNHSprescrip-
tionsaslongastheyaresignedinink.
Prescriptionwriting
exceptioniswherethereisademonstrabledifferencein
Prescriptionwriting
Supplyofmedicines
Whensupplyingamedicineforachild,thepharmacist
shouldensurethatthechildandthechildÕscarerunder-
standthenatureandidentityofthemedicineandhowit
shouldbeused.Thechildandthecarershouldbe
providedwithappropriateinformation(e.g.howlong
themedicineshouldbetakenforandwhattodoifa
doseismissedorthechildvomitssoonafterthedoseis
byaspecialistimporter,manufacturedbyacommercial
orhospitallicensedmanufacturingunit(seeSpecial-
orderManufacturers,p.809),orpreparedextempora-
neously(seebelow)againstaprescription.
shouldbesoughtfromamedicinesinformationcentre,
thepharmacyatachildrenÕshospital,ahospitalproduc-
tionunit,ahospitalqualitycontroldepartment,orthe
manufacturer.
Inmanycasesitispreferabletogivealicensedproduct
byanunlicensedroute(e.g.aninjectionsolutiongiven
bymouth)thantoprepareaspecialformulation.When
Supplyofmedicines
drugssuchasneomycin)shouldbe
avoided
orunder-
takenwithappropriateprecautionstoprotectstaffand
Supplyofmedicines
Emergencysupplyofmedicines
Emergencysupplyrequestedby
memberofthepublic
withoutunduedelay;
(ii)thattreatmentwiththeprescription-onlymed-
icinehasonapreviousoccasionbeenpre-
scribedforthepersonrequestingit;
(iii)astothedosethatitwouldbeappropriatefor
thepersontotake;
(b)thatnogreaterquantityshallbesuppliedthanwill
provide5daysÕtreatmentofphenobarbital,pheno-
barbitalsodium,orControlledDrugsinSchedules4
or5,
or30daysÕtreatmentforotherprescription-
onlymedicines,exceptwhentheprescription-only
medicineis:
(i)insulin,anointmentorcream,orapreparation
forthereliefofasthmainanaerosoldispenser
whenthesmallestpackcanbesupplied;
(ii)anoralcontraceptivewhenafullcyclemaybe
(iii)anantibioticinliquidformfororaladministra-
tionwhenthesmallestquantitythatwill
provideafullcourseoftreatmentcanbesup-
(c)thatanentryshallbemadebythepharmacistinthe
prescriptionbookstating:
(i)thedateofsupply;
(ii)thename,quantity,and,whereappropriate,the
pharmaceuticalformandstrength;
(iii)thenameandaddressofthepatient;
(iv)thenatureoftheemergency;
(d)thatthecontainerorpackagemustbelabelledto
(i)thedateofsupply;
(ii)thename,quantity,and,whereappropriate,the
pharmaceuticalformandstrength;
(iii)thenameofthepatient;
(iv)thenameandaddressofthepharmacy;
(v)thewordsÔEmergencysupplyÕ;
(vi)thewordsÔKeepoutofthereachofchildrenÕ(or
similarwarning);
(e)thattheprescription-onlymedicineisnotasub-
stancespeciÞcallyexcludedfromtheemergency
supplyprovision,anddoesnotcontainaControlled
DrugspeciÞedinSchedules1,2,or3totheMisuse
ofDrugsRegulations2001exceptforphenobarbital
orphenobarbitalsodiumforthetreatmentofepi-
Forconditionsthatapplytosuppliesmadeatthe
requestofapatient,see
DoctorsordentistsfromtheEuropeanEconomicAreaand
Switzerland,ortheirpatients,cannotrequestanemer-
gencysupplyofControlledDrugsinschedules1,2,or3,or
Emergencysupplyofmedicines
PrescribingControlledDrugs
TheMisuseofDrugsAct,1971prohibitscertainactiv-
itiesinrelationtoÔControlledDrugsÕ,inparticulartheir
manufacture,supply,andpossession.Thepenalties
applicabletooffencesinvolvingthedifferentdrugsare
gradedbroadlyaccordingtothe
harmfulnessattributa-
bletoadrugwhenitismisused
andforthispurposethe
drugsaredeÞnedinthefollowingthreeclasses:
ClassA
includes:alfentanil,cocaine,diamorphine
AllpreparationsinSchedules2and3,excepttemazepam.
Amachine-writtenprescriptionisacceptable.Thepre-
scriberÕssignaturemustbehandwritten.
PrescribingControlledDrugs
writingofprescriptionswillresultininconvenienceto
patientsandcarersanddelayinsupplyofthenecessary
medicine.AprescriptionforaControlledDruginSche-
dules2,3,or4isvalidfor28daysfromthedatestated
InstalmentsandÔrepeatsÕ
Aprescriptionmayorder
aControlledDrugtobedispensedbyinstalments;the
amountofinstalmentsandtheintervalstobeobserved
mustbespeciÞed.
Instalmentprescriptionsmustbedispensedinaccor-
dancewiththedirectionsintheprescription.However,
theHomeOfÞcehasapprovedspeciÞcwordingwhich
maybeincludedinaninstalmentprescriptiontocover
certainsituations;forexample,ifapharmacyisclosed
Theprescribermayforward-datetheprescription;thestart
datemayalsobespeciÞedinthebodyoftheprescription.
Atotalof14daysÕtreatmentbyinstalmentofanydrug
listedinSchedule2oftheMisuseofDrugsRegulations,
buprenorphineanddiazepammaybeprescribedin
England.In
,formsFP10(MDA)(blue)and
FP10H(MDA)(blue)shouldbeused.In
,forms
GP10(peach),HBP(blue),orHBPA(pink)shouldbeused.
atotalof14daysÕtreatmentbyinstalmentofany
druglistedinSchedules2Ð5oftheMisuseofDrugs
Regulationsmaybeprescribed.InWales,form
WP10(MDA)orformWP10HP(AD)shouldbeused.
PrescribingControlledDrugs
BNFC2011–
PrescribingControlledDrugs
toavoidbeingusedasanunwittingsourceofsupply
ingmedicineswhichincludevisitingmorethanone
doctor,fabricatingstories,andforgingprescriptions.
Patientsundertemporarycareshouldbegivenonly
smallsuppliesofdrugsunlesstheypresentanunequi-
www.homeofÞce.gov.uk/
drugs/licensing/personal
,orfromtheHomeOfÞceby
contactinglicensing_enquiry.aadu@homeofÞce.gsi.go-
v.uk(incasesofemergency,telephone(020)70350484).
PrescribingControlledDrugs
Adversereactionstodrugs
Anydrugmayproduceunwantedorunexpected
Adversereactionstodrugs
medicinesdependsontheavailabilityofinformation
fromroutineclinicalpractice.
Theblacktrianglesymbol(
)identiÞesnewlylicensed
medicinesthataremonitoredintensivelybytheMHRA.
Suchmedicinesincludenewactivesubstances,biosimi-
larmedicines,medicinesthathavebeenlicensedfor
administrationbyanewrouteordrugdeliverysystem,
orforsigniÞcantnewindicationswhichmayalterthe
establishedrisksandbeneÞtsofthatdrug,orthat
containanewcombinationofactivesubstances.
childisalreadytakingotherdrugs
includingover-
the-countermedicines
;interactionsmayoccur;
ageandhepaticorrenaldiseasemayalterthe
Adversereactionstodrugs
Prescribinginhepaticimpairment
Thevaluesusedintheseformulasmaydifferaccordingto
localityorlaboratory.
Prescribinginhepaticimpairment
BNFC2011–
Prescribinginhepaticimpairment
Important
Theinformationondoseadjustmentin
BNFfor
isexpressedintermsofestimatedglom-
erularÞltrationrate.
Renalfunctioninadultsisincreasinglybeing
reportedasestimatedglomerularÞltrationrate
(eGFR)normalisedtoabodysurfaceareaof
1.73m
;however,eGFRisderivedfromtheMDRD
Prescribinginrenalimpairment
Prescribinginpregnancy
areavailablewherethereisaknownriskofcertain
defects.
Prescribinginpregnancy
Prescribinginpalliativecare
Palliativecareistheactivetotalcareofchildrenand
youngadultswhohaveincurable,life-limitingcondi-
tionsandarenotexpectedtosurvivebeyondyoung
Thechildmaybecaredforinahospiceorathome
accordingtotheneedsofthechildandthechildÕsfamily.
Inallcases,childrenshouldreceivetotalcareoftheir
physical,emotional,social,andspiritualneeds,andtheir
familiesshouldbesupportedthroughout.Inparticular,
specialistpalliativecareisessentialforend-of-lifecare
ofthechildandforsupportingthefamilythroughdeath
andbereavement.
Drugtreatment
Thenumberofdrugsshouldbeas
fewaspossible.Oralmedicationisusuallyappropriate
unlessthereisseverenauseaandvomiting,dysphagia,
weakness,orcoma,whenparenteralmedicationmaybe
necessary.
Analgesicsaremoreeffectiveinpreventingpainthanin
thereliefofestablishedpain;itisimportantthattheyare
givenregularly.
Prescribinginpalliativecare
Rectalroute
Morphine(p.209)isalsoavailablefor
rectaladministration
assuppositories.
Transdermalroute
Transdermalpreparationsof
fentanyl(p.206)areavailable;theyarenotsuitablefor
acutepainorinthosechildrenwhoseanalgesicrequire-
mentsarechangingrapidlybecausethelongtimeto
steadystatepreventsrapidtitrationofthedose.Pre-
scribersshouldensurethattheyarefamiliarwiththe
correctuseoftransdermalpreparations(seeunder
fentanyl,p.206)becauseinappropriateusehascaused
fatalities.
Thefollowing24-hourdosesofmorphine
bymouth
consideredtobeapproximatelyequivalenttothe
fentanylpatchesshown:
Morphinesalt45mgdaily
fentanylÔ12Õpatch
Morphinesalt90mgdaily
fentanylÔ25Õpatch
Morphinesalt180mgdaily
fentanylÔ50Õpatch
Morphinesalt270mgdaily
fentanylÔ75Õpatch
Morphinesalt360mgdaily
fentanylÔ100Õpatch
Morphine(asoralsolutionorstandardformulation
Prescribinginpalliativecare
Prescribinginpalliativecare
whichcanprovidegoodcontrolofsymptomswithlittle
discomfortorinconveniencetothepatient.
Cyclizinemayprecipitateatconcentrationsabove10mg/
inthepresenceofsodiumchloride0.9%
asthe
concentrationofdiamorphinerelativetocyclizinein-
creases;mixturesofdiamorphineandcyclizinearealso
likelytoprecipitateafter24hours.
Specialcareisneededtoavoidprecipitationofdexa-
Prescribinginpalliativecare
Equivalentdosesofmorphinesulphateand
diamorphinehydrochloridegivenover24
Theseequivalencesare
approximateonly
andmay
needtobeadjustedaccordingtoresponse
PARENTERAL
infusionof
morphinesulphate
infusionof
hydrochloride
over24hoursover24hoursover24hours
30mg
15mg
10mg
60mg
30mg
20mg
90mg
45mg
30mg
120mg
60mg
40mg
180mg
90mg
60mg
240mg120mg
80mg
360mg180mg
120mg
480mg240mg
160mg
600mg300mg
200mg
780mg390mg
260mg
960mg480mg
320mg
1200mg600mg
400mg
Ifbreakthroughpainoccursgiveasubcutaneous
injectionequivalenttoone-tenthtoone-sixthofthe
total24-hoursubcutaneousinfusiondose.Withan
intermittentsubcutaneousinjectionabsorptionis
smoothersothattheriskofadverseeffectsatpeak
Prescribinginpalliativecare
Prescribingindentalpractice
Adviceonthedrugmanagementofdentalandoral
conditionsiscoveredinthemaintext.Foreaseof
access,guidanceonsuchconditionsisusuallyiden-
tiÞedbymeansofarelevantheading(e.g.Dentaland
OrofacialPain)intheappropriatesections.
Thefollowingisalistoftopicsofparticularrelevanceto
dentalsurgeons.
Generalguidance
Prescribingbydentalsurgeons,seeBNF
Oralside-effectsofdrugs,seeBNF
Medicalemergenciesindentalpractice,seeBNF
Medicalproblemsindentalpractice,seeBNF
Drugmanagementofdentalandoralconditions
Dentalandorofacialpain,
p.199
Neuropathicpain,p.212
Non-opioidanalgesicsandcompoundanalgesic
preparations,p.199
Opioidanalgesics,p.204
Non-steroidalanti-inßammatorydrugs,p.500
Oralinfections
Bacterialinfections,p.244
Prescribingindentalpractice
Drugsandsport
UKAnti-Doping,thenationalbodyresponsibleforthe
Drugsandsport
Emergencytreatmentof
Thesenotesprovideonlyanoverviewofthetreatment
ofpoisoninganditisstronglyrecommendedthateither
TOXBASE
orthe
UKNationalPoisonsInformation
Service
(seebelow)beconsultedwhenthereisdoubt
aboutthedegreeofriskoraboutappropriatemanage-
Mostchildhoodpoisoningisaccidental.Othercauses
includeintentionaloverdose,drugabuse,iatrogenicand
deliberatepoisoning.Thedrugsmostcommonly
InformationService.
pectedpoisoning.
Respirationisoftenimpairedinunconsciouschildren.
Anobstructedairwayrequiresimmediateattention.In
theabsenceoftrauma,theairwayshouldbeopened
withsimplemeasuressuchaschinliftorjawthrust.An
oropharyngealornasopharyngealairwaymaybeuseful
inchildrenwithreducedconsciousnesstoprevent
obstruction,providedventilationisadequate.Intubation
andventilationshouldbeconsideredinchildrenwhose
airwaycannotbeprotectedorwhohaverespiratory
acidosisbecauseofinadequateventilation;suchchil-
drenshouldbemonitoredinacriticalcarearea.
Mostpoisonsthatimpairconsciousnessalsodepress
respiration.Assistedventilation(eithermouth-to-mouth
orusingabag-valve-maskdevice)maybeneeded.
Oxygenisnotasubstituteforadequateventilation,
althoughitshouldbegiveninthehighestconcentration
possibleinpoisoningwithcarbonmonoxideandirritant
gases.
Thepotentialforpulmonaryaspirationofgastriccon-
tentsshouldbeconsidered.
Bloodpressure
Hypotensioniscommoninseverepoisoningwithcen-
tralnervoussystemdepressants;ifseverethismaylead
toirreversiblebraindamageorrenaltubularnecrosis.
Hypotensionshouldbecorrectedinitiallybyraisingthe
footofthebedandadministrationofeithersodium
chlorideintravenousinfusionoracolloidalinfusion.
Emergencytreatmentofpoisoning
sants,someantipsychotics,andsomeantihistamines.
Arrhythmiasoftenrespondtocorrectionofunderlying
hypoxia,acidosis,orotherbiochemicalabnormalities,
butventriculararrhythmiasthatcauseserioushypo-
tensionmayrequiretreatment(section2.3.1).Ifthe
QTintervalisprolonged,specialistadviceshouldbe
soughtbecausetheuseofsomeanti-arrhythmicdrugs
maybeinappropriate.Supraventriculararrhythmiasare
seldomlife-threateninganddrugtreatmentisbestwith-
helduntilthechildreacheshospital.
Bodytemperature
Hypothermiamaydevelopinpatientsofanyagewho
havebeendeeplyunconsciousforsomehours,particu-
larlyfollowingoverdosewithbarbituratesorphenothi-
azines.Itmaybemissedunlesscoretemperatureis
CHARCOAL,ACTIVATED
drowsyorcomatosechild(riskofaspira-
tionÑensureairwayprotected);reducedgastro-
intestinalmotility(riskofobstruction);
forpois-
Emergencytreatmentofpoisoning
ctiveeliminationofpoisons
Bymouth
1g/kgevery4hours
Child1month–12years
1g/kg(max.50g)every
4hours
hild12–18years
50gevery4hours
suspensionorreconstitutedpowder
Emergencytreatmentofpoisoning
isanalternativeifintravenousaccessisnotpossibleÑ
contacttheNationalPoisonsInformationServicefor
advice.Inremoteareas,
Emergencytreatmentofpoisoning
4hoursand6.25mg/litre(0.04mmol/litre)at24hours
abouttimingortheneedfortreatmentthenthechild
Emergencytreatmentofpoisoning
NALOXONEHYDROCHLORIDE
physicaldependenceonopioids;cardiac
irritability;naloxoneisshort-acting,seenotesabove
section15.1.7
section15.1.7
Indicationanddose
SafePractice
Dosesusedinacuteopioidoverdosagemaynotbe
appropriateforthemanagementofopioid-induced
respiratorydepressionandsedationinthosereceiving
palliativecareandinchronicopioiduse;seealso
section15.1.7formanagementofpostoperativeresp-
iratorydepression
verdosagewithopioids
Byintravenousinjection
10micrograms/kg;ifnoresponse,give
subsequentdoseof100micrograms/kg(then
reviewdiagnosis);furtherdosesmayberequiredif
Emergencytreatmentofpoisoning
butsotalolmayinduceventriculartachyarrhythmias
clearairwayandadequateventilationismandatory.An
intravenousinjectionofatropineisrequiredtotreat
bradycardia(40micrograms/kg,max.3mg).Cardio-
genicshockunresponsivetoatropineisprobablybest
treatedwithanintravenousinjectionofglucagon(50Ð
150micrograms/kg,max.10mg)[unlicensedindication
anddose]inglucose5%(withprecautionstoprotectthe
airwayincaseofvomiting)followedbyanintravenous
infusionof50micrograms/kg/hour.Ifglucagonisnot
available,intravenousisoprenaline(availablefromÔspe-
cial-orderÕmanufacturersorspecialistimportingcom-
panies,seep.809)isanalternative.Acardiacpace-
makercanbeusedtoincreasetheheartrate.
Calcium-channelblockers
Featuresofcalcium-channelblockerpoisoninginclude
nausea,vomiting,dizziness,agitation,confusion,and
DESFERRIOXAMINEMESILATE
(DeferoxamineMesilate)
section9.1.3
Renalimpairment
section9.1.3
section9.1.3
section9.1.3
section9.1.3
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturer)
Indicationanddose
ronpoisoning
Bycontinuousintravenousinfusion
upto15mg/kg/hour,reducedafter4Ð6
hours;max.80mg/kgin24hours(inseverecases,
higherdosesonadvicefromtheNationalPoisons
InformationService)
Child1month–18years
upto15mg/kg/hour,
reducedafter4Ð6hours;max.80mg/kgin24
hours(inseverecases,higherdosesonadvice
fromtheNationalPoisonsInformationService)
hronicironoverload
section9.1.3
Section9.1.3
Lithiumintoxicationcanoccurasacomplicationof
Emergencytreatmentofpoisoning
illness.Vomiting,diarrhoea,ataxia,weakness,dysar-
thria,muscletwitching,andtremormayfollow.Severe
poisoningisassociatedwithconvulsions,coma,renal
failure,electrolyteimbalance,dehydration,andhypo-
Therapeuticserum-lithiumconcentrationsarewithin
therangeof0.4Ð1mmol/litre;concentrationsinexcess
of2mmol/litreareusuallyassociatedwithserious
toxicityandsuchcasesmayneedtreatmentwith
haemodialysisifneurologicalsymptomsorrenalfailure
arepresent.Inacuteoverdosage,muchhigherserum-
litiumconcentrationsmaybepresentwithoutfeatures
oftoxicityandallthatisusuallynecessaryistotake
measurestoincreaseurineoutput(e.g.byincreasing
Emergencytreatmentofpoisoning
Cyanides
shouldbeadministeredtochildrenwithcya-
nidepoisoning.Thechoiceofantidotedependsonthe
severityofpoisoning,certaintyofdiagnosis,andthe
cause.
HYDROXOCOBALAMIN
gastro-intestinaldisturbances,transient
hypertension,peripheraloedema,dyspnoea,throat
disorders,hotßush,dizziness,headache,restlessness,
memoryimpairment,redcolorationofurine,lym-
phocytopenia,eyedisorders,pustularrashes,pruritus,
reversibleredcolorationofskinandmucousmem-
Indicationanddose
oisoningwithcyanides
seenotesabove
Byintravenousinfusion
Childbody-weight5kgandover
70mg/kg
(max.5g)over15minutes;aseconddose
of70mg/kg(max.5g)canbegivenover
15minutesÐ2hoursdependingonseverityof
poisoningandpatientstability
intravenousinfusion
,reconstitute
2.5-gvialwith100mLSodiumChloride0.9%;gently
invertvialforatleast30secondstomix;donotshake
Cyanokit
(SwedishOrphan)
Intravenousinfusion
,powderforreconstitution,
SODIUMNITRITE
ßushingandheadacheduetovasodila-
Indicationanddose
oisoningwithcyanides(usedinconjunction
withsodiumthiosulphate)
Seeunderpreparation
SodiumNitrite
,sodiumnitrite3%(30mg/mL)inwaterfor
Byintravenousinjectionover5–20minutes
Child1month–18years
4Ð10mg/kgmax.300mg
(0.13Ð0.33mL/kg,max.10mL,of3%solution)followed
bysodiumthiosulphateinjection400mg/kg,max.12.5g
(0.8mL/kg,max.25mL,of50%solution)over10min-
AvailablefromÔspecial-orderÕmanufacturersorspecialist
importingcompanies,seep.809
restrictiondoesnotapplywhereadministrationisfor
savinglifeinemergency
SODIUMTHIOSULPHATE
Indicationanddose
oisoningwithcyanides
(usedinconjunctionwith
sodiumnitrite)
SeeaboveunderSodiumNitrite
SodiumThiosulphate
,sodiumthiosulphate50%(500mg/mL)in
waterforinjections
AvailablefromÔspecial-orderÕmanufacturersorspecialist
importingcompanies,seep.809
restrictiondoesnotapplywhereadministrationisfor
savinglifeinemergency
NationalPoisonsInformationService.Itisimportant
tostartantidotetreatmentpromptlyincasesofsus-
pectedpoisoningwiththeseagents.
Emergencytreatmentofpoisoning
nausea,diarrhoea,abdominalpain,pain
atsiteofinjection,thrombophlebitisifgiventoo
rapidly,renaldamageparticularlyinoverdosage;
hypotension,lacrimation,myalgia,nasalcongestion,
sneezing,malaise,thirst,fever,chills,headacheand
throughtheAmbulanceServicefromtheNationalBlood
Service(ortheWelshBloodServiceinSouthWalesor
designatedhospitalpharmaciesinNorthernIrelandand
ScotlandÑseeTOXBASEforlistofdesignatedcentres).
NationalPoisonsInformationService
(Tel:
08448920111)willprovidespecialistadviceonall
aspectsofpoisoningdayandnight
Pesticides
Organophosphorusinsecticides
phorusinsecticidesareusuallysuppliedaspowdersor
dissolvedinorganicsolvents.Allareabsorbedthrough
thebronchiandintactskinaswellasthroughthegut
andinhibitcholinesteraseactivity,therebyprolonging
Emergencytreatmentofpoisoning
administration.Pralidoximechlorideiscontinueduntil
thepatienthasnotrequiredatropinefor12hours.
Pralidoximechloridecanbeobtainedfromdesignated
centres,thenamesofwhichareheldbytheNational
PoisonsInformationService(seep.24).
NationalPoisonsInformationService
(Tel:
08448920111)willprovidespecialistadviceonall
aspectsofpoisoningdayandnight
PRALIDOXIMECHLORIDE
myastheniagravis
Contra-indications
poisoningwithcarbamatesor
organophosphoruscompoundswithoutanti-
cholinesteraseactivity
Renalimpairment
usewithcaution
drowsiness,dizziness,disturbancesof
vision,nausea,tachycardia,headache,hyperventila-
tion,andmuscularweakness
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturer)
Indicationanddose
djuncttoatropineinthetreatmentofpois-
oningbyorganophosphorusinsecticideor
nerveagent
Byintravenousinfusionover20minutes
Childunder18years
initially30mg/kg,followed
by8mg/kg/hour;usualmax.12gin24hours
Theloadingdosemaybeadministered
byintra-
venousinjection
(dilutedtoaconcentrationof50mg/
mLwithwaterforinjections)overatleast5minutesif
pulmonaryoedemaispresentorifitisnotpracticalto
administeranintravenousinfusion;pralidoximechloride
dosesmaydifferfromthoseinproductliterature
Pralidoximechloride
,powderforreconstitutionpralidoxime
chloride1g/vial
Availableas
(fromdesignatedcentresfororgano-
phosphorusinsecticidepoisoningorfromtheNationalBlood
Service(orWelshAmbulanceServicesforMidWestandSouth
EastWales)ÑseeTOXBASEforlistofdesignatedcentres)
restrictiondoesnotapplywhereadministrationisfor
savinglifeinemergency
Snakebitesandanimalstings
Snakebites
Envenomingfromsnakebiteisuncom-
monintheUK.Manyexoticsnakesarekept,some
illegally,buttheonlyindigenousvenomoussnakeisthe
adder(
Viperaberus
).Thebitemaycauselocaland
systemiceffects.Localeffectsincludepain,swelling,
bruising,andtenderenlargementofregionallymph
nodes.Systemiceffectsincludeearlyanaphylactic
symptoms(transienthypotensionwithsyncope,angio-
edema,urticaria,abdominalcolic,diarrhoea,andvomi-
ting),withlaterpersistentorrecurrenthypotension,
ECGabnormalities,spontaneoussystemicbleeding,
coagulopathy,adultrespiratorydistresssyndrome,and
acuterenalfailure.Fatalenvenomingisrarebutthe
potentialforsevereenvenomingmustnotbeunder-
Earlyanaphylacticsymptomsshouldbetreatedwith
adrenaline
epinephrine
)(section3.4.3).Indications
forantivenomtreatmentinclude
systemicenvenoming
especiallyhypotension(seeabove),ECGabnormalities,
vomiting,haemostaticabnormalities,andmarkedlocal
envenomingsuchthatafterbitesonthehandorfoot,
swellingextendsbeyondthewristoranklewithin4
hoursofthebite.Thecontentsofonevial(10mL)of
Europeanvipervenomantiserum
(availablefrom
Movianto)isgiven
byintravenousinjection
over10Ð
15minutesor
byintravenousinfusion
over30minutes
afterdilutinginsodiumchlorideintravenousinfusion
0.9%(use5mLdiluent/kgbody-weight).The
shouldbeusedfor
children
.The
dosecanberepeatedafter1Ð2hoursifsymptomsof
systemicenvenoming
persist.However,forthosechil-
drenwhopresentwithclinicalfeaturesof
severeenve-
(e.g.shock,ECGabnormalities,orlocalswelling
thathasadvancedfromthefoottoabovethekneeor
fromthehandtoabovetheelbowwithin2hoursofthe
bite),aninitialdoseof2vials(20mL)oftheantiserumis
recommended;ifsymptomsof
systemicenvenoming
persistcontacttheNationalPoisonsInformationSer-
vice.Adrenaline(epinephrine)injectionmustbeimme-
diatelytohandfortreatmentofanaphylacticreactions
totheantivenom(forthemanagementofanaphylaxis
seesection3.4.3).
Antivenomisavailableforbitesbycertainforeign
snakesandspiders,stingsbyscorpionsandÞsh.For
informationonidentiÞcation,management,andfor
supplyinanemergency,telephonetheNationalPoisons
InformationService.WheneverpossibletheTOXBASE
entryshouldberead,andrelevantinformationcol-
lected,beforetelephoningtheNationalPoisonsInfor-
mationService(seep.24).
Insectstings
Emergencytreatmentofpoisoning
Gastro-intestinalsystem
Dyspepsiaandgastro-oeso-
phagealreßuxdisease
Gastro-intestinalsystem
hypercalcaemiaandalkalosis.
ALUMINIUMHYDROXIDE
seenotesabove;
Appendix1
Contra-indications
hypophosphataemia;neonates
andinfants
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
Gastro-intestinalsystem
Indicationanddose
fordoseseepreparations
yperphosphataemia
section9.5.2.2
Co-magaldrox
Co-magaldroxisamixtureofaluminiumhydroxideand
magnesiumhydroxide;theproportionsareexpressedinthe
form
arethestrengthsinmilligramsperunit
doseofmagnesiumhydroxideandaluminiumhydroxide
respectively
,sugar-free,co-magaldrox195/220
(magnesiumhydroxide195mg,driedaluminium
hydroxide220mg/5mL(lowNa
MAGNESIUMTRISILICATE
HYDROTALCITE
Aluminiummagnesiumcarbonatehydroxide
hydrate
seenotesabove;
Appendix1
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
Indicationanddose
fordoseseeunderpreparation
Gastro-intestinalsystem
Colicdrops
80mg/5mL.Contains3.1mmolNa
Gastro-intestinalsystem
Child1monthÐ2years
Body-weightunder4.5kg
doseasforneonate
BodyÐweightover4.5kg
2‘doses’mixedwithfeeds(or
water,forbreast-fedinfants)whenrequired(max.6times
in24hours)
Antimuscarinicsshouldbeusedwithcaution
inchildren(especiallychildrenwithDown’ssyndrome)
duetoincreasedriskofside-effects;theyshouldalsobe
usedwithcautioninautonomicneuropathy,hyper-
tension,conditionscharacterisedbytachycardia
(includinghyperthyroidism,cardiacinsufciency,car-
diacsurgery),pyrexia,andinchildrensusceptibleto
angle-closureglaucoma.Antimuscarinicsarenotused
inchildrenwithgastro-oesophagealreuxdisease,
diarrhoeaorulcerativecolitis.
Appendix
1(antimuscarinics).
Contra-indications
Antimuscarinicsarecontra-indi-
catedinmyastheniagravis(butmaybeusedtodecrease
muscarinicside-effectsofanticholinesterases—section
10.2.1),paralyticileus,pyloricstenosis,andtoxicmega-
Side-effectsofantimuscarinicsinclude
constipation,transientbradycardia(followedbytachy-
cardia,palpitationandarrhythmias),reducedbronchial
DICYCLOVERINEHYDROCHLORIDE
(Dicyclominehydrochloride)
seenotesabove
Contra-indications
seenotesabove;childunder6
notknowntobeharmful;manufacturer
advisesuseonlyifessential
avoid—presentinmilk;apnoea
reportedininfant
seenotesabove
Indicationanddose
ymptomaticreliefofgastro-intestinaldisor-
derscharacterisedbysmoothmusclespasm
Bymouth
Child6monthsÐ2years
5–10mg3–4timesdaily
15minutesbeforefeeds
hild2Ð12years
10mg3timesdaily
hild12Ð18years
10–20mg3timesdaily
Merbentyl
Compoundpreparations
Kolanticon
(Peckforton)
,sugar-free,dicycloverinehydrochloride2.5mg,
driedaluminiumhydroxide200mg,lightmagnesium
Gastro-intestinalsystem
HYOSCINEBUTYLBROMIDE
seenotesabove;alsointestinalandurinary
PROPANTHELINEBROMIDE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
manufactureradvisescaution
Renalimpairment
manufactureradvisescaution
manufactureradvisesavoidunlessessen-
maysuppresslactation
seenotesabove
Licenseduse
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Otherantispasmodics
Alverine
mebeverine
,and
peppermintoil
believedtobedirectrelaxantsofintestinalsmooth
muscleandmayrelievepainin
irritablebowel
syndrome
andprimarydysmenorrhoea.Theyhaveno
seriousadverseeffects;peppermintoiloccasionally
causesheartburn.
ALVERINECITRATE
Contra-indications
paralyticileus
usewithcaution
manufactureradvisesavoid—limited
informationavailable
nausea;headache,dizziness;pruritus,
rash;hepatitisalsoreported
Indicationanddose
djunctingastro-intestinaldisorderscharac-
terisedbysmoothmusclespasm,dysmenorr-
Bymouth
Child12Ð18years
60–120mg1–3timesdaily
Spasmonal
Capsules
MEBEVERINEHYDROCHLORIDE
avoidinacuteporphyria(section9.8.2)
Contra-indications
paralyticileus
notknowntobeharmful—manufacturers
advisecaution
allergicreactions(includingrash,urti-
caria,angioedema)reported
1.2Antispasmodicsandotherdrugsalteringgutmotility
BNFC2011–
Gastro-intestinalsystem
Licenseduse
ModiÞedrelease
Colofac
(AbbottHealthcare)
Capsules
,m/r,mebeverinehydrochloride200mg,
Compoundpreparations
Mebeverine
(ReckittBenckiser)
,buff,effervescent,ispaghulahusk3.5g,
PEPPERMINTOIL
sensitivitytomenthol
notknowntobeharmful
signicantlevelsofmentholinbreast
milkunlikely
heartburn,perianalirritation;
rarely
allergicreactions(includingrash,headache,brady-
cardia,muscletremor,ataxia)
Localirritation
Capsulesshouldnotbebrokenorchewed
becausepeppermintoilmayirritatemouthoroesophagus
Indicationanddose
eliefofabdominalcolicanddistension,par-
ticularlyinirritablebowelsyndrome
Bymouth
Child15Ð18years
1–2capsules,swallowed
wholewithwater,3timesdailyforupto3months
ifnecessary
Colpermin
Capsules
,e/c,lightblue/darkblue,blueband,
seeunderDomperidone(section4.6)
seeunderDomperidone(section4.6);
alsoQT-intervalprolongationreported
Licenseduse
notlicensedforuseingastro-intestinal
stasis;notlicensedforuseinchildrenforgastro-
oesophagealreuxdisease
Indicationanddose
astro-oesophagealreßuxdisease(butefÞcacy
notproven,seesection1.1),gastro-intestinal
Bymouth
100–300micrograms/kg4–6timesdaily
beforefeeds
Child1monthÐ12years
200–400micrograms/
kg(max.20mg)3–4timesdailybeforefood
hild12Ð18years
10–20mg,3–4timesdaily
beforefood
auseaandvomiting
section4.6
Section4.6
seesection5.1.5;
Appendix1
(macrolides)
seesection5.1.5
BNFC2011–
20121.2Antispasmodicsandotherdrugsalteringgutmotility
Gastro-intestinalsystem
Licenseduse
notlicensedforuseingastro-intestinal
Indicationanddose
astro-intestinalstasis
Bymouth
3mg/kg4timesdaily
Child1monthÐ18years
3mg/kg4timesdaily
Byintravenousinfusion
3mg/kg4timesdaily
Child1monthÐ1year
3mg/kg4timesdaily
Section5.1.5
Recommendedregimensfor
Helicobacterpylori
Eradicationtherapy
AgerangeOraldose
(tobeusedincombinationwithomeprazole,section1.3.5)
Amoxicillin
1–6years250mgtwicedaily(withclarithromycin)
Gastro-intestinalsystem
Testfor
Helicobacterpylori
C-Ureabreathtestkitsareavailableforconrmingthe
presenceofgastro-duodenalinfectionwith
Helicobacter
pylori
.Thetestinvolvescollectionofbreathsamples
beforeandafteringestionofanoralsolutionof
thesamplesaresentforanalysisbyanappropriate
laboratory.Thetestshouldnotbeperformedwithin4
weeksoftreatmentwithanantibacterialorwithin2
acuteporphyria;
Appendix1
(histamineH
Renalimpairment
usehalfnormaldoseifestimated
glomerularltrationratelessthan50mL/minute/
1.73m
manufactureradvisesavoidunlessessen-
tial,butnotknowntobeharmful
signicantamountpresentinmilk,
butnotknowntobeharmful
seenotesabove;also
lesscommonly
blurredvision;alsoreportedpancreatitis,involuntary
movementdisorders,interstitialnephritis,alopecia
Licenseduse
preparationsnotlicensedforuse
inchildrenunder3years;
injection
notlicensedfor
useinchildrenunder6months
Indicationanddose
eßuxoesophagitis,benigngastricandduo-
denalulceration,prophylaxisofstressulcer-
ation,otherconditionswheregastricacid
reductionisbeneÞcial
(seenotesaboveandsec-
tion1.9.4)
Bymouth
2mg/kg3timesdailybutabsorption
unreliable;max.3mg/kg3timesdaily
BNFC2011–
1.3.1H
-receptorantagonists
Gastro-intestinalsystem
Child1Ð6months
1mg/kg3timesdaily;max.
3mg/kg3timesdaily
hild6monthsÐ3years
2–4mg/kgtwicedaily
hild3Ð12years
2–4mg/kg(max.150mg)twice
daily;increasedupto5mg/kg(max.300mg)
twicedailyinseveregastro-oesophagealreux
hild12Ð18years
150mgtwicedaily
300mg
atnight;increasedifnecessary,to300mgtwice
150mg4timesdailyforupto12weeksin
moderatetoseveregastro-oesophagealreux
Infatmalabsorptionsyndrome,give1–2hours
beforefoodtoenhanceeffectsofpancreaticenzyme
Byslowintravenousinjection
0.5–1mg/kgevery6–8hours
Child1monthÐ18years
1mg/kg(max.50mg)
every6–8hours(maybegivenasanintermittent
infusionatarateof25mg/hour)
For
slowintravenousinjection
toaconcentrationof2.5mg/mLwithGlucose5%
SodiumChloride0.9%;giveoveratleast3minutes
Ranitidine
SUCRALFATE
administrationofsucralfateandenteral
feedsshouldbeseparatedby1hour;
Appendix1(sucralfate)
Bezoarformation
Followingreportsofbezoarformation
associatedwithsucralfate,cautionisadvisedinseriouslyill
patients,especiallythosereceivingconcomitantenteral
feedsorthosewithpredisposingconditionssuchasdelayed
gastricemptying
Renalimpairment
usewithcaution;aluminiumis
absorbedandmayaccumulate
noevidenceofharm;absorptionfrom
gastro-intestinaltractnegligible
amountprobablytoosmalltobe
harmful
lessfrequently
diarrhoea,
nausea,indigestion,atulence,gastricdiscomfort,
backpain,dizziness,headache,drowsiness,bezoar
formation(seeabove),drymouth,andrash
Licenseduse
notlicensedforuseinchildrenunder
Gastro-intestinalsystem
Protonpumpinhibitors
Appendix1(protonpump
Hepaticimpairment
child1–12years
max.10mg
dailyinsevereimpairment;
child12–18years
20mgdailyinsevereimpairment
Renalimpairment
manufactureradvisescautionin
severerenalinsufciency
manufactureradvisescaution—noinfor-
mationavailable
manufactureradvisesavoid—no
informationavailable
seenotesabove
Licenseduse
nasogastricorgastrictube
Appendix1(protonpump
Hepaticimpairment
usehalfnormaldoseinmoder-
atetosevereliverdisease
manufactureradvisesavoid
avoidunlessessential—presentin
milkin
animal
seenotesabove;alsoglossitis,pan-
creatitis,anorexia,restlessness,tremor,impotence,
Gastro-intestinalsystem
foradministrationbya
nasogastric
oran
oralsyringe
ZotonFasTab
canbe
dispersedinasmallamountofwater
Zoton
OMEPRAZOLE
Appendix1(protonpump
Hepaticimpairment
nomorethan700micrograms/
kg(max.20mg)oncedaily
notknowntobeharmful
presentinmilkbutnotknowntobe
harmful
seenotesabove;alsoagitationand
Licenseduse
Gastro-intestinalsystem
mendedforuseinchildrenunder12years.Fluidand
electrolytereplacement(section9.2.1.2)areofprime
importanceinthetreatmentofacutediarrhoea.
(section1.2)areoccasionallyofvalue
intreatingabdominalcrampassociatedwithdiarrhoea
buttheyshould
beusedforprimarytreatment.
CODEINEPHOSPHATE
seesection4.7.2;toleranceanddependence
mayoccurwithprolongeduse;
Appen-
dix1(opioidanalgesics)
Contra-indications
seesection4.7.2;alsoconditions
whereinhibitionofperistalsisshouldbeavoided,
whereabdominaldistensiondevelops,orinacute
diarrhoealconditionssuchasacuteulcerativecolitis
orantibiotic-associatedcolitis
Hepaticimpairment
section4.7.2
Renalimpairment
section4.7.2
section4.7.2
section4.7.2
section4.7.2
Indicationanddose
(butseenotesabove)
Bymouth
Child12Ð18years
30mg(range15–60mg)3–4
timesdaily
section4.7.2
Section4.7.2
CO-PHENOTROPE
Amixtureofdiphenoxylatehydrochlorideandatro-
pinesulphateinthemassproportions100partsto1
partrespectively
section4.7.2;alsoyoungchildrenareparti-
cularlysusceptibleto
overdosage
andsymptomsmay
bedelayedandobservationisneededforatleast48
hoursafteringestion;presenceofsubclinicaldosesof
atropinemaygiverisetoatropineside-effectsin
susceptibleindividualsorinoverdosage(section1.2);
Appendix1(antimuscarinics,opioid
Contra-indications
section4.7.2andalsoseeunder
Antimuscarinics(section1.2)
Hepaticimpairment
section4.7.2;alsoavoidin
Renalimpairment
section4.7.2
section4.7.2
maybepresentinmilk
section4.7.2andalsoseeunderAnti-
muscarinics(section1.2);alsoabdominalpain,ano-
rexia,fever
Licenseduse
notlicensedforuseinchildrenunder4
years
Indicationanddose
Seepreparations
foradministration
bymouth
LOPERAMIDEHYDROCHLORIDE
seenotesabove;
Appendix1
Contra-indications
conditionswhereinhibitionof
peristalsisshouldbeavoided,whereabdominaldis-
tensiondevelops,orinconditionssuchasactive
ulcerativecolitisorantibiotic-associatedcolitis
Hepaticimpairment
riskofaccumulation—manufac-
tureradvisescaution
manufactureradvisesavoid—noinforma-
tionavailable
amountprobablytoosmalltobe
harmful
BNFC2011–
1.4.1Adsorbentsandbulk-formingdrugs
Gastro-intestinalsystem
abdominalcramps,dizziness,drowsi-
ness,andskinreactionsincludingurticaria;paralytic
ileusandabdominalbloatingalsoreported
Licenseduse
notlicensedforuseinchil-
drenunder8years;
notlicensedforusein
childrenunder4years;notlicensedforusein
childrenforchronicdiarrhoea
Indicationanddose
hronicdiarrhoea
Bymouth
Child1monthÐ1year
100–200micrograms/kg
twicedaily,30minutesbeforefeeds;upto2mg/kg
dailyindivideddosesoccasionallyrequired
hild1Ð12years
100–200micrograms/kg(max.
2mg)3–4timesdaily;upto1.25mg/kgdailyin
divideddosesmayberequired(max.16mgdaily)
hild12Ð18years
2–4mg2–4timesdaily(max.
16mgdaily)
cutediarrhoea
(butseenotesabove)
Bymouth
Child4Ð8years
1mg3–4timesdailyfor
upto3
daysonly
hild8Ð12years
2mg4timesdailyforupto5
hild12Ð18years
initially4mg,then2mgafter
eachloosestoolforupto5days(usualdose6–
8mgdaily;max.16mgdaily)
Compoundpreparations
Inßammatoryboweldisease
Chronicinammatoryboweldiseasesinclude
ulcerative
CrohnÕsdisease
.Thetreatmentofinamm-
atoryboweldiseaseinchildrenshouldbeinitiatedand
supervisedbyapaediatricgastroenterologist.Effective
managementrequiresdrugtherapy,attentiontonutri-
tion,andinsevereorchronicactivedisease,surgery.
(balsalazide,mesalazine,olsalazine,
andsulfasalazine),
corticosteroids
(hydrocortisone,
budesonide,andprednisolone),and
drugsthataffect
theimmuneresponse
areusedinthetreatmentof
inammatoryboweldisease.
TreatmentofacuteulcerativecolitisandCrohnÕs
Acutemildtomoderatediseaseaffectingthe
rectum(proctitis)ortherecto-sigmoid(distalcolitis)is
treatedinitiallywithlocalapplicationofanaminosali-
cylate(section1.5.1);alternativelyalocalcorticosteroid
(section1.5.2)canbeusedbutitislesseffective.Foam
preparationsandsuppositoriesareusefulforchildren
Gastro-intestinalsystem
NICEguidance
InßiximabforCrohnÕsdisease(May2010)
Inchildrenover6yearsofage,iniximabisrecom-
mendedforthetreatmentofsevereactiveCrohn’s
diseasethathasnotrespondedtoconventional
therapy(includingcorticosteroids,otherdrugs
affectingtheimmuneresponse,andprimarynutri-
tiontherapy)orwhenconventionaltherapycannot
beusedbecauseofintoleranceorcontra-indications.
Iniximabshouldbegivenasaplannedcourseof
treatmentfor12monthsoruntiltreatmentfailure,
whicheverisshorter.Treatmentshouldbecontinued
beyond12monthsonlyifthereisevidenceofactive
disease—inthesecasestheneedfortreatment
shouldbereviewedatleastannually.Ifthedisease
relapsesafterstoppingtreatment,iniximabcanbe
restarted[butseeHypersensitivityReactionsunder
Iniximab,p.55].
NICEguidance
Inßiximabforsubacutemanifestationsof
ulcerativecolitis(April2008)
Iniximabis
recommendedforthetreatmentof
subacutemanifestationsofmoderatetosevere
activeulcerativecolitisthatwouldnormallybeman-
tulatingCrohn’sdiseaserefractorytoconventional
treatments;maintenancetherapywithiniximabshould
beconsideredforpatientswhorespondtotheinitial
inductioncourse.
Adjunctivetreatmentofinßammatoryboweldis-
Gastro-intestinalsystem
salicylicacid)and
(adimerof5-aminosali-
cylicacidwhichcleavesinthelowerbowel),thesulfo-
namide-relatedside-effectsofsulfasalazineareavoided,
but5-aminosalicylicacidalonecanstillcauseside-
effectsincludingblooddisorders(seerecommendation
below)andlupus-likesyndromealsoseenwithsulfasa-
lazine.
Renalfunctionshouldbemonitoredbefore
startinganoralaminosalicylate,at3monthsoftreat-
ment,andthenannuallyduringtreatment(morefre-
quentlyinrenalimpairment).Blooddisorderscanoccur
withaminosalicylates(seerecommendationbelow).
Blooddisorders
Childrenreceivingaminosalicylatesandtheircarers
shouldbeadvisedtoreportanyunexplainedbleed-
ing,bruising,purpura,sorethroat,feverormalaise
thatoccursduringtreatment.Abloodcountshould
beperformedandthedrugstoppedimmediatelyif
thereissuspicionofablooddyscrasia.
Contra-indications
Aminosalicylatesshouldbe
avoidedinsalicylatehypersensitivity.
Side-effectsoftheaminosalicylates
includediarrhoea,nausea,vomiting,abdominalpain,
exacerbationofsymptomsofcolitis,headache,hyper-
sensitivityreactions(includingrashandurticaria);side-
effectsthatoccurrarelyincludeacutepancreatitis,
hepatitis,myocarditis,pericarditis,lungdisorders
(includingeosinophiliaandbrosingalveolitis),periph-
eralneuropathy,blooddisorders(includingagranulo-
BALSALAZIDESODIUM
seenotesabove;alsohistoryofasthma;
Appendix1(aminosalicylates)
Blooddisorders
seerecommendationabove
Contra-indications
seenotesabove
Hepaticimpairment
avoidinsevereimpairment
Renalimpairment
manufactureradvisesavoidin
moderatetosevereimpairment
manufactureradvisesavoid
monitorinfantfordiarrhoea
seenotesabove;alsocholelithiasis
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
reatmentofmildtomoderateulcerativecolitis
andmaintenanceofremission
Bymouth
Child12Ð18years
acuteattack,2.25g3times
dailyuntilremissionoccursorforuptomax.12
weeks;maintenance,1.5gtwicedaily,adjusted
accordingtoresponse(max.3gtwicedaily)
Colazide
Capsules
seenotesabove;
Appendix1
Blooddisorders
seerecommendationabove
Contra-indications
seenotesabove;bloodclotting
abnormalities
Hepaticimpairment
avoidinsevereimpairment
Renalimpairment
usewithcaution;avoidifesti-
matedglomerularltrationratelessthan20mL/
minute/1.73m
negligiblequantitycrossesplacenta
diarrhoeareportedbutnegligible
Gastro-intestinalsystem
Asacol
(WarnerChilcott)
administration(seedose),blooddisordersymptoms
(seerecommendationabove)
Acuteattack
Bymouth
Child5Ð12years
15–20mg/kg(max.1g)3timesdaily
Child12Ð18years
1–2gtwicedaily;totaldailydose
mayalternativelybegivenin3–4divideddoses
Maintenanceofremission
Bymouth
Child5Ð12years
10mg/kg(max.500mg)2–3times
Child12Ð18years
2goncedaily
Gastro-intestinalsystem
Child6Ð18yearsandbody-weightover40kg
1.5–3g
oncedaily(preferablyinthemorning)
0.5–1g3times
Maintenanceofremission
Bymouth
Child6Ð18yearsandbody-weightunder40kg
10mg/kg3timesdaily;totaldailydosemayalternatively
begivenin2divideddoses
Child6Ð18yearsandbody-weightover40kg
500mg
3timesdaily
Granulesshouldbeplacedontongueand
washeddownwithwaterwithoutchewing
PreparationsthatlowerstoolpH(e.g.lactulose)may
preventreleaseofmesalazine
Suppositories
OLSALAZINESODIUM
seenotesabove;
Appendix1
Blooddisorders
seerecommendationabove
Contra-indications
seenotesabove
Renalimpairment
usewithcaution;manufacturer
advisesavoidinsignicantimpairment
manufactureradvisesavoidunlesspoten-
tialbenetoutweighsrisk
monitorinfantfordiarrhoea
seenotesabove;waterydiarrhoeacom-
mon;alsoreported,tachycardia,palpitation,pyrexia,
blurredvision,andphotosensitivity
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
reatmentofacuteattackofmildulcerative
Bymouth
Child2Ð18years
500mgtwicedailyafterfood
increasedifnecessaryover1weektomax.1g3
timesdaily
aintenanceofremissionofmildulcerative
Bymouth
Child2Ð18years
250–500mgtwicedailyafter
Capsulescanbeopenedandcontents
sprinkledonfood
Dipentum
(UCBPharma)
Capsules
seenotesabove;alsohistoryofallergyor
Gastro-intestinalsystem
aintenanceofremissionofmildtomoderate
andsevereulcerativecolitis
Bymouth
Child2Ð12years
5–7.5mg/kg(max.500mg)4
timesdaily
hild12Ð18years
500mg4timesdaily
reatmentofmildtomoderateorsevereulcer-
ativecolitisandmaintenanceofremission,
activeCrohnÕsdisease
Byrectumassuppositories
Child5Ð8years
500mgtwicedaily
hild8Ð12years
500mginthemorningand1g
atnight
hild12Ð18years
0.5–1gtwicedaily
uvenileidiopathicarthritis
section10.1.3
Sulfasalazine
section6.3.2;
Appendix1
(corticosteroids)
Contra-indications
section6.3.2
Hepaticimpairment
section6.3.2
section6.3.2
section6.3.2
section6.3.2
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seepreparations
Capsulescanbeopenedandthe
contentsmixedwithappleororangejuice
Budenofalk
(DrFalk)
Capsules
,pink,enclosinge/cgranules,budesonide
HYDROCORTISONE
section6.3.2;systemicabsorptionmay
occur;prolongeduseshouldbeavoided
Contra-indications
intestinalobstruction,bowelper-
foration,recentintestinalanastomoses,extensives-
tulas;untreatedinfection
section6.3.2;alsolocalirritation
Indicationanddose
nßammatoryboweldisease
Byintravenousadministration
Seep.375
Byrectum
Seepreparations
Colifoam
Gastro-intestinalsystem
PREDNISOLONE
section6.3.2;systemicabsorptionmay
occur;prolongeduseshouldbeavoided
Contra-indications
section6.3.2;intestinalobstruc-
tion,bowelperforation,recentintestinalanastomoses,
extensivestulas;untreatedinfection
Hepaticimpairment
section6.3.2
Renalimpairment
section6.3.2
section6.3.2
section6.3.2
section6.3.2
Licenseduse
Oralpreparations
Section6.3.2
Rectalpreparations
AZATHIOPRINE
section8.2.1;
Appendix1
Contra-indications
section8.2.1
Hepaticimpairment
section8.2.1
Renalimpairment
section8.2.1
section8.2.1
section8.2.1
section8.2.1
Licenseduse
notlicensedforuseinulcerativecol-
itisorCrohn’sdisease
Indicationanddose
evereulcerativecolitisandCrohnÕsdisease
Bymouth
Child2Ð18years
initially2mg/kgoncedaily,
thenincreasedifnecessaryupto2.5mg/kgonce
ransplantationrejection
section8.2.1
heumaticdiseases
section10.1.3
Section8.2.1
CICLOSPORIN
section8.2.2;
Appendix1
Hepaticimpairment
section8.2.2
Renalimpairment
section8.2.2
section8.2.2
section8.2.2
section8.2.2
Licenseduse
notlicensedforuseinulcerativecol-
1.5.3Drugsaffectingtheimmuneresponse
BNFC2011–
Gastro-intestinalsystem
Indicationanddose
efractoryulcerativecolitis
Bymouth
Child2Ð18years
initially2mg/kgtwicedaily,
doseadjustedaccordingtoblood-ciclosporin
concentrationandresponse;max.5mg/kgtwice
Important
Foradviceoncounsellingandconversion
Section8.2.2
MERCAPTOPURINE
section8.1.3;seealsoAzathioprine,section
Contra-indications
section8.1.3
Hepaticimpairment
section8.1.3
Renalimpairment
section8.1.3
section8.1.3
section8.1.3
section8.1.3
Licenseduse
notlicensedforuseinsevereulcer-
ativecolitisandCrohn’sdisease;forotherindica-
tions,seesection8.1.3
Indicationanddose
evereulcerativecolitisandCrohnÕsdisease
Bymouth
Child2Ð18years
1–1.5mg/kgoncedaily(initial
max.50mg;maybeincreasedto75mgoncedaily)
cuteleukaemias
section8.1.3
Section8.1.3
Section10.1.3
Cytokinemodulators
Inßiximab
isamonoclonalantibodywhichinhibitsthe
pro-inammatorycytokine,tumournecrosisfactor
alpha.Itshouldbeadministeredunderspecialistsuper-
visionwhereadequateresuscitationfacilitiesareavail-
ableandisusedinthetreatmentofsevererefractoryor
stulatingCrohn’sdiseaseinchildren.Iniximabshould
beusedonlywhentreatmentwithotherimmunomodu-
latingdrugshasfailedorisnottoleratedandforchildren
inwhomsurgeryisinappropriate.
monitorforinfectionsbefore,during,andfor
6monthsaftertreatment(seealsoTuberculosis
below);predispositiontoinfection;chronichepatitis
B—monitorforactiveinfection;heartfailure(dis-
continueifsymptomsdeveloporworsen;avoidin
moderateorsevereheartfailure);demyelinatingCNS
disorders(riskofexacerbation);historyofmalignancy
(considerdiscontinuingtreatmentifmalignancy
BNFC2011–
1.5.3Drugsaffectingtheimmuneresponse
Gastro-intestinalsystem
develops);historyofprolongedimmunosuppressant
orPUVAtreatmentinpatientswithpsoriasis;
inter-
Appendix1(iniximab)
Tuberculosis
Childrenshouldbeevaluatedfortuberculosis
beforetreatment.Activetuberculosisshouldbetreatedwith
standardtreatment(section5.1.9)foratleast2months
beforestartinginiximab.Childrenwhohavepreviously
receivedadequatetreatmentfortuberculosiscanstart
iniximabbutshouldbemonitoredevery3monthsfor
possiblerecurrence.Inthosewithoutactivetuberculosisbut
whowerepreviouslynottreatedadequately,chemoprophy-
SODIUMCROMOGLICATE
(Sodiumcromoglycate)
notknowntobeharmful
unlikelytobepresentinmilk
occasionalnausea,rashes,andjointpain
Indicationanddose
Gastro-intestinalsystem
Laxatives
Bulk-forminglaxatives
Stimulantlaxatives
Faecalsofteners
Osmoticlaxatives
Bowelcleansingpreparations
Peripheralopioid-receptor
antagonists
Beforeprescribinglaxativesitisimportanttobesure
thatthechild
constipatedandthattheconstipationis
secondarytoanunderlyingundiagnosedcomplaint.
Laxativesshouldbeprescribedbyahealthcareprofes-
sionalexperiencedinthemanagementofconstipation
ISPAGHULAHUSK
adequateuidintakeshouldbemaintained
toavoidintestinalobstruction
Contra-indications
difcultyinswallowing,intestinal
obstruction,colonicatony,faecalimpaction
atulenceandabdominaldistension
(especiallyduringtherstfewdaysoftreatment),
gastro-intestinalobstructionorimpaction;hyper-
sensitivityreported
Licenseduse
licensedforuseinchildren
(agerangenotspeciedbymanufacturer)
BNFC2011–
1.6Laxatives
Gastro-intestinalsystem
Indicationanddose
Seeunderpreparations
Counselling
Preparationsthatswellincontactwithliquid
shouldalwaysbecarefullyswallowedwithwaterandshould
notbetakenimmediatelybeforegoingtobed
,sugar-andgluten-free,ispaghulahusk
IspagelOrange
,beige,effervescent,sugar-andgluten-free,
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seeunderIspaghulaHusk
Contra-indications
seeunderIspaghulaHusk
seeunderIspaghulaHusk
Indicationanddose
fordoseseeunderpreparation
Counselling
Preparationsthatswellincontactwithliquid
shouldalwaysbecarefullyswallowedwithwaterandshould
notbetakenimmediatelybeforegoingtobed
Gastro-intestinalsystem
Stimulantlaxatives
Stimulantlaxativesinclude
sodiumpicosul-
,andmembersofthe
group,
.Theindicationsfordantronarelimited
(seebelow)byitspotentialcarcinogenicity(basedon
carcinogenicitystudies)andevidenceofgeno-
toxicity.Powerfulstimulantssuchas
(ananthra-
quinone)and
castoroil
BISACODYL
prolongeduse(riskofelectrolyteimbalance)
Contra-indications
intestinalobstruction,acute
abdominalconditions,acuteinammatorybowel
disease,severedehydration
seePregnancy,p.57
seenotesabove;nauseaandvomiting;
colitisalsoreported;
suppositories
localirritation
Indicationanddose
(Danthron)
avoidprolongedcontactwithskin(asin
incontinentpatientsorinfantswearingnappies)—risk
ofirritationandexcoriation;
studiesindicate
potentialcarcinogenicrisk
Contra-indications
seeBisacodylabove
manufacturersofco-danthramerandco-
danthrusateadviseavoid—noinformationavailable
manufacturersofco-danthramerand
co-danthrusateadviseavoid—limitedinformation
available
seenotesabove;alsourinemaybe
colouredred
Indicationanddose
onstipationinterminallyillchildren
fordose
seeunderpreparations
WithpoloxamerÔ188Õ(asco-danthramer)
Co-danthramersuspension5mL=oneco-danthramer
capsule,
strongco-danthramersuspension5mL=two
strongco-danthramercapsules
Co-danthramer
Gastro-intestinalsystem
Withdocusatesodium(asco-danthrusate)
Co-danthrusate
DOCUSATESODIUM
(Dioctylsodiumsulphosuccinate)
seenotesabove;donotgivewithliquid
parafn
Contra-indications
seenotesabove;alsofor
preparations
,haemorrhoidsoranalssure
notknowntobeharmful—manufacturer
advisescaution
presentinmilkfollowingoraladmin-
istration—manufactureradvisescaution;rectal
administrationnotknowntobeharmful
seenotesabove;alsorash
Licenseduse
adultoralsolutionandcapsules
licensedforuseinchildrenunder12years
Indicationanddose
Bymouth
Child6monthsÐ2years
12.5mg3timesdaily,
adjustedaccordingtoresponse(usepaediatricoral
hild2Ð12years
12.5–25mg3timesdaily,
adjustedaccordingtoresponse(usepaediatricoral
hild12Ð18years
upto500mgdailyindivided
doses,adjustedaccordingtoresponse
Oralpreparationsactwithin1–2days;responseto
rectaladministrationusuallyoccurswithin20minutes
djunctinabdominalradiologicalprocedures
Bymouth
Child12Ð18years
400mgwithbariummeal
foradministration
bymouth
,solution
maybemixedwithmilkorsquash
(UCBPharma)
Capsules
,yellow/white,docusatesodium100mg,
Rectalpreparations
NorgalaxMicro-enema
,docusatesodium120mgin10-gsingle-dose
GLYCEROL
Indicationanddose
Byrectum
Child1monthÐ1year
1-gsuppositoryasrequired
hild1Ð12years
2-gsuppositoryasrequired
hild12Ð18years
4-gsuppositoryasrequired
GlycerolSuppositories,BP
(GlycerinSuppositories)
Suppositories
,gelatin140mg,glycerol700mg,pur-
seenotesabove
Contra-indications
seenotesabove
seePregnancy,p.57
notknowntobeharmful
seenotesabove
Licenseduse
Gastro-intestinalsystem
Senokot
(ReckittBenckiser)
SODIUMPICOSULFATE
(Sodiumpicosulphate)
seenotesabove;activeinammatorybowel
disease(avoidiffulminant)
Contra-indications
seenotesabove;severedehydra-
seePregnancy,p.57
notknowntobepresentinmilkbut
manufactureradvisesavoidunlesspotentialbenet
outweighsrisk
seenotesabove
Licenseduse
,licensedforuseinchildren(age
rangenotspeciedbymanufacturer);
licensedforuseinchildrenunder4years
Indicationanddose
Bymouth
Child1monthÐ4years
2.5–10mgoncedaily,
adjustedaccordingtoresponse
hild4Ð18years
2.5–20mgoncedaily,adjusted
accordingtoresponse
Bowelcleansingpreparations
Section1.6.5
Faecalsofteners
Enemascontaining
arachisoil
(ground-nutoil,peanut
oil)lubricateandsoftenimpactedfaecesandpromotea
bowelmovement.
Bulklaxatives(section1.6.1)andnon-ionicsurfactant
ARACHISOIL
intestinalobstruction;hypersensitivityto
soya
Contra-indications
inammatoryboweldisease,
hypersensitivitytoarachisoilorpeanuts
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer
Indicationanddose
mpactedfaeces
Byrectum
Child3Ð7years
45–65mLasrequired
hild7Ð12years
65–100mLasrequired
hild12Ð18years
100–130mLasrequired
warmenemainwarmwaterbefore
ArachisOilEnema
LACTULOSE
lactoseintolerance;
Appendix
1(lactulose)
Contra-indications
galactosaemia,intestinalobstruc-
notknowntobeharmful;seealso
Pregnancy,p.57
nausea(canbereducedbyadministra-
tionwithwater,fruitjuiceorwithmeals),vomiting,
atulence,cramps,andabdominaldiscomfort
BNFC2011–
1.6.3Faecalsofteners
Gastro-intestinalsystem
Licenseduse
notlicensedforuseinchildrenfor
hepaticencephalopathy
Indicationanddose
(maytakeupto48hourstoact)
Bymouth
Child1monthÐ1year
2.5mLtwicedaily,
adjustedaccordingtoresponse
hild1Ð5years
2.5–10mLtwicedaily,adjusted
accordingtoresponse
hild5Ð18years
5–20mLtwicedaily,adjusted
accordingtoresponse
epaticencephalopathy
Bymouth
Child12Ð18years
30–50mL3timesdaily;adjust
dosetoproduce2–3softstoolsperday
Gastro-intestinalsystem
89.3mg,sodiumchloride175.4mg,potassiumchlor-
MAGNESIUMSALTS
seealsonotesabove;
Appen-
dix1(antacids)
Contra-indications
acutegastro-intestinalconditions
Hepaticimpairment
avoidinhepaticcomaifriskof
renalfailure
Renalimpairment
avoidorreducedose;increased
riskoftoxicity
Indicationanddose
seeunderpreparationsbelow
Magnesiumhydroxide
MagnesiumHydroxideMixture,BP
Aqueoussuspensioncontainingabout8%hydrated
magnesiumoxide.Donotstoreincoldplace
Bymouth
Child3Ð12years
5–10mLwithwateratbedtimewhen
Child12Ð18years
30–45mLwithwateratbedtime
whenrequired
Bowelcleansingpreparations
Section1.6.5
PHOSPHATES(RECTAL)
seealsonotesabove;
withenema
,electro-
lytedisturbances,congestiveheartfailure,ascites,
uncontrolledhypertension,maintainadequatehydra-
Contra-indications
acutegastro-intestinalconditions
(includinggastro-intestinalobstruction,inammatory
boweldisease,andconditionsassociatedwith
increasedcolonicabsorption)
Renalimpairment
useenemawithcaution
localirritation;
withenema
,electrolyte
Indicationanddose
onstipation,bowelevacuationbeforeabdo-
minalradiologicalprocedures,endoscopy,and
surgery
Fordoseseepreparations
Suppositories
,sodiumacidphosphate(anhydrous)
SODIUMCITRATE(RECTAL)
seenotesabove
Contra-indications
acutegastro-intestinalconditions
Indicationanddose
fordoseseeunderpreparations
Gastro-intestinalsystem
RelaxitMicro-enema
,sodiumcitrate450mg,sodiumlaurylsul-
seenotesabove;alsoheartfailure
Contra-indications
seenotesabove;alsogastro-
intestinalulceration
manufacturersadviseuseonlyifessen-
tial—noinformationavailable
manufacturersadviseuseonlyif
essential—noinformationavailable
seenotesabove;alsoanaldiscomfort
Licenseduse
notlicensedforusein
Indicationanddose
Seepreparations
Oralpowder
MAGNESIUMCITRATE
Gastro-intestinalsystem
Child10Ð18years
SODIUMPICOSULFATEWITH
MAGNESIUMCITRATE
seenotesabove;alsorecentgastro-intestinal
surgery;cardiacdisease(avoidincongestivecardiac
Contra-indications
seenotesabove;alsogastroin-
testinalulceration;ascites;congestivecardiacfailure
Hepaticimpairment
avoidinhepaticcomaifriskof
renalfailure
Renalimpairment
avoidifestimatedglomerularl-
trationratelessthan30mL/minute/1.73m
—riskof
hypermagnesaemia
seenotesabove;alsoanaldiscomfort,
sleepdisturbances,fatigue,andrash
Indicationanddose
Seepreparations
Oralpowder
,sugar-free,sodiumpicosulfate10mg/
AMIDOTRIZOATES
Diatrizoates
asthmaorhistoryofallergy,latenthyper-
thyroidism,dehydrationandelectrolytedisturbance
(correctrst);inchildrenwithoesophagealstulae
(aspirationmayleadtopulmonaryoedema);benign
nodulargoitre;enteritis;riskofanaphylactoidreac-
tionsincreasedbyconcomitantadministrationof
Gastro-intestinalsystem
Localpreparationsfor
analandrectaldisorders
Soothinganalandrectalpreparations
Compoundanalandrectal
preparationswithcorticosteroids
Rectalsclerosants
ManagementofanalÞssures
Inchildrenwithperianalsorenessorpruritusani,good
Corticosteroids
areoftencombinedwithlocalanaes-
Gastro-intestinalsystem
ProctofoamHC
Gastro-intestinalsystem
Ointmentscontainingglyceryltrinitrateinarangeof
strengthsordiltiazem2%areavailableasmanufactured
specials(seeSpecial-orderManufacturers,p.809).
Stomaandenteral
feedingtubes
Prescribingforchildrenwithstomacallsforspecialcare.
Thefollowingisabriefaccountofsomeofthemain
pointstobeborneinmind.
Whenasolid-doseformulationsuchasacapsuleora
preparation(section9.1.1.2)shouldbeused.Modied-
releaseironpreparationsshouldbe
avoided
Careofstoma
Childrenandcarersareusuallygiven
adviceabouttheuseof
cleansingagents
protective
lotions
deodorants
,or
sealants
whilstinhos-
pital,eitherbythesurgeonorbyastoma-carenurse.
Voluntaryorganisationsofferhelpandsupportto
patientswithstoma.
Enteralfeedingtubes
Careisrequiredinchoosinganappropriateformulation
ofadrugforadministrationthroughanasogastric
narrow-borefeedingtubeorthroughapercutaneous
endoscopicgastrostomy(PEG)orjejunostomytube.
Gastro-intestinalsystem
Ursodeoxycholicacidmayalsorelievethesevereitch-
ingassociatedwithcholestasis.
Insclerosingcholangitis,ursodeoxycholicacidisused
tolowerliverenzymeandserum-bilirubinconcentra-
tions.
Ursodeoxycholicacidisalsousedinthetreatmentof
intrahepaticcholestasisinpregnancy.
Smith-Lemli-Opitzsyndrome
Chenodeoxycholic
andursodeoxycholicacidhavebeenusedwithcholes-
terolinchildrenwithSmith-Lemli-Opitzsyndrome.
Chenodeoxycholicacidisalsousedincombination
withcholicacidtotreatbileacidsynthesisdefectsbut
cholicacidisdifculttoobtain.Chenodeoxycholicacid
andcholesterolareavailablefrom‘special-order’man-
ufacturersorspecialistimportingcompanies,seep.809.
URSODEOXYCHOLICACID
Appendix1(bileacids)
Contra-indications
radio-opaquestones;non-func-
tioninggallbladder(inpatientswithradiolucent
Hepaticimpairment
avoidinchronicliverdisease
(butusedinprimarybiliarycirrhosis)
noevidenceofharmbutmanufacturer
advisesavoid
notknowntobeharmfulbutmanu-
factureradvisesavoid
rarely
,diarrhoea
Licenseduse
notlicensedforuseinchildrenfor
indicationsshownbelow
Indicationanddose
holestasis
Bymouth
5mg/kg3timesdaily,adjustdoseand
frequencyaccordingtoresponse,max.10mg/kg3
timesdaily
Child1monthÐ2years
5mg/kg3timesdaily,
adjustdoseandfrequencyaccordingtoresponse,
max.10mg/kg3timesdaily
CHENODEOXYCHOLICACID
seeunderUrsodeoxycholicAcid;
:Appendix1(bileacids)
Contra-indications
seeunderUrsodeoxycholicAcid
Gastro-intestinalsystem
consultproductliterature
Contra-indications
consultproductliterature
Licenseduse
notlicensed
Indicationanddose
mith-Lemli-Opitzsyndrome
Bymouth
5–10mg/kg3–4timesdaily
Child1monthÐ18years
5–10mg/kg3–4times
daily(dosesupto15mg/kg4timesdailyhave
beenused)
cholesterolpowdercanbemixedwith
COLESTYRAMINE
(Cholestyramine)
section2.12
Contra-indications
section2.12
section2.12
section2.12
section2.12
Licenseduse
notlicensedforuseinchildrenunder6
years
Indicationanddose
ruritusassociatedwithpartialbiliary
obstructionandprimarybiliarycirrhosis,
diarrhoeaassociatedwithCrohnÕsdisease,
hild6Ð12years
4goncedailyinasuitable
liquid,adjustedaccordingtoresponse;totaldaily
dosemayalternativelybegivenin2–4divided
doses(max.24gdaily)
hild12Ð18years
4–8goncedailyinasuitable
liquid,adjustedaccordingtoresponse;totaldaily
dosemayalternativelybegivenin2–4divided
doses(max.36gdaily)
Counselling
Otherdrugsshouldbetakenatleast1hour
beforeor4–6hoursaftercolestyraminetoreducepos-
sibleinterferencewithabsorption
Fortreatmentofdiarrhoeainducedbybileacid
malabsorption,ifnoresponsewithin3daysanalterna-
tivetherapyshouldbeinitiated
ypercholesterolaemia
section2.12
Section2.12
Classicationnotusedin
BNFforChildren
Pancreatin
Pancreatin,containingamixtureofprotease,lipaseand
amylaseinvaryingproportions,aidsthedigestionof
starch,fat,andprotein.Supplementsofpancreatinare
givenbymouthtocompensateforreducedorabsent
Gastro-intestinalsystem
Higher-strengthpancreatinpreparations
Pancrease
Nutrizym22
havebeenassociatedwiththe
developmentoflargebowelstrictures(brosingcolono-
PANCREATIN
seenotesabove;hyperuricaemiaand
hyperuricosuriahavebeenassociatedwithveryhigh
Appendix1(pancreatin)
notknowntobeharmful
nausea,vomiting,abdominaldiscomfort;
skinandmucosalirritation(seenotesabove)
Indicationanddose
ancreaticinsufÞciency
fordoseseeindividual
preparations,below
Creon
10000
(AbbottHealthcare)
Capsules
,brown/clear,enclosingbuff-colourede/c
granulesofpancreatin(pork),providing:protease
Gastro-intestinalsystem
Child1Ð18years
2–6capsuleswithmeals,swallowed
wholeorsprinkledonfood
Capsules‘125’
,pancreatin(pork),providingmini-
mumof:protease160units,lipase2950units,amylase
Higher-strengthpreparations
Seewarningabove
Counselling
Itisimportanttoensureadequatehydrationatall
timesinchildrenreceivinghigher-strengthpancreatinprepara-
tions.
Creon
25000
(AbbottHealthcare)
Capsules
,orange/clear,enclosingbrown-coloured
Gastro-intestinalsystem
Cardiovascularsystem
Positiveinotropicdrugs
Cardiacglycosides
Phosphodiesterasetype-3inhi-
bitors
Cardiovascularsystem
responseinpersistentatrialÞbrillation(section2.3.1).
Digoxinhasalimitedroleinchildrenwithchronicheart
failure;forreferencetotheroleofdigoxininheart
failure,seesection2.2.
ForthemanagementofatrialÞbrillation,themainte-
sicksinussyndrome;thyroiddisease;
hypoxia;severerespiratorydisease;avoidhypokal-
aemia,hypomagnesaemia,hypercalcaemia,and
hypoxia(riskofdigitalistoxicity);monitorserum
electrolytesandrenalfunction;avoidrapidintra-
venousadministration(riskofhypertensionand
reducedcoronaryßow);
Appendix1
(cardiacglycosides)
Contra-indications
dizziness;blurredoryellowvision;rash,eosinophilia;
lesscommonly
veryrarely
intestinalischaemiaandnecrosis,psychosis,apathy,
confusion,headache,fatigue,weakness,gynaeco-
mastiaonlong-termuse,andthrombocytopenia
Cardiovascularsystem
Child10Ð18years
initially0.5Ð1mgin3divided
dosesfor24hoursthen62.5Ð250microgramsdaily
in1Ð2divideddoses(higherdosesmaybeneces-
sary)
Theabovedosesmayneedtobereducedifdigoxin(or
anothercardiacglycoside)hasbeengiveninthepreceding2
weeks.Whenswitchingfromintravenoustooralroutemay
needtoincreasedoseby20Ð30%tomaintainthesame
plasma-digoxinconcentration.Plasmamonitoringmaybe
requiredwhenchangingformulationtotakeaccountof
varyingbioavailabilities.Forplasmaconcentrationmonitor-
ing,bloodshouldideallybetakenatleast6hoursafteradose
intravenousinfusion
,dilutewith
SodiumChloride0.9%
Glucose5%toamax.
concentrationof62.5micrograms/mL;loadingdoses
shouldbegivenover30Ð60minutesandmaintenance
doseover10Ð20minutes.
For
administration,oralsolutionmust
heartfailureassociatedwithhypertrophic
cardiomyopathy,stenoticorobstructivevalvulardis-
seeunderEnoximone;alsocorrecthypo-
kalaemia;monitorrenalfunction;
Appendix1(phosphodiesterasetype-3inhibitors)
Renalimpairment
usehalftothree-quartersnormal
doseandmonitorresponseifestimatedglomerular
Þltrationratelessthan50mL/minute/1.73m
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
BNFC2011–
2.1.2Phosphodiesterasetype-3inhibitors
Cardiovascularsystem
manufactureradvisescautionÑno
informationavailable
ectopicbeats,ventriculartachycardia,
supraventriculararrhythmias(morelikelyinchildren
withpre-existingarrhythmias),hypotension;head-
lesscommonly
ventricularÞbrillation,chest
pain,tremor,hypokalaemia,thrombocytopenia;
very
bronchospasm,anaphylaxis,andrash
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
ongestiveheartfailure,lowcardiacoutput
followingcardiacsurgery,shock
Byintravenousinfusion
initially50Ð75micrograms/kgover30Ð
60minutes(reduceoromitinitialdoseifatriskof
hypotension)then30Ð45micrograms/kg/hourby
continuousintravenousinfusion
for2Ð3days
(usuallyfor12hoursaftercardiacsurgery)
Child1monthÐ18years
initially50Ð75micr-
ograms/kgover30Ð60minutes(reduceoromit
initialdoseifatriskofhypotension)then30Ð
45micrograms/kg/hourby
continuousintra-
venousinfusion
for2Ð3days(usuallyfor12hours
aftercardiacsurgery)
intravenousinfusion
dilutewith
Glucose5%
SodiumChloride0.9%
ChlorideandGlucoseintravenousinfusiontoacon-
centrationof200micrograms/mL(higherconcentra-
tionsof400micrograms/mLhavebeenused);loading
dosemaybegivenundilutedifßuid-restricted
withpreservedleftventricularfunctionhasnotbeen
Acuteheartfailure
canoccuraftercardiacsurgeryor
asacomplicationinsevereacuteinfectionswithor
withoutmyocarditis.Therapyconsistsofvolumeload-
ing,vasodilatororinotropicdrugs.
Chronicheartfailure
isinitiallytreatedwitha
diuretic
(section2.2.2),usuallyfurosemidesupplemen-
tedwith
amiloride
,or
IfdiuresiswithfurosemideisinsufÞcient,theadditionof
Cardiovascularsystem
BENDROFLUMETHIAZIDE
(Bendroßuazide)
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
edemainheartfailure,renaldisease,and
hepaticdisease;pulmonaryoedema;hyper-
Bymouth
Child1monthÐ2years
50Ð100micrograms/kg
dailyadjustedaccordingtoresponse
hild2Ð12years
initially50Ð400micrograms/kg
(max.10mg)dailythen50Ð100micrograms/kg
dailyadjustedaccordingtoresponse(max.10mg
hild12Ð18years
initially5Ð10mgdailyoron
alternatedays(2.5mgdailyinhypertension)asa
singlemorningdose,adjustedaccordingto
response(max.10mgdaily)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
CHLOROTHIAZIDE
Chlorothiazideoralsuspension250mg/5mLisavail-
ablefromÔspecial-orderÕmanufacturersorspecialist
importingcompanies,seep.809
BNFC2011–
Cardiovascularsystem
CHLORTALIDONE
(Chlorthalidone)
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;also
rarely
Indicationanddose
ypertension
Bymouth
Child5Ð12years
0.5Ð1mg/kginthemorning
every48hours;max.1.7mg/kgevery48hours
hild12Ð18years
25mgdailyinthemorning,
increasedto50mgdailyifnecessary(butseenotes
tableheartfailure
Bymouth
Child5Ð12years
0.5Ð1mg/kginthemorning
every48hours;max.1.7mg/kgevery48hours
hild12Ð18years
25Ð50mgdailyinthemorn-
ing,increasedifnecessaryto100Ð200mgdaily
(reducetolowesteffectivedoseformaintenance)
scites,oedemainnephroticsyndrome
Bymouth
Child5Ð12years
0.5Ð1mg/kginthemorning
every48hours;max.1.7mg/kgevery48hours
hild12Ð18years
upto50mgdaily
(Alliance)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Cardiovascularsystem
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
(Frusemide)
seenotesabove;alsohypoproteinaemiamay
reduceeffectandincreaseriskofside-effects;hepa-
torenalsyndrome;riskofototoxicitymaybereduced
bygivinghighoraldosesin2ormoredivideddoses;
effectmaybeprolongedinneonates;someliquid
preparationscontainalcohol,cautionespeciallyin
Renalimpairment
seenotesabove;alsolowerrateof
infusionmaybenecessary
seenotesabove
amounttoosmalltobeharmful;may
inhibitlactation
seenotesabove;alsointrahepatic
cholestasisandgout
Indicationanddose
edemainheartfailure,renaldisease,and
hepaticdisease;pulmonaryoedema
Bymouth
0.5Ð2mg/kgevery12Ð24hours(every
24hoursifpostmenstrualageunder31weeks)
Child1monthÐ12years
0.5Ð2mg/kg2Ð3times
daily(every24hoursifpostmenstrualageunder
31weeks);higherdosesmayberequiredinresis-
tantoedema;max.12mg/kgdaily,nottoexceed
80mgdaily
hild12Ð18years
20Ð40mgdaily,increasedin
resistantoedemato80Ð120mgdaily
Byslowintravenousinjection
0.5Ð1mg/kgevery12Ð24hours(every
24hoursifpostmenstrualageunder31weeks)
Child1monthÐ12years
0.5Ð1mg/kgrepeated
every8hoursasnecessary;max.2mg/kg(max.
40mg)every8hours
hild12Ð18years
20Ð40mgrepeatedevery8
hoursasnecessary;higherdosesmayberequired
inresistantcases
Bycontinuousintravenousinfusion
Child1monthÐ18years
0.1Ð2mg/kg/hour(fol-
lowingcardiacsurgery,initially100micrograms/
kg/hour,doubledevery2hoursuntilurineoutput
exceeds1mL/kg/hour)
liguria
Bymouth
Child12Ð18years
initially250mgdaily;if
necessary,doseincreasedinstepsof250mggiven
every4Ð6hours;max.singledose2g(rarelyused)
Byintravenousinfusion
Child1monthÐ12years
2Ð5mg/kgupto4times
daily(max.1gdaily)
hild12Ð18years
initially250mgover1hour
(ratenotexceeding4mg/minute),increaseto
500mgover2hoursifsatisfactoryurineoutputnot
obtained,thengiveafurther1gover4hoursifno
satisfactoryresponsewithinsubsequenthour,ifno
responseobtaineddialysisprobablyrequired;
effectivedose(upto1g)canberepeatedevery24
hours
foradministration
bymouth
Cardiovascularsystem
AMILORIDEHYDROCHLORIDE
Compoundpreparationswiththiazideorloop
Cardiovascularsystem
Indicationanddose
edemainheartfailureandinascites,
nephroticsyndrome,reductionofhypokal-
POTASSIUMCANRENOATE
PotassiumcanrenoateinjectionisavailablefromÔspe-
cial-orderÕmanufacturersorspecialistimportingcom-
panies,seep.809
Potassium-sparing
Amiloridewiththiazides
Co-amilozide
extravasationcausesinßammationand
thrombophlebitis;monitorßuidandelectrolytebal-
ance,serumosmolality,andpulmonaryandrenal
function;assesscardiacfunctionbeforeandduring
Appendix1(mannitol)
Contra-indications
severeheartfailure;severepulm-
onaryoedema;intracranialbleeding(exceptduring
craniotomy);anuria;severedehydration
Renalimpairment
usewithcautioninsevereimpair-
manufactureradvisesavoidunlessessen-
tialÑnoinformationavailable
BNFC2011–
Cardiovascularsystem
manufactureradvisesavoidunless
essentialÑnoinformationavailable
lesscommonly
hypotension,thrombo-
phlebitis,ßuidandelectrolyteimbalance;
dry
mouth,thirst,nausea,vomiting,oedema,raised
intracranialpressure,arrhythmia,hypertension,
pulmonaryoedema,chestpain,headache,con-
Cardiovascularsystem
Ventriculartachycardiaandventricular
PulselessventriculartachycardiaorventricularÞbrilla-
tionrequireresuscitation,seePaediatricAdvancedLife
Supportalgorithm(insidebackcover).Amiodaroneis
usedinresuscitationforpulselessventriculartachy-
cardiaorventricularÞbrillationunresponsivetod.c.
shock;lidocainecanbeusedasanalternativeonlyif
amiodaroneisnotavailable.
Amiodaroneisalsousedinahaemodynamicallystable
childwhendrugtreatmentisrequired;lidocainecanbe
usedasanalternativeonlyifamiodaroneisnotavail-
able.
Torsadedepointes
Torsadedepointesisaformof
ventriculartachycardiaassociatedwithlongQT
syndrome,whichmaybecongenitalordruginduced.
Episodesmaybeself-limiting,butarefrequentlyrecur-
rentandcancauseimpairmentorlossofconsciousness.
Ifnotcontrolled,thearrhythmiacanprogresstoventri-
Cardiovascularsystem
canbeusedincardiopulmonaryresusci-
tationinchildrenwithventricularÞbrillationorpulse-
lessventriculartachycardiaunresponsivetod.c.shock,
butonlyifamiodaroneisnotavailable.Dosesmayneed
tobereducedinchildrenwithpersistentlypoorcardiac
outputandhepaticorrenalfailure(seeunderlidocaine,
Verapamil
(section2.6.2)cancauseseverehaemody-
namiccompromise(refractoryhypotensionandcardiac
arrest)whenusedfortheacutetreatmentofarrhyth-
miasinneonatesandinfants;itiscontra-indicatedin
childrenunder1year.Itisalsocontra-indicatedinthose
withcongestiveheartfailure,syndromesassociated
withaccessoryconductingpathways(e.g.Wolff-Parkin-
son-Whitesyndrome)andinmostreceivingconcomi-
monitorECGandhaveresuscitationfacil-
itiesavailable;atrialÞbrillationorßutterwithacces-
sorypathway(conductiondownanomalouspathway
mayincrease);ÞrstdegreeAVblock;bundlebranch
block;leftmaincoronaryarterystenosis;uncorrected
hypovolaemia;stenoticvalvularheartdisease;leftto
rightshunt;pericarditis;pericardialeffusion;auto-
nomicdysfunction;stenoticcarotidarterydisease
withcerebrovascularinsufÞciency;recentmyocardial
infarction;heartfailure;hearttransplant(seedose);
Appendix1(adenosine)
Contra-indications
second-orthird-degreeAVblock
andsicksinussyndrome(unlesspacemakerÞtted);
longQTsyndrome;severehypotension;decompen-
satedheartfailure;asthma
AMIODARONEHYDROCHLORIDE
liver-functionandthyroid-functiontests
requiredbeforetreatmentandthenevery6months
(seenotesabovefortestsofthyroidfunction);hypo-
kalaemia(measureserum-potassiumconcentration
beforetreatment);pulmonaryfunctiontestsandchest
x-rayrequiredbeforetreatment;heartfailure;severe
bradycardiaandconductiondisturbancesinexcessive
dosage;intravenoususemaycausemoderateand
transientfallinbloodpressure(circulatorycollapse
precipitatedbyrapidadministrationoroverdosage)or
severehepato-cellulartoxicity(monitortransami-
nasesclosely);ECGmonitoringandresuscitation
facilitiesmustbeavailableduringintravenoususe;
acuteporphyria(section9.8.2);avoidbenzylalcohol
containinginjectionsinneonates(seeExcipients,
p.2);
Appendix1(amiodarone)
Contra-indications
exceptincardiacarrest
:sinus
bradycardia,sino-atrialheartblock;unlesspacemaker
Þttedavoidinsevereconductiondisturbancesor
sinusnodedisease;thyroiddysfunction;iodinesen-
sitivity;avoid
intravenoususe
insevererespiratory
failure,circulatorycollapse,orseverearterialhypo-
tension;avoidbolusinjectionincongestiveheart
failureorcardiomyopathy;avoidrapidloadingafter
cardiacsurgery
possibleriskofneonatalgoitre;useonlyif
noalternative
avoid;signiÞcantamountpresentin
milkÑriskofneonatalhypothyroidismfromreleaseof
nausea,vomiting,tastedisturbances,
raisedserumtransaminases(mayrequiredose
reductionorwithdrawalifaccompaniedbyacuteliver
disorders),jaundice;bradycardia(seeCautions);
pulmonarytoxicity(includingpneumonitisandÞbro-
sis);tremor,sleepdisorders;hypothyroidism,hyper-
thyroidism;reversiblecornealmicrodeposits(some-
timeswithnightglare);phototoxicity,persistentslate-
greyskindiscoloration(seealsonotesabove);
commonly
Cardiovascularsystem
neuropathyandmyopathy(usuallyreversibleon
withdrawal);
veryrarely
chronicliverdiseaseinclud-
ingcirrhosis,sinusarrest,bronchospasm(inpatients
withsevererespiratoryfailure),ataxia,benignintra-
cranialhypertension,headache,vertigo,epididymo-
orchitis,impotence,haemolyticoraplasticanaemia,
thrombocytopenia,rash(includingexfoliative
dermatitis),hypersensitivityincludingvasculitis,alo-
pecia,impairedvisionduetoopticneuritisoroptic
neuropathy(includingblindness),anaphylaxison
rapidinjection,alsohypotension,respiratorydistress
syndrome,sweating,andhotßushes
Licenseduse
notlicensedforuseinchildrenunder3
years
Indicationanddose
upraventricularandventriculararrhythmias
seenotesabove(initiatedinhospitalorunderspe-
cialistsupervision)
Bymouth
initially5Ð10mg/kgtwicedailyfor7Ð10
days,thenreducedtomaintenancedoseof5Ð
10mg/kgoncedaily
Child1monthÐ12years
initially5Ð10mg/kg
(max.200mg)twicedailyfor7Ð10days,then
reducedtomaintenancedoseof5Ð10mg/kgonce
daily(max.200mgdaily)
hild12Ð18years
200mg3timesdailyfor1
weekthen200mgtwicedailyfor1weekthen
usually200mgdailyadjustedaccordingto
Byintravenousinfusion
initially5mg/kgover30minutesthen
5mg/kgover30minutesevery12Ð24hours
Child1monthÐ18years
initially5Ð10mg/kg
over20minutesÐ2hoursthen
bycontinuous
300micrograms/kg/hour,increased
accordingtoresponsetomax.1.5mg/kg/hour;do
notexceed1.2gin24hours
entricularÞbrillationorpulselessventricular
tachycardiarefractorytodeÞbrillation
(seealso
section2.3.1)
Byintravenousinjection
5mg/kgoveratleast3minutes
Child1monthÐ18years
5mg/kg(max.300mg)
overatleast3minutes
intravenousadministrationviacentral
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
CordaroneX
Cardiovascularsystem
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
esistantre-entrysupraventriculartachy-
cardia,ventricularectopicbeatsorventricular
tachycardia,arrhythmiasassociatedwith
accessoryconductionpathways(e.g.Wolff-
Parkinson-Whitesyndrome),paroxysmalatrial
Bymouth
2mg/kg2Ð3timesdailyadjusted
accordingtoresponseandplasma-ßecainidecon-
Child1monthÐ12years
2mg/kg2Ð3timesdaily
adjustedaccordingtoresponseandplasma-ße-
cainideconcentration(max.8mg/kg/dayor
300mgdaily)
hild12Ð18years
initially50Ð100mgtwice
daily;max.300mgdaily(max.400mgdailyfor
ventriculararrhythmiasinheavilybuiltchildren)
Byslowintravenousinjectionorintravenous
1Ð2mg/kgover10Ð30minutes;if
necessaryfollowedbycontinuousinfusionatarate
of100Ð250micrograms/kg/houruntilarrhythmia
controlled;transferto
treatmentasabove
Child1monthÐ12years
2mg/kgover10Ð30
minutes;ifnecessaryfollowedbycontinuous
infusionatarateof100Ð250micrograms/kg/hour
untilarrhythmiacontrolled(max.cumulativedose
600mgin24hours);transferto
treatmentas
hild12Ð18years
2mg/kg(max.150mg)over
10Ð30minutes;ifnecessaryfollowedbycontinu-
ousinfusionatarateof1.5mg/kg/hourfor1hour,
thenreducedto100Ð250micrograms/kg/hour
untilarrhythmiacontrolled(max.cumulativedose
600mginÞrst24hours);transferto
asabove
foradministration
bymouth
,milk,
infantformula,anddairyproductsmayreduce
absorptionofßecainideÑseparatedosesfromfeeds.
ModiÞedrelease
Tambocor
Capsules
LIDOCAINEHYDROCHLORIDE
(Lignocainehydrochloride)
lowerdosesincongestiveheartfailureand
followingcardiacsurgery;monitorECG;resuscitation
facilitiesshouldbeavailable;
Appendix
1(lidocaine)
Contra-indications
sino-atrialdisorders,allgradesof
atrioventricularblock,severemyocardialdepression;
acuteporphyria(section9.8.2)
Hepaticimpairment
cautionÑincreasedriskofside-
effects
Renalimpairment
possibleaccumulationoflidocaine
Cardiovascularsystem
eonatalseizures
(section4.8.1)
Byintravenousinfusion
initially2mg/kgover10minutes,fol-
lowedby6mg/kg/hourfor6hours;reducedose
overthefollowing24hours(4mg/kg/hourfor12
hours,then2mg/kg/hourfor12hours)
Cardiovascularsystem
PROPRANOLOLHYDROCHLORIDE
seenotesabove;alsoavoidabruptwith-
drawal;Þrst-degreeAVblock;portalhypertension
Cardiovascularsystem
Child12Ð18years
initially80mgtwicedaily;
increasedatweeklyintervalsasrequired;mainte-
nance160Ð320mgdaily;slow-releaseprepara-
tionsmaybeusedforoncedailyadministration
ModiÞedrelease
ModiÞed-releasepreparationsforoncedailyadministra-
tion;useinolderchildrenonly
Half-InderalLA
(AstraZeneca)
Capsules
,m/r,lavender/pink,propranololhydro-
ATENOLOL
seeunderPropranololHydrochloride
Contra-indications
seeunderPropranololHydro-
Renalimpairment
initiallyuse50%ofusualdoseif
estimatedglomerularÞltrationrate10Ð35mL/min-
ute/1.73m
;initiallyuse30Ð50%ofusualdoseif
estimatedglomerularÞltrationratelessthan10mL/
minute/1.73m
seenotesabove
seenotesabove
seeunderPropranololHydrochloride
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
ypertension
Bymouth
0.5Ð2mg/kgoncedaily;maybegivenin
2divideddoses
Child1monthÐ12years
0.5Ð2mg/kgoncedaily
(doseshigherthan50mgdailyrarelynecessary);
maybegivenin2divideddoses
hild12Ð18years
25Ð50mgoncedaily(higher
dosesrarelynecessary);maybegivenin2divided
Bymouth
0.5Ð2mg/kgoncedaily;maybegivenin
2divideddoses
Child1monthÐ12years
0.5Ð2mg/kgoncedaily
(max.100mgdaily);maybegivenin2divided
hild12Ð18years
50Ð100mgoncedaily;maybe
givenin2divideddoses
CARVEDILOL
seeunderPropranololHydrochloride;
monitorrenalfunctionduringdosetitrationinchil-
drenwithheartfailurewhoalsohavelowblood
BNFC2011–
Cardiovascularsystem
pressure,renalimpairment,ischaemicheartdisease,
ordiffusevasculardisease
Contra-indications
seeunderPropranololHydro-
chloride;acuteordecompensatedheartfailure
requiringintravenousinotropes
Hepaticimpairment
avoid
seenotesabove
seenotesabove
posturalhypotension,dizziness,head-
ache,fatigue,gastro-intestinaldisturbances,brady-
cardia;occasionallydiminishedperipheralcirculation,
peripheraloedemaandpainfulextremities,dry
mouth,dryeyes,eyeirritationordisturbedvision,
impotence,disturbancesofmicturition,inßuenza-like
symptoms;rarelyangina,AVblock,exacerbationof
intermittentclaudicationorRaynaudÕsphenomenon;
allergicskinreactions,exacerbationofpsoriasis,nasal
stufÞness,wheezing,depressedmood,sleepdistur-
bances,paraesthesia,heartfailure,changesinliver
enzymes,thrombocytopenia,leucopeniaalso
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
djunctinheartfailure
(limitedinformation
available)
Bymouth
Child2Ð18years
initially50micrograms/kg
(max.3.125mg)twicedaily,doubledoseatinter-
valsofatleast2weeksupto350micrograms/kg
(max.25mg)twicedaily
Carvedilol
ESMOLOLHYDROCHLORIDE
seeunderPropranololHydrochloride
Contra-indications
seeunderPropranololHydro-
Renalimpairment
manufactureradvisescaution
seenotesabove
seenotesabove
seeunderPropranololHydrochloride;
infusioncausesvenousirritationandthrombophleb-
Licenseduse
notlicensedforuseinchildren
Indicationanddose
rrhythmias,hypertensiveemergencies
alsonotesaboveandsection2.5)
Byintravenousadministration
Child1monthÐ18years
initiallyby
intravenous
injection
over1minute500micrograms/kgthen
intravenousinfusion
50micrograms/kg/min-
utefor4minutes(ratereducediflowbloodpres-
sureorlowheartrate);ifinadequateresponse,
repeatloadingdoseandincreasemaintenance
infusionby50micrograms/kg/minuteincrements;
repeatuntileffectiveormax.infusionof
200micrograms/kg/minutereached;dosesover
300micrograms/kg/minutenotrecommended
Cardiovascularsystem
Byintravenousinjection
Child1monthÐ12years
250Ð500micrograms/
kgasasingledose;max.20mg
hild12Ð18years
50mgoveratleast1minute,
repeatedafter5minutesifnecessary;max.total
dose200mg
Excessivebradycardiacanbecounteredwithintra-
venousinjectionofatropinesulphate;for
overdosage
p.29
intravenousinfusion
,dilutetoa
concentrationof1mg/mLinGlucose5%
ChlorideandGlucose5%;ifßuidrestrictedmaybe
givenundiluted,preferablythroughacentralvenous
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
ModiÞedrelease
LopresorSR
(Recordati)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
SOTALOLHYDROCHLORIDE
seeunderPropranololHydrochloride;cor-
recthypokalaemia,hypomagnesaemia,orother
electrolytedisturbances;severeorprolongeddiarr-
hoea;reducedoseordiscontinueifcorrectedQT
intervalexceeds550msec
Contra-indications
seeunderPropranololHydro-
chloride;congenitaloracquiredlongQTsyndrome;
torsadedepointes
Renalimpairment
halvenormaldoseifestimated
glomerularÞltrationrate30Ð60mL/minute/1.73m
useone-quarternormaldoseifestimatedglomerular
Þltrationrate10Ð30mL/minute/1.73m
;avoidif
estimatedglomerularÞltrationratelessthan10mL/
minute/1.73m
seenotesabove
seenotesabove
seeunderPropranololHydrochloride;
arrhythmogenic(pro-arrhythmic)effect(torsadede
pointesÑincreasedriskinfemales)
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
entriculararrhythmias,life-threatening
ventriculartachyarrhythmiaandsupraventri-
culararrhythmias
initiatedunderspecialistsuper-
visionandECGmonitoringandmeasurementof
correctedQTinterval
Bymouth
initially1mg/kgtwicedaily,increasedas
necessaryevery3Ð4daystomax.4mg/kgtwice
trialßutter,ventriculararrhythmias,life-
threateningventriculartachyarrhythmiaand
supraventriculararrhythmias
initiatedunder
specialistsupervisionandECGmonitoringand
measurementofcorrectedQTinterval
Bymouth
Child1monthÐ12years
initially1mg/kgtwice
daily,increasedasnecessaryevery2Ð3daysto
max.4mg/kgtwicedaily(max.80mgtwicedaily)
hild12Ð18years
initially80mgoncedaily
40mgtwicedaily,increasedgraduallyatintervals
of2Ð3daystousualdose80Ð160mgtwicedaily;
higherdosesof480Ð640mgdailyforlife-threa-
teningventriculararrhythmiasunderspecialist
supervision
BNFC2011–
Cardiovascularsystem
foradministration
bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Hypertension
Vasodilatorantihypertensivedrugs
andpulmonaryhypertension
Centrallyactingantihypertensive
Adrenergicneuroneblockingdrugs
Alpha-adrenoceptorblockingdrugs
Drugsaffectingtherenin-angiotensin
Hypertensioninchildrenandadolescentscanhavea
substantialeffectonlong-termhealth.Possiblecauses
ofhypertension(e.g.congenitalheartdisease,renal
diseaseandendocrinedisorders)andthepresenceof
anycomplications(e.g.leftventricularhypertrophy)
shouldbeestablished.Treatmentshouldtakeaccount
ofcontributoryfactorsandanyfactorsthatincreasethe
riskofcardiovascularcomplications.
Serioushypertensionisrarein
butitcan
presentwithsignsofcongestiveheartfailure;the
causeisoftenrenalandcanfollowembolicarterial
damage.
Children(ortheirparentsorcarers)shouldbegiven
adviceonlifestylechangestoreducebloodpressureor
cardiovascularrisk;theseincludeweightreduction(in
Cardiovascularsystem
organdamage.Treatmentshouldbeinitiatedwithintra-
venousdrugs;oncebloodpressureiscontrolled,oral
therapycanbestarted.Itmaybenecessarytoinfuse
ßuidsparticularlyduringtheÞrst12hourstoexpand
plasmavolumeshouldthebloodpressuredroptoo
rapidly.
Controlledreductionofbloodpressureisachievedby
2.5.1.1
Vasodilatorantihypertensives
Vasodilatorshaveapotenthypotensiveeffect,espe-
duringprolongedusemonitorwhitecelland
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
HYDRALAZINEHYDROCHLORIDE
cerebrovasculardisease;occasionallyblood
pressurereductiontoorapidevenwithlowparenteral
doses;manufactureradvisestestforantinuclearfactor
Cardiovascularsystem
Contra-indications
idiopathicsystemiclupuserythe-
matosus,severetachycardia,highoutputheartfailure,
myocardialinsufÞciencyduetomechanicalobstruc-
tion,corpulmonale;acuteporphyria(section9.8.2)
Hepaticimpairment
reducedose
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan30mL/minute/1.73m
neonatalthrombocytopeniareported,but
riskshouldbebalancedagainstriskofuncontrolled
maternalhypertension;manufactureradvisesavoid
beforethirdtrimester
presentinmilkbutnotknowntobe
harmful;monitorinfant
tachycardia,palpitation,ßushing,hypo-
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seenotesabove;acuteporphyria(section
Appendix1(vasodilatoranti-
hypertensives)
Contra-indications
phaeochromocytoma
Renalimpairment
usewithcautioninsigniÞcant
impairment
avoidÑpossibletoxicityincludingreduced
placentalperfusion;neonatalhirsutismreported
presentinmilkbutnotknowntobe
harmful
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
SODIUMNITROPRUSSIDE
hypothyroidism,hyponatraemia,impaired
cerebralcirculation,hypothermia;monitorblood
pressureandblood-cyanideconcentration,andif
treatmentexceeds3daysalsoblood-thiocyanate
concentration;avoidsuddenwithdrawalÑterminate
infusionover15Ð30minutes;
Appendix
1(nitroprusside)
Contra-indications
severevitaminB
LeberÕsopticatrophy;compensatoryhypertension
2.5.1Vasodilatorantihypertensivedrugs
BNFC2011–
Cardiovascularsystem
Hepaticimpairment
usewithcaution;avoidin
2.5.1.2
Pulmonaryhypertension
Onlypulmonary
hypertensioniscurrentlysui-
tablefordrugtreatment.Pulmonaryarterialhyper-
tensionincludespersistentpulmonaryhypertensionof
thenewborn,idiopathicpulmonaryarterialhyper-
tensioninchildren,andpulmonaryhypertensionrelated
tocongenitalheartdiseaseandcardiacsurgery.
Sometypesofpulmonaryhypertensionaretreatedwith
vasodilatorantihypertensivetherapyandoxygen.Diur-
Cardiovascularsystem
above).Tolazolineisanalpha-blockerandproduces
bothpulmonaryandsystemicvasodilation.
BOSENTAN
nottobeinitiatedifsystemicsystolicblood
pressureisbelow85mmHg;monitorliverfunction
beforeandatmonthlyintervalsduringtreatment,and
2weeksafterdoseincrease(reducedoseorsuspend
treatmentifliverenzymesraisedsigniÞcantly)Ñdis-
continueifsymptomsofliverimpairment(seeCon-
tra-indicationsbelow);monitorhaemoglobinbefore
andduringtreatment(monthlyforÞrst4months,then
3-monthlythereafter),withdrawtreatmentgradually;
Appendix1(bosentan)
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
avoidinmoderateandsevere
impairment
avoid(teratogenicin
animal
effectivecontraceptionrequiredduringandforat
least3monthsafteradministration(hormonal
contraceptionnotconsideredeffective);monthly
pregnancytestsadvised
manufactureradvisesavoidÑno
informationavailable
gastro-intestinaldisturbances,dry
mouth,rectalhaemorrhage,hepaticimpairment(see
Cautions,above);ßushing,hypotension,palpitation,
oedema,chestpain;dyspnoea;headache,dizziness,
fatigue;backpainandpaininextremities;anaemia;
hypersensitivityreactions(includingrash,pruritus,
andanaphylaxis)
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
diopathicpulmonaryarterialhypertension
Bymouth
Child3Ð18yearsandbody-weight10Ð20kg
initially31.25mgoncedailyincreasedafter4
weeksto31.25mgtwicedaily
hild3Ð18yearsandbody-weight20Ð40kg
initially31.25mgtwicedailyincreasedafter4
weeksto62.5mgtwicedaily
hild12Ð18yearsandbody-weightover40kg
initially62.5mgtwicedailyincreasedafter4weeks
to125mgtwicedaily;max.250mgtwicedaily
anticoagulantmonitoringrequiredwhen
givenwithanticoagulants;haemorrhagicdiathesis;
avoidabruptwithdrawal(seenotesabove);monitor
bloodpressure;concomitantuseofdrugsthat
increaseriskofbleeding
Contra-indications
severeleftventriculardysfunc-
tion;pulmonaryveno-occlusivedisease
manufactureradvisescautionÑnoinfor-
mationavailable
seenotesabove;gastro-intestinaldistur-
bances,hypotension,bradycardia,tachycardia,pallor,
ßushing,sweatingwithhigherdoses;headache;las-
ILOPROST
unstablepulmonaryhypertensionwith
advancedrightheartfailure;hypotension(donot
initiateifsystolicbloodpressurebelow85mmHg);
acutepulmonaryinfection;severeasthma;
Appendix1(iloprost)
Contra-indications
decompensatedcardiacfailure
(unlessundermedicalsupervision);severecoronary
heartdisease;severearrhythmias;congenitalor
acquiredvalvulardefectsofthemyocardium;pulm-
onaryveno-occlusivedisease;conditionswhich
increaseriskofhaemorrhage
2.5.1Vasodilatorantihypertensivedrugs
BNFC2011–
Cardiovascularsystem
Hepaticimpairment
dosemayneedtobehalvedin
livercirrhosisÑinitially2.5microgramsatintervalsof
atleast3hours(max.6timesdaily),adjusted
accordingtoresponse(consultproductliterature)
manufactureradvisesavoid(toxicityin
studies);effectivecontraceptionmustbeused
duringtreatment
manufactureradvisesavoidÑno
informationavailable
vasodilatation,hypotension,syncope,
cough,headache,throatorjawpain;nausea,vomi-
ting,diarrhoea,chestpain,dyspnoea,bronchospasm,
andwheezingalsoreported
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
diopathicorfamilialpulmonaryarterial
hypertension
Byinhalationofnebulisedsolution
Child8Ð18years
initialdose2.5micrograms
increasedto5microgramsforseconddose,if
toleratedmaintainat5micrograms6Ð9timesdaily
accordingtoresponse;reduceto2.5micrograms
6Ð9timesdailyifhigherdosenottolerated
aynaudÕssyndrome
section2.6.4.1
Ventavis
(BayerSchering)
Nebulisersolution
MAGNESIUMSULPHATE
seesection9.5.1.3
Hepaticimpairment
seesection9.5.1.3
Renalimpairment
seesection9.5.1.3
seesection9.5.1.3
Indicationanddose
ersistentpulmonaryhypertensionofthe
Byintravenousinfusion
initially200mg/kgover20Ð30minutes;
ifresponseoccurs,thenbycontinuousintravenous
infusionof20Ð75mg/kg/hour(tomaintain
hypotension(avoidifsevere);intravascular
Cardiovascularsystem
(Pzer)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
TOLAZOLINE
mitralstenosis;cardiotoxicaccumulation
mayoccurwithcontinuousinfusion,particularlyin
renalimpairmentÑmonitorbloodpressureregularly
forsustainedsystemichypotension;
Appendix1(alpha-blockers)
Contra-indications
pepticulcerdisease
Renalimpairment
accumulatesinrenalimpairment;
riskofcardiotoxicity;lowerdosesmaybenecessary
nausea,vomiting,diarrhoea,epigastric
pain;ßushing,tachycardia,cardiacarrhythmias;
CLONIDINEHYDROCHLORIDE
mustbewithdrawngraduallytoavoid
hypertensivecrisis;mildtomoderatebradyarrhyth-
mia;constipation;polyneuropathy;RaynaudÕs
syndromeorotherocclusiveperipheralvasculardis-
ease;historyofdepression;
Appendix1
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving);effectsofalcoholmaybeenhanced
Contra-indications
severebradyarrhythmiasecond-
arytosecond-orthird-degreeAVblockorsicksinus
Renalimpairment
usewithcaution
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Adrenergicneurone
blockingdrugs
Adrenergicneuroneblockingdrugspreventtherelease
ofnoradrenalinefrompostganglionicadrenergicneu-
rones.Thesedrugsdonotcontrolsupinebloodpressure
andmaycauseposturalhypotension.Forthisreason
2.5.2Centrallyactingantihypertensivedrugs
BNFC2011–
Cardiovascularsystem
theyhavelargelyfallenfromuseinadultsandarerarely
usedinchildren.
Alpha-adrenoceptor
blockingdrugs
Doxazosin
havepost-synapticalpha-
blockingandvasodilatorpropertiesandrarelycause
tachycardia.Theycan,however,reducebloodpressure
rapidlyaftertheÞrstdoseandshouldbeintroducedwith
Alpha-blockerscanbeusedwithotherantihypertensive
drugsinthetreatmentofresistanthypertension.
carewithinitialdose(posturalhypotension);
pulmonaryoedemaduetoaorticormitralstenosis;
cataractsurgery(riskofintra-operativeßoppyiris
syndrome);heartfailure;
Appendix1
(alpha-blockers)
Mayaffectperformanceofskilledtaskse.g.driving
Contra-indications
historyofposturalhypotension
Hepaticimpairment
usewithcaution;manufacturer
advisesavoidinsevereimpairmentÑnoinformation
available
noevidenceofteratogenicity;manufac-
turersadviseuseonlywhenpotentialbeneÞtout-
weighsrisk
accumulatesinmilkin
diesÑmanufactureradvisesavoid
gastro-intestinaldisturbances;oedema,
hypotension,posturalhypotension,palpitation,
tachycardia;dyspnoea,rhinitis,coughing;asthenia,
fatigue,vertigo,dizziness,headache,paraesthesia,
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
ModiÞed-release
Childrenstabilisedonimmediate-releasedoxazosincan
betransferredtotheequivalentdoseofmodiÞed-releasedox-
Þrstdosemaycausecollapseduetohypo-
Cardiovascularsystem
ongestiveheartfailure
(butrarelyused,see
section2.2)
Bymouth
Child1monthÐ12years
5micrograms/kgtwice
daily(initialdoseatbedtime),increasedgradually
tomax.100micrograms/kgdailyindivideddoses
hild12Ð18years
500micrograms2Ð4times
daily(initialdoseatbedtime),increasingto4mg
dailyindivideddoses;maintenance4Ð20mgdaily
individeddoses
foradministration
bymouth
HYDROCHLORIDE
congestiveheartfailure;severeischaemic
heartdisease(seealsoContra-indications);cerebro-
vasculardisease(avoidifhistoryofcerebrovascular
accident);monitorbloodpressureregularlyduring
infusion;carcinogenicin
animals
;avoidinacute
porphyria(section9.8.2);avoidextravasation(irritant
totissues);avoidcontactwithskin(riskofcontact
Contra-indications
historyofcerebrovascularacci-
dent;avoidinfusioninhypovolaemia
Renalimpairment
usewithcaution
hypotensioninnewbornmayoccur
maybepresentinmilk
posturalhypotensionwithdizzinessand
markedcompensatorytachycardia,lassitude,nasal
congestion,miosis,inhibitionofejaculation;
gastro-intestinaldisturbances;decreasedsweating
anddrymouthafterintravenousinfusion;idiosyn-
craticprofoundhypotensionwithinfewminutesof
startinginfusion;convulsionsfollowingrapidintra-
venousinfusionalsoreported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ypertensioninphaeochromocytoma
Bymouth
Child1monthÐ18years
0.5Ð1mg/kgtwicedaily
adjustedaccordingtoresponse
Byintravenousinfusion
Child1monthÐ18years
0.5Ð1mg/kgdaily
adjustedaccordingtoresponse;occasionallyupto
2mg/kgdailymayberequired;donotrepeatdose
within24hours
foradministration
bymouth
,capsules
maybeopened.
For
intravenousinfusion
,dilutewithSodiumChloride
0.9%andgiveoveratleast2hours;max.4hours
2.5.5.1
Angiotensin-convertingenzyme
Angiotensin-convertingenzymeinhibitors(ACEinhi-
bitors)inhibittheconversionofangiotensinItoangio-
tensinII.ThemainindicationsofACEinhibitorsin
childrenareshownbelow.Ininfantsandyoungchildren,
captoprilisoftenconsideredÞrst.
Initiationunderspecialistsupervision
withACEinhibitorsshouldbeinitiatedunderspecialist
supervisionandwithcarefulclinicalmonitoringinchil-
Heartfailure
ACEinhibitorshaveavaluableroleinall
gradesofheartfailure,usuallycombinedwithaloop
Cardiovascularsystem
Hypertension
ACEinhibitorsmaybeconsideredfor
Cardiovascularsystem
recommendedthatACEinhibitorsareavoidedwhen-
CAPTOPRIL
seenotesabove;acuteporphyria(section
Contra-indications
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
avoidinÞrstfewweeksafterdelivery,
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
ENALAPRILMALEATE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
monitorclosely
Renalimpairment
seenotesabove
seenotesabove
avoidinÞrstfewweeksafterdelivery,
Cardiovascularsystem
,variousstrengthsavailablefromÔspecial-
orderÕmanufacturersorspecialistimportingcompa-
nies,seep.809
seenotesabove
Contra-indications
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
avoidÑnoinformationavailable
seenotesabove;also
lesscommonly
tachycardia,palpitation,cerebrovascularaccident,
RaynaudÕssyndrome,confusion,moodchanges,
vertigo,sleepdisturbances,asthenia,impotence;
drymouth,gynaecomastia,alopecia,psoriasis;
veryrarely
allergicalveolitis,pulmonaryinÞltrates,
profusesweating,pemphigus,Stevens-Johnson
syndrome,andtoxicepidermalnecrolysis
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ypertension,proteinuriainnephritis
specialistsupervision)
Bymouth
Child6Ð12years
initially70micrograms/kg
(max.5mg)oncedaily,increasedinintervalsof1Ð
2weekstomax.600micrograms/kg(
40mg)
oncedaily
hild12Ð18years
initially5mgoncedaily;usual
maintenancedose10Ð20mgoncedaily;max.
80mgoncedaily
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
2.5.5.2
Angiotensin-IIreceptor
antagonists
Losartan
andvalsartanarespeciÞcangiotensin-II
receptorantagonistswithmanypropertiessimilarto
thoseoftheACEinhibitors.However,unlikeACEinhi-
bitors,theydonotinhibitthebreakdownofbradykinin
andotherkinins,andthusarelesslikelytocausethe
persistentdrycoughwhichcancomplicateACEinhibi-
tortherapy.Theyarethereforeausefulalternativefor
childrenwhohavetodiscontinueanACEinhibitor
becauseofpersistentcough.
Losartanorvalsartancanbeusedasanalternativetoan
ACEinhibitorinthemanagementofhypertension.
Angiotensin-IIreceptorantagonistsshould
beusedwithcautioninrenalarterystenosis(seealso
RenalEffectsunderACEInhibitors,section2.5.5.1).
Monitoringofplasma-potassiumconcentrationis
advised,particularlyinchildrenwithrenalimpairment.
Angiotensin-IIreceptorantagonistsshouldbeusedwith
cautioninaorticormitralvalvestenosisandinhyper-
trophiccardiomyopathy.Theyshouldbeusedwith
cautioninthosewithahistoryofangioedema.Children
withprimaryaldosteronism,andAfro-Caribbeanchil-
dren(particularlythosewithleftventricularhyper-
trophy),maynotbeneÞtfromanangiotensin-IIreceptor
:Appendix1(angiotensin-II
receptorantagonists).
Angiotensin-IIreceptorantagonistsshould
beavoidedinpregnancy,unlessessential.Theymay
LOSARTANPOTASSIUM
seenotesabove;alsosevereheartfailure
Hepaticimpairment
avoidÑnoinformationavailable
Renalimpairment
seenotesabove;alsoavoidif
estimatedglomerularÞltrationratelessthan30mL/
Ñnoinformationavailable
seenotesabove
seenotesabove
seenotesabove;alsomalaise,anaemia;
lesscommonly
abdominalpain,constipation,diarr-
BNFC2011–
2.5.5Drugsaffectingtherenin-angiotensinsystem
Cardiovascularsystem
hoea,nausea,vomiting,angina,palpitation,oedema,
dyspnoea,cough,headache,sleepdisorders,drowsi-
ness,urticaria,pruritus,rash;
hepatitis,atrial
Þbrillation,cerebrovascularaccident,andparaes-
alsoreported
pancreatitis,depression,erectile
dysfunction,thrombocytopenia,hyponatraemia,
arthralgia,myalgia,rhabdomyolysis,tinnitus,photo-
sensitivity,andvasculitis(includingHenoch-Scho
leinpurpura)
Indicationanddose
ypertension
(underspecialistsupervision)
Bymouth
Child6Ð18years
ody-weight20Ð50kg
initially700micrograms/
kg(max.25mg)oncedaily(lowerdoseinintra-
VALSARTAN
seenotesabove
Contra-indications
biliarycirrhosis,cholestasis
Hepaticimpairment
max.80mgdailyinmildto
moderateimpairment;avoidinsevereimpairment
Renalimpairment
seenotesabove;alsoavoidif
estimatedglomerularÞltrationratelessthan30mL/
Ñnoinformationavailable
seenotesabove
seenotesabove
seenotesabove;also
lesscommonly
abdominalpain,nausea,diarrhoea,cough,malaise,
alsoreported
anaemia,renalfailure,neu-
tropenia,thrombocytopenia,myalgia,vasculitis,
serumsickness,rash,pruritus
Licenseduse
capsulesnotlicensedforuseinchil-
Indicationanddose
ypertension
(underspecialistsupervision)
Bymouth
Child6Ð18years
ody-weight18Ð35kg
initially40mgoncedaily,
adjustedaccordingtoresponse;max.80mgdaily
ody-weight35Ð80kg
initially80mgoncedaily,
adjustedaccordingtoresponse;max.160mgdaily
ody-weight80kgandover
initially80mgonce
daily,adjustedaccordingtoresponse;max.320mg
Capsules
GLYCERYLTRINITRATE
hypothyroidism;malnutrition;hypothermia;
recenthistoryofmyocardialinfarction;heartfailure
duetoobstruction;hypoxaemiaorotherventilation
andperfusionabnormalities;susceptibilitytoangle-
Cardiovascularsystem
Contra-indications
hypersensitivitytonitrates;hypo-
tensiveconditionsandhypovolaemia;hypertrophic
cardiomyopathy;aorticstenosis;cardiactamponade;
constrictivepericarditis;mitralstenosis;toxicpulm-
onaryoedema;headtrauma;cerebralhaemorrhage;
cerebrovasculardisease;markedanaemia
Hepaticimpairment
cautioninsevereimpairment
Renalimpairment
manufacturersadviseusewith
cautioninsevereimpairment
notknowntobeharmful
noinformationavailableÑmanufac-
turersadviseuseonlyifpotentialbeneÞtoutweighs
posturalhypotension,tachycardia(but
paradoxicalbradycardiaalsoreported);throbbing
headache,dizziness;
lesscommonly
nausea,vomiting,
heartburn,ßushing,syncope,temporaryhypoxaemia,
rash,application-sitereactionswithtransdermal
veryrarely
angle-closureglaucoma
SpeciÞcside-effectsfollowinginjection(particu-
larlyifgiventoorapidly)includeseverehypotension,dia-
Cardiovascularsystem
mentofhypertension.Side-effectsassociatedwithvaso-
dilatationsuchasßushingandheadache(whichbecome
lessobtrusiveafterafewdays),andankleswelling
AMLODIPINE
acuteporphyria(butseesection9.8.2);
Appendix1(calcium-channelblockers)
Contra-indications
cardiogenicshock,signiÞcant
aorticstenosis
Hepaticimpairment
mayneeddosereductionÑhalf-
lifeprolonged
noinformationavailableÑmanufacturer
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
DILTIAZEMHYDROCHLORIDE
heartfailureorsigniÞcantlyimpairedleft
ventricularfunction,bradycardia(avoidifsevere),Þrst
degreeAVblock,orprolongedPRinterval;
Appendix1(calcium-channelblockers)
Contra-indications
severebradycardia,signiÞcant
aorticstenosis,cardiogenicshock,leftventricular
failurewithpulmonarycongestion,second-orthird-
degreeAVblock(unlesspacemakerÞtted),sicksinus
syndrome;acuteporphyria(section9.8.2)
Hepaticimpairment
reducedose
Renalimpairment
startwithsmallerdose
avoid
signiÞcantamountpresentinmilkÑ
noevidenceofharmbutavoidunlessnosaferalter-
bradycardia,sino-atrialblock,AVblock,
palpitation,dizziness,hypotension,malaise,asthenia,
headache,hotßushes,gastro-intestinaldisturbances,
oedema(notablyofankles);rarelyrashes(including
erythemamultiformeandexfoliativedermatitis),
photosensitivity;hepatitis,gynaecomastia,gum
hyperplasia,extrapyramidalsymptoms,depression
Licenseduse
notlicensedforuseinchildren
Indicationanddose
aynaudÕssyndrome
Bymouth
Child12Ð18years
30Ð60mg2Ð3timesdaily
Standardformulations
Theseformulationsarelicensedasgenericsandthereis
norequirementforbrandnamedispensing.Althoughtheir
meansofformulationhascalledforthestrictdesignation
ÔmodiÞed-releaseÕtheirdurationofactioncorrespondstothat
NICARDIPINEHYDROCHLORIDE
congestiveheartfailureorsigniÞcantly
impairedleftventricularfunction;avoidgrapefruit
Cardiovascularsystem
Hepaticimpairment
half-lifeprolongedinsevere
impairmentÑmayneeddosereduction
Renalimpairment
startwithsmallerdose
mayinhibitlabour;toxicityin
seenotesabove;alsopoorcardiacreserve;
heartfailureorsigniÞcantlyimpairedleftventricular
Cardiovascularsystem
ModiÞedrelease
DifferentversionsofmodiÞed-releasepreparationsmay
cerebraloedemaorseverelyraisedintra-
cranialpressure;hypotension;avoidconcomitant
Cardiovascularsystem
bloodpressurestable),increaseafter2hoursto1Ð
2mg/hourifnoseverefallinbloodpressure;
continueforatleast5days(max.14days)
reventionofvasospasmfollowingsubarach-
noidhaemorrhage
Bymouth
Child1monthÐ18years
0.9Ð1.2mg/kg(max.
60mg)6timesdaily,startingwithin4daysof
haemorrhageandcontinuedfor21days
continuousintravenousinfusion
administerundiluted
aY-pieceonacentral
VERAPAMILHYDROCHLORIDE
andgingivalhyperplasiaafterlong-termtreatment;
afterintravenousadministrationorhighdoses,hypo-
tension,heartfailure,bradycardia,heartblock,and
asystole;hypersensitivityreactionsinvolvingreversi-
blyraisedliverfunctiontests
Licenseduse
ModiÞedreleasepreparationnot
licensedforuseinchildren
Indicationanddose
ypertension,prophylaxisofsupraventricular
underspecialistadviceonly
Bymouth
Child1Ð2years
20mg2Ð3timesdaily
hild2Ð18years
40Ð120mg2Ð3timesdaily
reatmentofsupraventriculararrhythmias
Byintravenousinjectionover2Ð3minutes
(withECGandblood-pressuremonitoringand
underspecialistadvice)
Child1Ð18years
100Ð300micrograms/kg(max.
5mg)asasingledose,repeatedafter30minutesif
necessary
intravenousinjection
,maybe
dilutedwithGlucose5%
SodiumChloride0.9%;
incompatiblewithsolutionsofpHgreaterthan6
Verapamil
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
ModiÞedrelease
HalfSecuronSR
Cardiovascularsystem
(Cephalon)
Capsules
,m/r,verapamilhydrochloride120mg
ILOPROST
seesection2.5.1.2
Contra-indications
seesection2.5.1.2
Hepaticimpairment
dosemayneedtobehalvedin
livercirrhosis
seesection2.5.1.2
Licenseduse
notlicensedforuseinchildren
Indicationanddose
aynaudÕssyndrome
seenotesabove
Byintravenousinfusion
Child12Ð18years
initially30nanograms/kg/
hour,increasedgraduallyto60Ð120nanograms/
kg/hourgivenover6hoursdailyfor3Ð5days
ulmonaryhypertension
section2.5.1.2
intravenousinfusion
,dilutetoa
concentrationof200nanograms/mLwithGlucose
5%orSodiumChloride0.9%;alternatively,maybe
dilutedtoaconcentrationof2micrograms/mLand
givenviasyringedriver
Cardiovascularsystem
vascularresistanceishigh(coldshock),
adrenaline
(epinephrine)(section2.7.2)shouldbeadded.Addition-
ally,incoldshock,avasodilatorsuchas
milrinone
(section2.1.2),
glyceryltrinitrate
(section2.6.1),or
sodiumnitroprusside
(onspecialistadviceonly)(sec-
tion2.5.1.1)canbeusedtoreducevascularresistance.
Iftheshockisresistanttovolumeexpansionandcate-
cholamines,andthereissuspectedorprovenadrenal
insufÞciency,lowdose
hydrocortisone
(section6.3.2)
canbeused.ACTH-stimulatedplasma-cortisolconcen-
trationshouldbemeasured;however,hydrocortisone
canbestartedwithoutsuchinformation.
Alternatively,ifthechildisresistanttocatecholamines,
andvascularresistanceislow,
6.5.2)canbeadded.
Neonatalsepticshock
canbecomplicatedbythetransi-
DOBUTAMINE
arrhythmias,acutemyocardialinfarction,
acuteheartfailure,severehypotension,marked
obstructionofcardiacejection(suchasidiopathic
hypertrophicsubaorticstenosis);correcthypovol-
aemiabeforestartingtreatment;tolerancemay
developwithcontinuousinfusionslongerthan72
hours;hyperthyroidism;
Appendix1
DOPAMINEHYDROCHLORIDE
correcthypovolaemia;hyperthyroidism;
Cardiovascularsystem
Child1monthÐ18years
initially5micrograms/
kg/minuteadjustedaccordingtoresponse(max.
20micrograms/kg/minute)
continuousintravenousinfusion
dilutetoamax.concentrationof3.2mg/mLwith
Glucose5%
SodiumChloride0.9%.Infusehigher
EPHEDRINEHYDROCHLORIDE
Cardiovascularsystem
intravenousinfusion
,dilutetoa
concentrationof30Ð200micrograms/mLwithGlu-
cose5%
SodiumChloride0.9%andgivethrougha
coronary,mesenteric,orperipheralvascular
thrombosis;followingmyocardialinfarction;Prinz-
PHENYLEPHRINEHYDROCHLORIDE
seeunderNoradrenaline;longerdurationof
actionthannoradrenaline(norepinephrine),see
below;coronarydisease
Hypertensiveresponse
Phenylephrinehasalongerdura-
tionofactionthannoradrenaline,andanexcessivevaso-
pressorresponsemaycauseaprolongedriseinblood
Contra-indications
seeunderNoradrenaline;severe
hyperthyroidism
avoidifpossible;malformationsreported
ischaemicheartdisease,severeangina,
obstructivecardiomyopathy,hypertension,arrhyth-
mias,cerebrovasculardisease;occlusivevascular
disease,monitorbloodpressureandECG;corpulm-
onale;organicbraindamage,psychoneurosis;
Cardiovascularsystem
mayreduceplacentalperfusionandcan
delaysecondstageoflabour;manufacturersadvise
useonlyifbeneÞtoutweighsrisk
presentinmilkbutunlikelytobe
harmfulaspoororalbioavailability
nausea,vomiting,drymouth,anorexia,
hypersalivation;arrhythmias,palpitation,tachycardia,
syncope,angina,hypertension(riskofcerebral
haemorrhage),coldextremities,pallor;dyspnoea,
pulmonaryoedema(onexcessivedosageorextreme
Section3.4.3
Cardiopulmonary
Thealgorithmsforcardiopulmonaryresuscitation(see
insidebackcover)reßecttherecommendationsofthe
ResuscitationCouncil(UK);theycoverpaediatricbasic
lifesupport,paediatricadvancedlifesupport,andnew-
bornlifesupport.Theguidelinesareavailableat
www.resus.org.uk
Paediatricadvancedlifesupport
Cardiopulmonary
(cardiac)arrestinchildrenisrareandfrequentlyrepre-
sentstheterminaleventofprogressiveshockorrespir-
atoryfailure.
Duringcardiopulmonaryarrestinchildrenwithout
intravenousaccess,theintraosseousrouteischosen
becauseitprovidesrapidandeffectiveresponse;if
circulatoryaccesscannotbegained,theendotracheal
tubecanbeused.Whentheendotrachealrouteisused
tentimestheintravenousdoseshouldbeused;thedrug
shouldbeinjectedquicklydownanarrowboresuction
Cardiovascularsystem
torymonitoringofcoagulationactivity,preferablyona
HEPARIN
seenotesabove;concomitantuseofdrugs
thatincreaseriskofbleeding;
Appendix
1(heparin)
Heparin-inducedthrombocytopenia
Clinicallyimportant
heparin-inducedthrombocytopeniaisimmune-mediatedand
doesnotusuallydevelopuntilafter5Ð10days;itcanbe
aftermajortraumaorrecentsurgerytoeyeorner-
voussystem;acutebacterialendocarditis;spinalor
epiduralanaesthesiawithtreatmentdosesofunfrac-
tionatedorlowmolecularweightheparin;hyper-
sensitivitytounfractionatedorlowmolecularweight
Hepaticimpairment
riskofbleedingincreasedÑ
reducedoseoravoidinsevereimpairment(including
oesophagealvarices)
Renalimpairment
riskofbleedingincreasedinsevere
impairmentÑdosemayneedtobereduced
doesnotcrosstheplacenta;maternal
osteoporosisreportedafterprolongeduse;multidose
vialsmaycontainbenzylalcoholÑsomemanufac-
turersadviseavoid;seealsonotesabove
Cardiovascularsystem
continuousintravenousinfusion
dilutewithGlucose5%
SodiumChloride0.9%.
DALTEPARINSODIUM
seeunderHeparinandnotesabove
Contra-indications
seeunderHeparin
Hepaticimpairment
seenotesabove
Renalimpairment
riskofbleedingmaybe
increasedÑdosereductionandmonitoringofanti-
FactorXamayberequired;useofunfractionated
heparinmaybepreferable
seenotesabove;alsomultidosevialcon-
tainsbenzylalcoholÑmanufactureradvisesavoid
seenotesabove
seeunderHeparin
Licenseduse
notlicensedforuseinchildren
Indicationanddose
reatmentofthromboticepisodes
Bysubcutaneousinjection
100units/kgtwicedaily
Child1monthÐ12years
100units/kgtwicedaily
hild12Ð18years
200units/kg(max.
18000units)oncedaily,ifincreasedriskofbleed-
ingreducedto100units/kgtwicedaily
reatmentofvenousthromboembolismin
pregnancy
Bysubcutaneousinjection
Child12Ð18years
earlypregnancybody-weight
under50kg,5000unitstwicedaily;body-weight
50Ð70kg,6000unitstwicedaily;body-weight70Ð
90kg,8000unitstwicedaily;body-weightover
90kg,10000unitstwicedaily
rophylaxisofthromboticepisodes
Bysubcutaneousinjection
100units/kgoncedaily
Child1monthÐ12years
100units/kgoncedaily
hild12Ð18years
2500Ð5000unitsoncedaily
(single-dosesyringe),dalteparinsodium
ENOXAPARINSODIUM
seeunderHeparinandnotesabove
Contra-indications
seeunderHeparin
Hepaticimpairment
seenotesabove
Renalimpairment
riskofbleedingmaybeincreased;
reducedoseifestimatedglomerularÞltrationrateless
than30mL/minute/1.73m
;monitoringofanti-Fac-
torXamayberequired;useofunfractionatedheparin
maybepreferable
seenotesabove
2.8.1Parenteralanticoagulants
BNFC2011–
Cardiovascularsystem
seenotesabove
seeunderHeparin
Licenseduse
notlicensedforuseinchildren
Indicationanddose
reatmentofthromboticepisodes
Bysubcutaneousinjection
1.5Ð2mg/kgtwicedaily
Child1Ð2months
1.5mg/kgtwicedaily
hild2monthsÐ18years
1mg/kgtwicedaily
reatmentofvenousthromboembolismin
pregnancy
Bysubcutaneousinjection
Child12Ð18years
earlypregnancybody-weight
under50kg,40mg(4000units)twicedaily;body-
weight50Ð70kg,60mg(6000units)twicedaily;
body-weight70Ð90kg,80mg(8000units)twice
daily;body-weightover90kg,100mg
(10000units)twicedaily
rophylaxisofthromboticepisodes
Bysubcutaneousinjection
750micrograms/kgtwicedaily
Child1Ð2months
750micrograms/kgtwicedaily
hild2monthsÐ18years
500micrograms/kg
twicedaily;max.40mgdaily
TINZAPARINSODIUM
seeunderHeparinandnotesabove
Contra-indications
seeunderHeparin
Hepaticimpairment
seenotesabove
Renalimpairment
riskofbleedingmaybe
increasedÑdosereductionandmonitoringofanti-
FactorXamayberequired;unfractionatedheparin
maybepreferable
seenotesabove;alsovialscontainbenzyl
alcoholÑmanufactureradvisesavoid
seenotesabove
seeunderHeparin
Licenseduse
notlicensedforuseinchildren
Indicationanddose
reatmentofthromboticepisodes
Bysubcutaneousinjection
Child1Ð2months
275units/kgoncedaily
hild2monthsÐ1year
250units/kgoncedaily
hild1Ð5years
240units/kgoncedaily
hild5Ð10years
200units/kgoncedaily
hild10Ð18years
175units/kgoncedaily
reatmentofvenousthromboembolismin
pregnancy
Bysubcutaneousinjection
Child12Ð18years
175units/kgoncedaily(based
onearlypregnancybody-weight)
rophylaxisofthromboticepisodes
Bysubcutaneousinjection
Child1monthÐ18years
50units/kgoncedaily
DANAPAROIDSODIUM
recentbleedingorriskofbleeding;conco-
mitantuseofdrugsthatincreaseriskofbleeding;
antibodiestoheparins(riskofantibody-induced
thrombocytopenia)
Contra-indications
haemophiliaandotherhaemor-
rhagicdisorders,thrombocytopenia(unlesspatient
hasheparin-inducedthrombocytopenia),recent
cerebralhaemorrhage,severehypertension,active
pepticulcer(unlessthisisthereasonforoperation),
Cardiovascularsystem
Child1monthÐ16years
initially30units/kg
(max.1250unitsifbody-weightunder55kg,
2500unitsifover55kg)
byintravenousinjection
bycontinuousintravenousinfusion
2units/kg/houradjustedaccordingtocoagulation
hild16Ð18years
initially2500units(1250units
ifbody-weightunder55kg,3750unitsifover
90kg)
byintravenousinjection
bycontinuous
intravenousinfusion
400units/hourfor2hours,
300units/hourfor2hours,
200units/
hourfor5daysadjustedaccordingtocoagulation
intravenousinfusion
,dilutewith
Glucose5%
SodiumChloride0.9%
Cardiovascularsystem
driedprothrombincomplexunavailable,freshfro-
zenplasma15mL/kgcanbegivenbutisless
effective)
8.0,nobleedingorminorbleedingÑstop
warfarinandgivephytomenadione(vitaminK
2.5Ð5mgbymouthusingtheintravenousprepara-
tionorally[unlicenseduse],or0.5Ð1mgbyslow
WARFARINSODIUM
seenotesabove;alsorecentsurgery;recent
ischaemicstroke;historyofgastro-intestinalbleeding;
pepticulcer;concomitantuseofdrugsthatincrease
riskofbleeding;bacterialendocarditis(increasedrisk
ofbleeding;useonlyifwarfarinotherwiseindicated);
avoidcranberryjuice;
Appendix1
(warfarin)
Contra-indications
haemorrhagicstroke;signiÞcant
bleeding;avoidusewithin48hourspostpartum
Hepaticimpairment
avoidinsevereimpairment,
especiallyifprothrombintimealreadyprolonged
Renalimpairment
usewithcaution(avoidinsevere
impairment)
seenotesabove
notpresentinmilkinsigniÞcant
amounts;noevidenceofharm;seealsonotesabove
haemorrhageÑseenotesabove;also
nausea,vomiting,diarrhoea,jaundice,hepaticdys-
function,pancreatitis,pyrexia,alopecia,purpura,
rash,ÔpurpletoesÕ,skinnecrosis(increasedriskin
patientswithproteinCorproteinSdeÞciency)
Licenseduse
notlicensedforuseinchildren
Indicationanddose
reatmentandprophylaxisofthromboticepi-
Bymouth
eonate(underspecialistadvice)
200micr-
ograms/kgasasingledoseonÞrstday,reducedto
100micrograms/kgoncedailyforfollowing3days
(butifINRstillbelow1.4use200micrograms/kg
oncedaily,orifINRabove3use50micrograms/
kgoncedaily,ifINRabove3.5omitdose);then
adjustedaccordingtoINR,usualmaintenance
100Ð300micrograms/kgoncedaily(mayneedup
to400micrograms/kgoncedailyespeciallyif
bottlefedÑseenotesabove)
Child1monthÐ18years
200micrograms/kg
(max.10mg)asasingledoseonÞrstday,reduced
to100micrograms/kg(max.5mg)oncedailyfor
following3days(butifINRstillbelow1.4use
200micrograms/kg(max.10mg)oncedaily,orif
INRabove3use50micrograms/kg(max.2.5mg)
oncedaily,orifINRabove3.5omitdose);then
adjustedaccordingtoINR,usualmaintenance
100Ð300micrograms/kgoncedaily(mayneedup
to400micrograms/kgoncedailyespeciallyif
bottlefedÑseenotesabove)
Inductiondosemayneedtobealteredaccordingto
condition(e.g.abnormalliverfunctiontests,cardiac
failure),concomitantinteractingdrugs,andifbaseline
INRabove1.3
Warfarin
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
BNFC2011–
2.8.2Oralanticoagulants
Cardiovascularsystem
Protaminesulphate
Protaminesulphate
isusedtotreatoverdosageof
unfractionatedorlowmolecularweightheparin.The
longhalf-lifeoflowmolecularweightheparinsshould
PROTAMINESULPHATE
(ProtamineSulfate)
seeabove;alsomonitoractivatedpartial
thromboplastintimeorotherappropriatebloodclot-
Cardiovascularsystem
bronchospasm;gastro-intestinal
haemorrhage(occasionallymajor),alsoother
haemorrhage(e.g.subconjunctival)
Licenseduse
Notlicensedforuseinchildrenunder
16years
Indicationanddose
awasakisyndrome
Bymouth
initially8mg/kg4timesdailyfor2weeks
untilafebrile,followedby5mg/kgoncedailyfor
6Ð8weeks;ifnoevidenceofcoronarylesionsafter
8weeks,discontinuetreatmentorseekexpert
Child1monthÐ12years
initially7.5Ð12.5mg/kg
4timesdailyfor2weeksoruntilafebrile,then2Ð
5mg/kgoncedailyfor6Ð8weeks;ifnoevidence
ofcoronarylesionsafter8weeks,discontinue
treatmentorseekexpertadvice
aorticstenosis,leftventricularoutßow
obstruction,heartfailure;mayexacerbatemigraine;
hypotension;myastheniagravis(riskofexacerbation);
concomitantuseofdrugsthatincreaseriskofbleed-
ing;coagulationdisorders;
Appendix1
(dipyridamole)
notknowntobeharmful
manufacturersadviseuseonlyif
essentialÑsmallamountpresentinmilk
gastro-intestinaleffects,dizziness,myal-
gia,throbbingheadache,hypotension,hotßushesand
tachycardia;hypersensitivityreactionssuchasrash,
urticaria,severebronchospasmandangioedema;
increasedbleedingduringoraftersurgery;thrombo-
cytopeniareported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
awasakisyndrome
Bymouth
Child1monthÐ12years
1mg/kg3timesdaily
reventionofthrombusformationaftercardiac
surgery
Bymouth
Child1monthÐ12years
2.5mg/kgtwicedaily
hild12Ð18years
100Ð200mg3timesdaily
injectionsolutioncanbegivenorally
Dipyridamole
Cardiovascularsystem
alsobeusedwithcautioninexternalchestcompression,
pregnancy(seeindividualdrugs),hypertension,other
conditionsinwhichthrombolysismightgiveriseto
emboliccomplicationssuchasenlargedleftatrium
withatrialÞbrillation(riskofdissolutionofclotand
subsequentembolisation),andrecentorconcurrent
useofdrugsthatincreasetheriskofbleeding.
Contra-indications
Thrombolyticdrugsarecontra-
indicatedinrecenthaemorrhage,trauma,orsurgery
(includingdentalextraction),coagulationdefects,bleed-
ingdiatheses,aorticdissection,aneurysm,coma,his-
toryofcerebrovasculardiseaseespeciallyrecentevents
orwithanyresidualdisability,recentsymptomsof
possiblepepticulceration,heavyvaginalbleeding,
severehypertension,activepulmonarydiseasewith
cavitation,acutepancreatitis,pericarditis,bacterial
endocarditis,severeliverdisease,andoesophagealvari-
ces;alsointhecaseofstreptokinase,previousallergic
reactionstostreptokinase.
Prolongedpersistenceofantibodiestostreptokinase
canreducetheeffectivenessofsubsequenttreatment;
therefore,streptokinaseshouldnotbeusedagain
beyond4daysofÞrstadministration.Streptokinase
shouldalsobeavoidedinchildrenwhohavehadstrep-
tococcalinfectioninthelast12months.
Hepaticimpairment
Thrombolyticdrugsshouldbe
avoidedinseverehepaticimpairmentasthereisan
increasedriskofbleeding.
Thrombolyticdrugscanpossiblyleadto
prematureseparationoftheplacentaintheÞrst18
weeksofpregnancy.Thereisalsoariskofmaternal
haemorrhagethroughoutpregnancyandpost-partum,
ALTEPLASE
(rt-PA,tissue-typeplasminogenactivator)
seenotesabove;inchildrenwhohavehad
acutestroke
,monitorforintracranialhaemorrhage
andmonitorbloodpressure
Contra-indications
seenotesabove;inchildrenwho
havehadan
acutestroke
,convulsionaccompanying
stroke,severestroke,historyofstrokeinchildrenwith
STREPTOKINASE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
ntravascularthrombosis
Byintravenousinfusion
Child1monthÐ12years
initially2500Ð
4000units/kgover30minutes,followedby
tinuousintravenousinfusion
of500Ð1000units/
kg/hourforupto3daysuntilreperfusionoccurs
hild12Ð18years
initially250000unitsover30
minutes,followedby
continuousintravenous
of100000units/hourforupto3days
untilreperfusionoccurs
reconstitutewithSodiumChloride
0.9%,thendilutefurtherwithGlucose5%orSodium
Chloride0.9%afterreconstitution.MonitorÞbrinogen
concentrationclosely;ifÞbrinogenconcentrationless
than1g/litre,stopstreptokinaseinfusionandstart
unfractionatedheparin;restartstreptokinaseonce
Þbrinogenconcentrationreaches1g/litre
2.10.2Fibrinolyticdrugs
BNFC2011–
Cardiovascularsystem
(CSLBehring)
,powderforreconstitution,streptokinase,
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
TRANEXAMICACID
Cardiovascularsystem
Cyklokapron
DRIEDPROTHROMBINCOMPLEX
(HumanProthrombinComplex)
Driedprothrombincomplexispreparedfromhumanplasmaby
asuitablefractionationtechnique,andcontainsfactorIX,
FACTORVIIa(RECOMBINANT)
Eptacogalfa(activated)
riskofthrombosisordisseminatedintravas-
cularcoagulation
veryrarely
nausea,thromboticevents
(includingmyocardialinfarctionandcerebrovascular
accident),coagulationdisorders,fever,pain,and
allergicreactionsincludingrash
Indicationanddose
reatmentandprophylaxisofhaemorrhagein
haemophiliaAorBwithinhibitorstofactors
VIIIorIX,acquiredhaemophilia,factorVII
deÞciency,orGlanzmannÕsthrombasthenia
Consulthaematologist
AvailablefromNovoNordisk(
FACTORVIIIFRACTION,DRIED
(HumanCoagulationFactorVIII,Dried)
DriedfactorVIIIfractionispreparedfromhumanplasmabya
suitablefractionationtechnique;itmayalsocontainvarying
amountsofvonWillebrandfactor
monitorfordevelopmentoffactorVIIIinhi-
bitors;intravascularhaemolysisafterlargeorfre-
quentlyrepeateddosesinpatientswithbloodgroups
A,B,orABÑlesslikelywithhighpotencyconcen-
trates;vaccinationagainsthepatitisA(p.607)and
hepatitisB(p.608)mayberequired(notnecessary
withrecombinantpreparation)
gastro-intestinaldisturbances,tastedis-
turbances;ßushing,palpitation;dyspnoea,coughing;
headache,dizziness,paraesthesia,drowsiness;blurred
vision;antibodyformation;hypersensitivityreactions
includinghypotension,angioedema,chills,fever,
urticaria,andanaphylaxis
Indicationanddose
reatmentandprophylaxisofhaemorrhagein
congenitalfactorVIIIdeÞciency(haemophilia
A),acquiredfactorVIIIdeÞciency,orvonWill-
ebrandÕsdisease
Consulthaematologist
AvailablefromBiotestUK(
),CSLBehring
),BPL(
),Grifols(
),Octapharma(
,and
arenot
indicatedforuseinvonWillebrandÕsdisease
Preparationofrecombinanthumancoagulationfactor
VIII(octocogalfa)availablefromCSLBehring(
),Baxter(
),BayerSchering(
);preparationofrecombinanthumancoagulation
FACTORVIIIINHIBITORBYPASSING
PreparationswithfactorVIIIinhibitorbypassingactivityare
preparedfromhumanplasma
vaccinationagainsthepatitisA(p.607)and
hepatitisB(p.608)mayberequired
Contra-indications
disseminatedintravascularcoa-
thrombosis,disseminatedintravascular
coagulation,myocardialinfarction;paraesthesia;
pyrexia;hypersensitivityreactionsincludinghypo-
tension,ßushing,urticaria,rash,andanaphylaxis
Indicationanddose
reatmentandprophylaxisofhaemorrhagein
congenitalfactorVIIIdeÞciency(haemophilia
A)andfactorVIIIinhibitors;treatmentof
haemorrhageinnon-haemophiliacchildren
withacquiredfactorVIIIinhibitors
Consulthaematologist
AvailablefromBaxter(
FACTORIXFRACTION,DRIED
DriedfactorIXfractionispreparedfromhumanplasmabya
suitablefractionationtechnique;itmayalsocontainclotting
factorsII,VII,andX
riskofthrombosisÑprincipallywithformer
lowpurityproducts;vaccinationagainsthepatitisA
(p.607)andhepatitisB(p.608)mayberequired(not
necessarywithrecombinantpreparation)
Contra-indications
disseminatedintravascularcoa-
2.11Antibrinolyticdrugsandhaemostatics
BNFC2011–
Cardiovascularsystem
gastro-intestinaldisturbances;headache,
dizziness;allergicreactionsincludingchills,fever
Indicationanddose
reatmentandprophylaxisofhaemorrhagein
congenitalfactorIXdeÞciency(haemophiliaB)
Consulthaematologist
AvailablefromCSLBehring(
),BPL(
,DriedFactorIXFraction),Grifols(
PreparationofrecombinantcoagulationfactorIX
FACTORXIIIFRACTION,DRIED
(HumanFibrin-stabilisingFactor,Dried)
vaccinationagainsthepatitisA(p.607)and
hepatitisB(p.608)mayberequired
rarely
allergicreactionsandfever
Indicationanddose
ongenitalfactorXIIIdeÞciency
Consulthaematologist
AvailablefromCSLBehring(
FRESHFROZENPLASMA
Freshfrozenplasmaispreparedfromthesupernatantliquid
obtainedbycentrifugationofonedonationofwholeblood
needforcompatibility;vaccinationagainst
hepatitisA(p.607)andhepatitisB(p.608)maybe
Contra-indications
circulatoryoverload;avoiduseas
avolumeexpander
allergicreactionsincludingchills,fever,
bronchospasm;acuterespiratorydistresssyndrome
Indicationanddose
eplacementofcoagulationfactorsorother
plasmaproteinswheretheirconcentrationor
functionalactivityiscriticallyreduced
Consulthaematologist
AvailablefromRegionalBloodTransfusionServices
Childrenunder16yearsshouldonlyreceivevirucidally
inactivatedpreparationsoffreshfrozenplasma,sourced
fromÔlowprevalenceBSEregionsÕsuchastheUSA
PROTEINCCONCENTRATE
ProteinCispreparedfromhumanplasma
hypersensitivitytoheparins;vaccination
againsthepatitisA(p.607)andhepatitisB(p.608)
mayberequired
veryrarely
fever,bleeding,dizziness,and
hypersensitivityreactions
Indicationanddose
ongenitalproteinCdeÞciency
Consulthaematologist
AvailablefromBaxter(
Lipid-regulatingdrugs
Atherosclerosisbeginsinchildhoodandraisedserum-
cholesterolinchildrenisassociatedwithcardiovascular
diseaseinadulthood.Loweringthecholesterol,without
hinderinggrowthanddevelopmentinchildrenand
adolescents,shouldreducetheriskofcardiovascular
diseaseinlaterlife.
Theriskfactorsfordevelopingcardiovasculardisease
includeraisedserumcholesterolconcentration,
smoking,hypertension,impairedglucosetolerance,
Cardiovascularsystem
ATORVASTATIN
seenotesabove;alsohaemorrhagicstroke
Hepaticimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsochestpain;back
pain;pruritus;
lesscommonly
anorexia,malaise,
weightgain,hypoglycaemia,hyperglycaemia,and
cholestaticjaundiceandperipheral
veryrarely
tastedisturbances,gynaeco-
mastia,hearingloss,Stevens-Johnsonsyndrome,and
toxicepidermalnecrolysis
NICEclinicalguideline67(May2008).LipidModiÞca-
tionÑCardiovascularriskassessmentandthemodiÞcation
ofbloodlipidsfortheprimaryandsecondarypreventionof
cardiovasculardisease
2.12Lipid-regulatingdrugs
BNFC2011–
Cardiovascularsystem
Indicationanddose
yperlipidaemiaincludingfamilialhyper-
cholesterolaemia
Bymouth
Child10Ð18years
initially10mgoncedaily,
increasedifnecessaryatintervalsofatleast4
weekstousualmax.20mgoncedaily(max.80mg
oncedailyinhomozygousfamilialhyper-
cholesterolaemia)
Reduceddoserequiredwithconcomitantciclos-
porin,clarithromycin,oritraconazoleÑseekspecialist
(Pzer)
FLUVASTATIN
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
manufactureradvisesdosesabove
40mgdailyshouldbeinitiatedwithcautionifesti-
matedglomerularÞltrationrateislessthan30mL/
minute/1.73m
seenotesabove
seenotesabove
seenotesabove;also
veryrarely
Indicationanddose
ModiÞedrelease
Fluvastatin
PRAVASTATINSODIUM
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
startwithlowerdosesinmoderate
tosevereimpairment
seenotesabove
seenotesabove
seenotesabove;
lesscommonly
abnor-
malurination(includingdysuria,nocturia,andfre-
veryrarely
fulminanthepaticnecrosis
Indicationanddose
yperlipidaemiaincludingfamilialhyper-
cholesterolaemia
Bymouth
Child8Ð14years
10mgoncedailyatnight,
adjustedatintervalsofatleast4weekstomax.
20mgoncedailyatnight
hild14Ð18years
10mgoncedailyatnight,
adjustedatintervalsofatleast4weekstomax.
40mgoncedailyatnight
Pravastatin
ROSUVASTATIN
seenotesabove;childrenofAsianorigin;use
lowermax.doseinchildrenwithriskfactorsfor
myopathyorrhabdomyolysis(includingpersonalor
familyhistoryofmusculardisordersortoxicity)
Hepaticimpairment
seenotesabove
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan60mL/minute/1.73m
avoidifestimatedglomerularÞltrationratelessthan
30mL/minute/1.73m
seenotesabove
seenotesabove
Cardiovascularsystem
SIMVASTATIN
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
dosesabove10mgdailyshouldbe
usedwithcautionifestimatedglomerularÞltration
ratelessthan30mL/minute/1.73m
seenotesabove
seenotesabove
seenotesabove;also
rarely
Licenseduse
notlicensedforuseinchildrenunder
10years
Indicationanddose
yperlipidaemiaincludingfamilialhyper-
cholesterolaemia
Bymouth
Child5Ð10years
initially10mgatnight
increased,ifnecessary,atintervalsofatleast4
weekstomax.20mgatnight
hild10Ð18years
initially10mgatnight
increased,ifnecessary,atintervalsofatleast4
weekstomax.40mgatnight
Reduceddoserequiredwithconcomitantciclos-
porin,danazol,Þbrates(exceptfenoÞbrate),amiodarone,
diltiazem,orverapamilÑseekspecialistadvice
Simvastatin
COLESTYRAMINE
(Cholestyramine)
seenotesabove
Contra-indications
Cardiovascularsystem
COLESTIPOLHYDROCHLORIDE
seenotesabove
seenotesabove
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
amilialhypercholesterolaemia
Bymouth
Child12Ð18years
initially5g1Ð2timesdaily
increasedifnecessaryin5-gincrementsatinter-
valsof1monthtomax.of30gdailyin1Ð2divided
BEZAFIBRATE
correcthypothyroidismbeforeinitiating
treatment(seeHypothyroidism,p.125);seeunder
Myotoxicitybelow;
Appendix1
Contra-indications
hypoalbuminaemia,primary
biliarycirrhosis,gallbladderdisease,nephrotic
Hepaticimpairment
avoidinsevereliverdisease
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationrate15Ð60mL/minute/1.73m
;avoid
ifestimatedglomerularÞltrationratelessthan15mL/
minute/1.73m
Myotoxicity
Specialcareneededinchildrenwithrenal
disease,asprogressiveincreasesinserum-creatininecon-
centrationorfailuretofollowdosageguidelinesmayresultin
myotoxicity(rhabdomyolysis);discontinueifmyotoxicity
suspectedorcreatinekinaseconcentrationincreasessignif-
manufacturersadviseavoidÑembryotoxi-
cityin
manufactureradvisesavoidÑno
informationavailable
gastro-intestinaldisturbances,anorexia;
lesscommonly
cholestasis,weightgain,dizziness,
headache,fatigue,drowsiness,renalimpairment,
raisedserumcreatinine(unrelatedtorenalimpair-
ment),erectiledysfunction,myotoxicity(withmyas-
theniaormyalgia)Ñparticularriskinrenalimpair-
ment(seeCautions),urticaria,pruritus,
photosensitivityreactions;
veryrarely
gallstones,
hypoglycaemia,anaemia,leucopenia,thrombocyto-
Cardiovascularsystem
FENOFIBRATE
seeunderBezaÞbrate;liverfunctiontests
recommendedevery3monthsforÞrstyear(discon-
tinuetreatmentifsigniÞcantlyraised)
Contra-indications
gallbladderdisease;photosensit-
maymasksymptomsofinfection;monitor
forbleeding;monitorgastro-intestinalfunction;aller-
gicdisorders;
Appendix1(NSAIDs)
Contra-indications
life-threateninginfection;active
bleedingespeciallyintracranialorgastro-intestinal;
thrombocytopeniaorcoagulationdefects;marked
unconjugatedhyperbilirubinaemia;knownorsus-
pectednecrotisingenterocolitis;pulmonaryhyper-
Hepaticimpairment
increasedriskofgastro-intes-
Cardiovascularsystem
concomitantuseofnephrotoxicdrugs;mayinduce
ALPROSTADIL
seenotesabove;alsohistoryofhaemorr-
hage;avoidinhyalinemembranedisease;monitor
arterialpressure,respiratoryrate,heartrate,tem-
perature,andvenousbloodpressureinarmandleg;
facilitiesforintubationandventilationmustbe
immediatelyavailable;
Appendix1
(alprostadil)
apnoea(particularlyinneonatesunder
2kg),ßushing,bradycardia,hypotension,tachycardia,
cardiacarrest,oedema,diarrhoea,fever,convulsions,
disseminatedintravascularcoagulation,hypokal-
aemia;corticalproliferationoflongbones;weakening
ofthewalloftheductusarteriosusandpulmonary
seenotesabove;alsohistoryofhaemorr-
hage;avoidinhyalinemembranedisease;monitor
arterialoxygenation,heartrate,temperature,and
bloodpressureinarmandleg;facilitiesforintubation
andventilationmustbeimmediatelyavailable;
inter-
Appendix1(prostaglandins)
Hepaticimpairment
manufactureradvisesavoid
Renalimpairment
manufactureradvisesavoid
nausea,vomiting,diarrhoea;ßushing,
bradycardia,hypotension,cardiacarrest;respiratory
depressionandapnoea,particularlywithhighdoses
andinlowbirth-weightneonates,bronchospasm;
pyrexiaandraisedwhitebloodcellcount,shivering;
localreactions,erythema;ifusedforlongerthan5
Cardiovascularsystem
Indicationanddose
aintainingpatencyoftheductusarteriosus
Bycontinuousintravenousinfusion
initially5nanograms/kg/minute,
increasedasnecessaryin5nanogram/kg/minute
incrementsto20nanograms/kg/minute
Dosesupto100nanograms/kg/minutehavebeen
usedbutareassociatedwithincreasedside-effects
Bymouth
20Ð25micrograms/kgevery1Ð2hours
doubledifnecessary;iftreatmentcontinuesfor
morethan1weekgraduallyreducethedose
continuousintravenousinfusion
dilutetoaconcentrationof1microgram/mLwith
Glucose5%
SodiumChloride0.9%.
Foradministration
bymouth
,injectionsolutioncanbe
givenorally;dilutewithwater
Intravenoussolution
,fordilutionanduseasan
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
2.14Drugsaffectingtheductusarteriosus
BNFC2011–
Cardiovascularsystem
Respiratorysystem
Bronchodilators
Adrenoceptoragonists
Respiratorysystem
asthmashouldpreferablybeadministeredbyinhalation
Adviceonthemanagementofacuteasthmaisbasedon
Respiratorysystem
Managementofchronicasthma
Important
Startat
stepmostappropriate
Respiratorysystem
Managementofacuteasthma
Important
Theassessmentofacuteasthmainearlychildhoodcanbedifcult.Childrenwithsevereorlife-
threateningacuteasthmamaynotbedistressedandmaynothavealloftheseabnormalities;thepresenceofany
shouldalertthedoctor.Regardeachemergencyconsultationasbeingfor
severeacuteasthma
untilshownotherwise
Moderateacuteasthma
Abletotalk
Respiration(breaths/minute)
2–5years
40,5–12years
30,12–18years
Pulse(beats/minute)
140,5–12years
12–18years
Arterialoxygensaturation
Peakow
5–12years
ofpredictedorbest,12–18years
Treatathomeorinsurgeryand
assessresponsetotreatment
Treatment
Respiratorysystem
Croup
Mildcroupislargelyself-limiting,buttreatmentwitha
singledoseofacorticosteroid(e.g.
3.1.1.1
pooroverallcontrolandcallsforreassessmentof
asthmatreatment.
Respiratorysystem
asthmaandshouldbemanagedwitha
prophylacticdrugsuchasaninhaledcorticosteroid.
Thechildandthechild’scarershouldbeadvisedto
FORMOTEROLFUMARATE
(Eformoterolfumarate)
Foruseinasthmaonlyinchildrenwhoregularlyusean
inhaledcorticosteroid,seenotesabove
seenotesabove
seep.133
seep.133
seenotesabove;nausea,dizziness,rash,
tastedisturbances,andpruritusalsoreported
Indicationanddose
eversibleairwaysobstruction(including
nocturnalasthmaandpreventionofexercise-
inducedbronchospasm)inpatientsrequiring
long-termregularbronchodilatortherapy
alsoManagementofChronicAsthmatable,p.135;
fordoseseepreparationsbelow
Counselling
Advisechildrenandcarersnottoexceedpre-
scribeddose,andtofollowmanufacturer’sdirections;ifa
previouslyeffectivedoseofinhaledformoterolfailsto
provideadequaterelief,adoctor’sadviceshouldbeobtained
assoonaspossible
Formoterol
Respiratorysystem
Reliefofbronchospasm
Byinhalationofpowder
Child6Ð18years
6–12micrograms
Preventionofexercise-inducedbronchospasm
Byinhalationofpowder
Child6Ð18years
6–12microgramsbeforeexercise
Compoundpreparations
For
compoundpreparations
containingformoterol,
seesection3.2
SALBUTAMOL
(Albuterol)
seenotesabove
seep.133
seep.133
seenotesabove;alsolacticacidosiswith
highdoses
Licenseduse
notlicensedforuseinhyperkalaemia;
syrupnotlicensedforuseinchildrenunder2years;
hild2Ð6years
1–2mg3–4timesdaily
hild6Ð12years
2mg3–4timesdaily
hild12Ð18years
4mg(sensitivepatientsiniti-
ally2mg)3–4timesdaily;max.singledose8mg
(butunlikelytoprovideextrabenetortobe
everehyperkalaemia(section9.2.1.1)
Byintravenousinjectionover5minutes
4micrograms/kgasasingledose;repeat
ifnecessary
Child1monthÐ18years
4micrograms/kgasa
singledose;repeatifnecessary
Byinhalationofnebulisedsolution(butintra-
venousinjectionpreferred)
2.5–5mgasasingledose;repeatif
necessary
Child1monthÐ18years
2.5–5mgasasingle
dose;repeatifnecessary
continuousintravenousinfusion
dilutetoaconcentrationof200micrograms/mLwith
Glucose5%
SodiumChloride0.9%;ifuid-
restricted,canbegivenundilutedthroughcentral
Salbutamol
Ventolin
,salbutamol(assulphate)500micrograms/
Respiratorysystem
Counselling
Advisechildrenandcarersnottoexceedpre-
scribeddoseandtofollowmanufacturer’sdirections;ifa
previouslyeffectivedoseofinhaledsalbutamolfailsto
provideatleast3hoursrelief,adoctor’sadviceshouldbe
obtainedassoonaspossible.
Salbutamol
Prophylaxisofallergen-orexercise-inducedbron-
chospasm
Byinhalationofpowder
Child6Ð12years
100–200micrograms
Child12Ð18years
200micrograms
Ventolin
(drypowderforinhalation),diskcon-
taining60blistersofsalbutamol(assulphate)
200micrograms/blisterwith
Accuhaler
(drypowderforinhalation),diskcon-
Respiratorysystem
aerosolinhalation
Compoundpreparations
For
compoundpreparations
TERBUTALINESULPHATE
seenotesabove
seep.133
seep.133
seenotesabove
Licenseduse
Oralandparenteral
(AstraZeneca)
Counselling
Advisechildrenandcarersnottoexceedpre-
scribeddoseandtofollowmanufacturer’sdirections;ifa
previouslyeffectivedoseofinhaledterbutalinefailsto
provideatleast3hoursrelief,adoctor’sadviceshouldbe
obtainedassoonaspossible
(AstraZeneca)
Turbohaler
(=drypowderinhaler),terbutaline
3.1.1.2
Otheradrenoceptoragonists
Adrenaline
epinephrine
(1in1000)isused
intheemergencytreatmentofacuteallergicandana-
phylacticreactions(section3.4.3),inangioedema(sec-
tion3.4.3),andincardiopulmonaryresuscitation(sec-
tion2.7.3).Adrenalinesolution(1in1000)isusedby
nebulisationinthemanagementofseverecroup(sec-
tion3.1).
Antimuscarinic
bronchodilators
Ipratropium
bynebulisationcanbeaddedtoother
standardtreatmentinlife-threateningacuteasthmaor
ifacuteasthmafailstoimprovewithstandardtherapy
(seeManagementofAcuteAsthma,p.134).Ipra-
tropiumcanbeusedtoprovideshort-termreliefin
IPRATROPIUMBROMIDE
riskofglaucoma(seebelow),bladderout-
owobstruction;
Appendix1(anti-
muscarinics)
Acuteangle-closureglaucoma
reportedwith
nebulisedipratropium,particularlywhengivenwithnebu-
Respiratorysystem
junctivalhyperaemia,cornealoedema,stomatitis,
rash,pruritus;
atrialbrillation
Indicationanddose
cuteasthma
Byinhalationofnebulisedsolution
SeeManagementofAcuteAsthma,section3.1
eversibleairwaysobstruction
seenotesabove
Byaerosolinhalation
Child1monthÐ6years
20micrograms3times
hild6Ð12years
20–40micrograms3timesdaily
hild12Ð18years
20–40micrograms3–4times
Byinhalationofpowder
Child12Ð18years
40micrograms3–4timesdaily
(dosemaybedoubledinlessresponsivecondition)
Counselling
Advisechildandcarernottoexceedprescribed
doseandtofollowmanufacturer’sdirections
section12.2.2
IpratropiumBromide
THEOPHYLLINE
seenotesabove;alsocardiacarrhythmiasor
othercardiacdisease,hypertension,hyperthyroidism;
pepticulcer;epilepsy;fever;hypokalaemiarisk,
p.138;avoidinacuteporphyria(section9.8.2);
monitorplasma-theophyllineconcentration(see
notesabove);doseadjustmentmaybenecessaryif
smokingstartedorstoppedduringtreatment;
inter-
Appendix1(theophylline)andnotesabove
Hepaticimpairment
reducedose
neonatalirritabilityandapnoeareported;
seealsop.133
presentinmilk—irritabilityininfant
reported;modied-releasepreparationspreferable;
seealsop.133
nausea,vomiting,gastricirritation,
diarrhoea,palpitation,tachycardia,arrhythmias,
headache,CNSstimulation,insomnia,convulsions
overdosage:
seeEmergencyTreatmentofPoisoning,
p.31
Licenseduse
capsulesnotlicensedfor
useinchildrenunder2years
3.1.3Theophylline
BNFC2011–
Respiratorysystem
Indicationanddose
hronicasthma
SeeunderpreparationsbelowandManagementof
ChronicAsthmatablep.135
Plasma-theophyllineconcentrationforoptimum
response10–20mg/litre(55–110micromol/litre);nar-
Modiedrelease
Therateofabsorptionfrommodied-releaseprepara-
Aminophyllineisastablemixtureorcombinationof
Respiratorysystem
eonatalapnoea
(butseenotesabove)
Byintravenousinjectionover20minutes
initially6mg/kg,then2.5mg/kgevery
12hours(increasedifnecessaryto3.5mg/kg
every12hours)
Plasma-theophyllineconcentrationforoptimum
responseinneonatalapnoea8–12mg/litre(44–66micr-
omol/litre),seealsonotesabove
For
intravenousinfusion
,dilutetoa
concentrationof1mg/mLwithGlucose5%
iumChloride0.9%
Aminophylline
Modiedrelease
Adviceaboutmodied-releasetheophyllinepreparations
onp.143alsoappliestomodied-releaseaminophyllinepre-
PhyllocontinContinus
Respiratorysystem
NICEguidance
Inhalerdevicesforchildrenwithchronic
asthma(childrenunder5years,August
2000;children5Ð15years,March2002)
Achild’sneeds,abilitytodevelopandmaintain
effectivetechnique,andlikelihoodofgoodcompli-
anceshouldgovernthechoiceofinhalerandspacer
device;onlythenshouldcostbeconsidered.
Forchildrenagedunder5years:
corticosteroidandbronchodilatortherapy
Respiratorysystem
inthemouthpieceandtubing.Theextenttowhichthe
nebulisedsolutionisdepositedintheairwaysoralveoli
dependsonparticlesize.Particleswithamediandia-
Forstandarddosesofotherinhaledcorticosteroids,see
ManagementofChronicAsthmatable,p.135
3.2Corticosteroids
BNFC2011–
Respiratorysystem
generallybeexceeded;however,ifahigherdoseis
requireditshouldbeinitiatedandsupervisedbya
respiratorypaediatrician.Theuseofhighdosesofan
inhaledcorticosteroidcanminimisetherequirementfor
anoralcorticosteroid.
Cautionsofinhaledcorticosteroids
Systemicther-
apymayberequiredduringperiodsofstress,suchas
duringsevereinfections,orwhenairwaysobstructionor
mucuspreventdrugaccesstosmallerairways;
Appendix1(corticosteroids).
Paradoxicalbronchospasm
Thepotentialforparadox-
icalbronchospasm(callingfordiscontinuationandalter-
nativetherapy)shouldbeborneinmind—mildbron-
chospasmmaybepreventedbyinhalationofashort-
Respiratorysystem
seenotesabove
seep.133
seep.133
seenotesabove
Licenseduse
nebulisersolution
licensedforuseinchildrenunder3months;not
licensedforuseinbronchopulmonarydysplasia;
notlicensedforuseinchildrenfor
asthmamaintenanceandrelievertherapy
Indicationanddose
rophylaxisofasthma
seeManagementof
ChronicAsthmatable,p.135,andpreparations
Byinhalationofnebulisersuspension
Childover1month
2mgassingledoseorin2
divideddosesseparatedby30minutes;dosemay
berepeatedafter12hoursifnecessary
ronchopulmonarydysplasiawithassisted
Byaerosolinhalation
400microgramstwicedaily
Child1Ð4months
400microgramstwicedaily
ronchopulmonarydysplasiawithsponta-
neousrespiration
Byinhalationofnebulisersuspension
500microgramstwicedaily
3.2Corticosteroids
BNFC2011–
Respiratorysystem
Child1Ð4months
500microgramstwicedaily;
forseveresymptomsinchildbody-weight2.5kgor
over,1mgtwicedaily
For
aerosolinhalation
inventilated
babieswithbronchopulmonarydysplasia,usemed-
ium-volumespacer(section3.1.5)attacheddirectlyto
endotrachealtube;hand-ventilatethroughspacer,
Compoundpreparations
Forprescribinginformationonformoterolfumarate,
seesection3.1.1.1
Symbicort
(AstraZeneca)
Symbicort100/6Turbohaler
(=drypowder
inhaler),budesonide100micrograms,formoterol
Respiratorysystem
seenotesabove
seep.133
seep.133
seenotesabove
Indicationanddose
rophylaxisofasthma
Byaerosolinhalation
Child12Ð18years
160microgramsdailyasa
singledosereducedto80microgramsdailyif
controlmaintained
(Nycomed)
Aerosolinhalation
,ciclesonide80micrograms/
FLUTICASONEPROPIONATE
seenotesabove
seep.133
seep.133
seenotesabove;also
veryrarely
pepsia,hyperglycaemia,andarthralgia
Indicationanddose
rophylaxisofasthma
seeManagementof
ChronicAsthmatable,p.135,andpreparations
(drypowderforinhalation),diskcon-
taining60blistersof
uticasonepropionate
50micr-
ograms/blisterwith
Compoundpreparations
Respiratorysystem
price120-doseunit=£35.00.Label:8,counselling,
administration,10,steroidcard
Prophylaxisofasthma
Byaerosolinhalation
Child12Ð18years
2puffstwicedaily
childreniscontentious.Prophylaxiswithcromoglicate
ornedocromilislesseffectivethanwithinhaledcorti-
costeroids(seeManagementofChronicAsthmatable).
Withdrawalofsodiumcromoglicateornedocromil
shouldbedonegraduallyoveraperiodofoneweek—
symptomsofasthmamayrecur.
Nedocromilmaybeofsomebenetintheprophylaxis
ofexercise-inducedasthma.
Fortheuseofsodiumcromoglicateandnedocromilin
allergicconjunctivitisseesection11.4.2;sodiumcromo-
glicateisusedalsoinallergicrhinitis(section12.2.1)
andallergy-relateddiarrhoea(section1.5.4).
Paradoxicalbronchospasm
Ifparadoxicalbroncho-
SODIUMCROMOGLICATE
(SodiumCromoglycate)
seenotesabove;alsodiscontinueifeosino-
philicpneumoniaoccurs
seep.133
seep.133
seenotesabove;rhinitisandeosinophilic
pneumoniaalsoreported
Indicationanddose
rophylaxisofasthma
(seealsoManagementof
ChronicAsthma,p.135)
Byaerosolinhalation
Child5Ð18years
10mg(2puffs)4timesdaily,
increasedifnecessaryto6–8timesdaily;an
additionaldosemayalsobetakenbeforeexercise;
maintenance,5mg(1puff)4timesdaily
oodallergy
section1.5.4
llergicconjunctivitis
section11.4.2
llergicrhinitis
section12.2.1
CFC-freeinhaler
Aerosolinhalation
,sodiumcromoglicate5mg/
NEDOCROMILSODIUM
seenotesabove
seep.133
seep.133
seenotesabove;alsonausea,vomiting,
dyspepsia,abdominalpain,pharyngitis;
Licenseduse
notlicensedforuseinchildrenunder6
years
BNFC2011–
3.3Cromoglicateandrelatedtherapy
Respiratorysystem
Indicationanddose
rophylaxisofasthma
(butseenotesabove)
Counselling
Regularuseisnecessary
Byaerosolinhalation
Child5Ð18years
4mg(2puffs)4timesdaily,
whencontrolachievedmaybepossibletoreduce
totwicedaily
llergicconjunctivitis
section11.4.2
CFC-freeinhaler
Aerosolinhalation
,mint-avoured,nedocromilsod-
Appendix1(leukotriene
receptorantagonists)
manufactureradvisesavoidunlessessen-
tial;seealsonotesabove
manufactureradvisesavoidunless
abdominalpain,thirst;hyperkinesia(in
youngchildren),headache;
veryrarely
syndrome(seenotesabove);drymouth,diarrhoea,
dyspepsia,nausea,vomiting,hepaticdisorders,pal-
pitation,oedema,increasedbleeding,epistaxis,skin
reactions,respiratoryinfections,depression,tremor,
asthenia,dizziness,hallucinations,suicidalthoughts
andbehaviour,paraesthesia,hypoaesthesia,sleep
disturbances,sleepwalking,abnormaldreams,agita-
Appendix1(leukotriene
receptorantagonists)
Hepaticdisorders
Childrenortheircarersshouldbetold
howtorecognisedevelopmentofliverdisorderandadvised
toseekmedicalattentionifsymptomsorsignssuchas
persistentnausea,vomiting,malaiseorjaundicedevelop
Hepaticimpairment
manufactureradvisesavoid
Renalimpairment
manufactureradvisescaution
manufactureradvisesuseonlyifpotential
benetoutweighsrisk;seealsonotesabove
presentinmilk—manufacturer
advisesavoid
gastro-intestinaldisturbances;headache;
bleedingdisorders,hypersensitivityreactions
includingangioedemaandskinreactions,arthralgia,
myalgia,hepatitis,hyperbilirubinaemia,thrombocy-
veryrarely
Churg-Strausssyndrome(see
notesabove),agranulocytosis
3.3.2Leukotrienereceptorantagonists
BNFC2011–
Respiratorysystem
Indicationanddose
rophylaxisofasthma
seenotesaboveandMan-
agementofChronicAsthma,p.135
Bymouth
Child12Ð18years
20mgtwicedaily
Accolate
(AstraZeneca)
Respiratorysystem
ACRIVASTINE
seenotesabove
Contra-indications
seenotesabove;alsohypersensi-
tivitytotriprolidine
Renalimpairment
avoidinsevereimpairment
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
ymptomaticreliefofallergysuchashayfever,
chronicidiopathicurticaria
Bymouth
Child12Ð18years
8mg3timesdaily
DESLORATADINE
FEXOFENADINEHYDROCHLORIDE
Respiratorysystem
Indicationanddose
ymptomaticreliefofallergysuchashayfever,
urticaria
Bymouth
Child2Ð6years
1.25mgtwicedaily
hild6Ð18years
5mgoncedaily
LORATADINE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
reducedosefrequencytoalter-
natedaysinsevereimpairment
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
ymptomaticreliefofallergysuchashayfever,
chronicidiopathicurticaria
Bymouth
Child2Ð12years
ody-weightunder30kg
5mgoncedaily
ody-weightover30kg
10mgoncedaily
hild12Ð18years
10mgoncedaily
seenotesabove
Contra-indications
seenotesabove;alsosusceptibil-
itytoQT-intervalprolongation(includingcardiac
diseaseandhypokalaemia)
Hepaticimpairment
manufacturerrecommends
avoidinsignicantimpairment
seenotesabove
seenotesabove
RUPATADINE
seenotesabove;alsosusceptibilitytoQT-
intervalprolongation(includingcardiacdiseaseand
hypokalaemia)
Hepaticimpairment
manufactureradvisesavoid—no
informationavailable
Renalimpairment
manufactureradvisesavoid—no
informationavailable
manufactureradvisescaution—limited
informationavailable;seealsonotesabove
manufactureradvisescaution;see
alsonotesabove
seenotesabove;alsoasthenia;
commonly
ALIMEMAZINETARTRATE
(Trimeprazinetartrate)
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
avoid
seenotesabove
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder2
years
Indicationanddose
rticaria,pruritus
Bymouth
Child6monthsÐ2years
250micrograms/kg
(max.2.5mg)3–4timesdaily—specialistuseonly
hild2Ð5years
2.5mg3–4timesdaily
hild5Ð12years
5mg3–4timesdaily
hild12Ð18years
10mg2–3timesdaily,in
severecasesuptomax.100mgdaily
section15.1.4
Bymouth
Child2Ð7years
uptomax.2mg/kg1–2hours
beforeoperation
BNFC2011–
3.4.1Antihistamines
Respiratorysystem
Alimemazine
CHLORPHENAMINEMALEATE
(Chlorpheniraminemaleate)
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsoexfoliative
dermatitisandtinnitusreported;injectionsmaycause
transienthypotensionorCNSstimulationandmaybe
irritant
Licenseduse
notlicensedforuseinchildren
under1year;
,chlorphenaminemaleate10mg/mL,
HYDROXYZINEHYDROCHLORIDE
seenotesabove;alsosusceptibilitytoQT-
intervalprolongation
Contra-indications
seenotesabove
Hepaticimpairment
reducedailydosebyone-third;
seealsonotesabove
Renalimpairment
reducedailydosebyhalf
toxicityin
studieswithhighdoses;
seealsonotesabove
seenotesabove
seenotesabove
Licenseduse
syrupnotlicensedforusein
childrenunder1year
Indicationanddose
Bymouth
Child6monthsÐ6years
initially5–15mgat
night,increasedifnecessaryto50mgdailyin3–4
divideddoses
hild6Ð12years
initially15–25mgatnight,
increasedifnecessaryto50–100mgdailyin3–4
divideddoses
hild12Ð18years
initially25mgatnight,
increasedifnecessaryto100mgin3–4divided
(Alliance)
Respiratorysystem
Zaditen
(SwedishOrphan)
BEEANDWASPALLERGEN
seenotesaboveandconsultproductlitera-
Contra-indications
seenotesaboveandconsultpro-
ductliterature
avoid
consultproductliterature
Indicationanddose
ypersensitivitytowasporbeevenom
notesabove)
Bysubcutaneousinjection
Consultproductliterature
Pharmalgen
(ALK-Abello
Beevenomextract(
Apismellifera
)orwaspvenom
extract(
GRASSANDTREEPOLLEN
seenotesaboveandconsultproductlitera-
BNFC2011–
3.4.2Allergenimmunotherapy
Respiratorysystem
Contra-indications
seenotesaboveandconsultpro-
ductliterature
avoid
consultproductliterature
Indicationanddose
reatmentofseasonalallergichayfeverdueto
grassortreepollen
(seenotesabove)
Seeunderpreparations,below
Grasspollenextract
(ALK-Abello
responseshouldbeassessedat16weeksandomalizu-
mabtreatmentdiscontinuedinpatientswhohavenot
shownamarkedimprovementinoverallasthmacon-
NICEguidance
Omalizumabforseverepersistentallergic
asthma(November2007)
Omalizumabisrecommendedasadditionaltherapy
fortheprophylaxisofseverepersistentallergic
asthmainchildrenover12years,whocannotbe
controlledadequatelywithhigh-doseinhaledcorti-
autoimmunedisease;susceptibilitytohel-
minthinfections—discontinueifinfectiondoesnot
respondtoanthelmintic
Hepaticimpairment
manufactureradvisescaution—
noinformationavailable
Renalimpairment
manufactureradvisescaution—no
informationavailable
manufactureradvisesavoidunlessessen-
tial;noevidenceofteratogenicityin
manufactureradvisesavoid—present
inmilkin
headache;injection-sitereactions;
commonly
nausea,diarrhoea,dyspepsia,ushing,
fatigue,dizziness,drowsiness,paraesthesia,inuenza-
likesymptoms,photosensitivity,hypersensitivity
reactions(includinghypotension,bronchospasm,lar-
yngoedema,rash,pruritus,serumsickness,and
anaphylaxis);arterialthromboembolicevents,Churg-
Strausssyndrome(seenotesabove),thrombocyto-
penia,arthralgia,myalgia,andalopeciaalsoreported
3.4.2Allergenimmunotherapy
BNFC2011–
Respiratorysystem
Indicationanddose
rophylaxisofseverepersistentallergic
(seenotesabove)
Bysubcutaneousinjection
Child6Ð18years
accordingtoimmunoglobulinE
concentrationandbody-weight,consultproduct
adequacyofthecirculation,theinitialinjectionofadr-
enalinemayneedtobegivenasa
dilutesolutionbythe
intravenousroute
,orbytheintraosseousrouteifvenous
Respiratorysystem
revisedrecommendationsoftheWorkingGroupofthe
ResuscitationCouncil(UK).
Doseof
injectionofadrena-
line(epinephrine)foranaphylaxis
Agerange
Volumeof
1in1000
(1mg/mL)
Under6years150micrograms0.15mL
6–12years
300micrograms0.3mL
12–18years500micrograms0.5mL
Thesedosesmayberepeatedseveraltimesifnecessary
at5-minuteintervalsaccordingtobloodpressure,pulse,
andrespiratoryfunction.
Usesuitablesyringeformeasuringsmallvolume
300micrograms(0.3mL)ifchildissmallorprepubertal
Intravenousadrenaline(epinephrine)
Intravenousadrenalineshouldbegivenonlybythose
aboutadequacyofthecirculationandabsorptionfrom
theintramuscularinjectionsite,adrenalinemaybegiven
intravenousinjection
.Childrenmayrespondto
aslittleas1microgram/kg(0.01mL/kg)ofthedilute1
in10000adrenalineinjectionby
intravenous
injection
repeatedaccordingtoresponse.Asingle
doseofadrenalinebyintravenousinjectionshouldnot
exceed50micrograms;ifmultipledosesarerequired
considergivingadrenalinebyslowintravenous
Greatvigilanceisneededtoensurethatthe
strength
ofadrenalineinjectionisused;anaphylactic
shockkitsneedtomakea
verycleardistinction
preparationavailable).Asyringedelivering300micr-
ogramsofadrenalineisrecommendedforachildover
30kg.Asyringedelivering150microgramsofadrena-
lineisrecommendedforachild15–30kg,butonthe
basisofadoseof10micrograms/kg,300micrograms
maybemoreappropriateforsomechildren.
forcautionsinnon-life-threateningsitua-
tions,seesection2.7.2
theadequacyofthecirculation
Byslowintravenousinjectionof1in10000
(100micrograms/mL)solution(extremecau-
tion—specialistuseonly)
Seenotesabove
SafePractice
Intravenousrouteshouldbeusedwith
extremecare
byspecialistsonly,seenotesabove
(section3.1)
Byinhalationofnebulisedsolutionofadrena-
line1in1000(1mg/mL)
Child1monthÐ12years
400micrograms/kg
(max.5mg),repeatedafter30minutesifnecessary
Fornebulisation,diluteadrenaline1in
1000solutionwithsterilesodiumchloride0.9%solution
cutehypotension,lowcardiacoutput
ardiopulmonaryresuscitation
section2.7.3
Intramuscularorsubcutaneous
Adrenaline/Epinephrine1in1000
restrictiondoesnotapplytoadrenalineinjection
1mg/mLwhereadministrationisforsavinglifein
3.4.3Allergicemergencies
BNFC2011–
Respiratorysystem
Extremecaution
,seenotesabove
Adrenaline/Epinephrine1in10000,Dilute
Intramuscularinjectionforself-administration
(LincolnMedical)
(deliveringasingledoseofadrenaline
restrictiondoesnotapplytoadrenalineinjection
1mg/mLwhereadministrationisforsavinglifein
BNFC2011–
3.4.3Allergicemergencies
Respiratorysystem
Trachealintubationmaybenecessary.Insomechildren
withlaryngealoedema,adrenaline1in1000(1mg/mL)
solutionmaybegivenbynebuliser.However,nebulised
adrenalinecannotberelieduponforasystemiceffect—
intramuscularadrenalineshouldbeused.
Hereditaryangioedema
TheadministrationofC1-
esteraseinhibitor(infreshfrozenplasmaorinpartially
puriedform)mayterminateacuteattacksof
hereditary
angioedema
,butisnotpracticalforlong-termprophy-
laxis;itcanalsobeusedforshort-termprophylaxis
beforesurgeryordentalprocedures[unlicensedindica-
Tranexamicacid
(section2.11)isusedforshort-
termorlong-termprophylaxisofhereditaryangio-
edema;short-termprophylaxisisstartedseveraldays
beforeplannedprocedureswhichmaytriggeranacute
attackofhereditaryangioedema(e.g.dentalwork)and
continuedfor2–5daysafterwards.
indication,seeBNFsection6.7.2]isbestavoidedin
childrenbecauseofitsandrogeniceffectsbutitcanbe
usedforshort-termprophylaxisofhereditaryangio-
C1-ESTERASEINHIBITOR
vaccinationagainsthepatitisA(p.607)and
hepatitisB(p.608)mayberequired
manufactureradvisesavoidunlessessen-
manufactureradvisesuseonlyif
potentialbenetoutweighsrisk—noinformation
available
rarely
injection-sitereactions,hyper-
sensitivityreactions(includinganaphylaxis)
Licenseduse
notlicensedforshort-termprophy-
laxisofhereditaryangioedema
Indicationanddose
cuteattacksofhereditaryangioedema,short-
termprophylaxisofhereditaryangioedema
beforesurgeryordentalprocedures
Byslowintravenousinjectionorintravenous
infusion(specialistuseonly)
20units/kg
Child1monthÐ18years
20units/kg
Berinert
(CSLBehring)
,powderforreconstitutionC1-esterase
treatment.Theyaretypicallyusedinthemanagement
gastro-oesophagealreux;cardiovascular
disease;monitorplasma-caffeineconcentration(see
notesabove);monitorcloselyfor1weekafterstop-
pingtreatment
hypertension,tachycardia;irritability,
restlessness;hypoglycaemia,hyperglycaemia;uid
andelectrolyteimbalance
Indicationanddose
Doseexpressedascaffeinebase
eonatalapnoea
Bymouth,expressedascaffeinebase
initially10mg/kg,then2.5–5mg/kg
oncedailystarting24hoursafterinitialdose
Byintravenousinfusion,expressedascaffeine
initially10mg/kgover30minutes,then
2.5–5mg/kgover10minutesoncedailystarting
24hoursafterinitialdose
Safepractice
Whenprescribing,alwaysstatedoseintermsofcaff-
einebase
Caffeinebase1mg=caffeine
2mg
caffeineinjectionmaybeadminis-
bymouth
byintravenousinfusion
Respiratorysystem
BERACTANT
seenotesaboveandconsultproductlitera-
seenotesabove
Licenseduse
licensedforuseinrespiratorydistress
syndromeinnewbornprematureinfants,birth-
weightover700g,andasprophylaxisinneonates
lessthan32weekspost-menstrualage
Indicationanddose
reatmentofrespiratorydistresssyndromein
PORACTANTALFA
seenotesaboveandconsultproductlitera-
seenotesabove;also
rarely
hypotension
Licenseduse
licensedforuseinrespiratorydistress
syndromeinnewbornprematureinfants,birth-
weightover700g,andasprophylaxisinneonates
24–32weekspost-menstrualage
Indicationanddose
reatmentofrespiratorydistresssyndromeor
Respiratorysystem
severekyphoscoliosisorsevereankylosing
severelungscarringcausedbytuberculosis;
Respiratorysystem
HOOFandfurtherinstructionsareavailableat
www.bprs.co.uk/oxygen.html
EasternEngland
BOCMedical
toorder:
Tel:0800136603
Fax:08001699989
NorthEast
SouthWest
AirLiquide
toorder:
Tel:08082022229
Fax:01914974340
SouthLondon
SouthEastCoast
SouthCentral
AirLiquide
toorder:
Tel:0500823773
Fax:08007814610
NorthWest
YorkshireandHumberside
EastMidlands
WestMidlands
NorthLondon
Wales
AirProducts
toorder:
Tel:0800373580
Fax:0800214709
,referthechildforassessmentbyapaed-
iatricrespiratoryconsultant.Iftheneedforaconcen-
tratorisconrmedtheconsultantwillarrangeforthe
provisionofaconcentratorthroughtheCommonSer-
vicesAgency.In
NorthernIreland
oxygenconcentra-
torsandcylindersshouldbeprescribedonformHS21;
oxygenconcentratorsaresuppliedbyalocalcontractor.
NorthernIreland
,prescriptionsfor
oxygencylindersandaccessoriescanbedispensedby
pharmaciescontractedtoprovidedomiciliaryoxygen
services.
Mucolytics,suchas
mecysteine
,are
usedtofacilitatemucociliaryclearanceandexpect-
orationbyreducingsputumviscositybutevidenceof
efcacyislimited.
Dornasealfa
SeeEmergencytreatmentofpoisoning,p.28
historyofpepticulceration
Contra-indications
activepepticulceration
manufactureradvisesavoidinrsttrime-
noinformationavailable
rarely
gastro-intestinalbleeding;hyper-
sensitivityreactions(includingrashandanaphylaxis)
alsoreported
Indicationanddose
eductionofsputumviscosity
Bymouth
Child2Ð5years
62.5–125mg4timesdaily
hild5Ð12years
250mg3timesdaily
BNFC2011–
3.7Mucolytics
Respiratorysystem
Child12Ð18years
initially2.25gdailyindivided
doses,then1.5gdailyindivideddosesascondi-
tionimproves
Capsules
DORNASEALFA
Phosphorylatedglycosylatedrecombinant
humandeoxyribonuclease1(rhDNase)
noevidenceofteratogenicity;manufac-
tureradvisesuseonlyifpotentialbenetoutweighs
amountprobablytoosmalltobe
harmful—manufactureradvisescaution
pharyngitis,voicechanges,chestpain;
occasionallylaryngitis,rashes,urticaria,conjunctivitis
Indicationanddose
anagementofcysticbrosispatientswitha
forcedvitalcapacity(FVC)ofgreaterthan40%
ofpredictedtoimprovepulmonaryfunction
MECYSTEINEHYDROCHLORIDE
sodiumchloridetoreducetheriskoftheseadverse
effects.
MucoClear
Nebulisersolution
Respiratorysystem
Coughpreparations
Coughsuppressants
Expectorantanddemulcentcough
Coughsuppressants
Coughmaybeasymptomofanunderlyingdisorder
suchasasthma(section3.1),gastro-oesophagealreux
disease(section1.1),orrhinitis(section12.2.1),which
shouldbeaddressedbeforeprescribingcoughsuppres-
sants.Coughmaybeassociatedwithsmokingorenvir-
onmentalpollutants.Coughcanalsoresultfrom
bronchiectasisincludingthatassociatedwithcystic
brosis;coughcanalsohaveasignicanthabitcompo-
nent.Thereislittleevidenceofanysignicantbenet
fromtheuseofcoughsuppressantsinchildrenwith
PHOLCODINE
asthma;chronic,persistent,orproductive
:Appendix1(pholcodine)
Contra-indications
chronicbronchitis,bronchiectasis,
bronchiolitis,childrenatriskofrespiratoryfailure
Hepaticimpairment
avoid
Renalimpairment
usewithcaution;avoidinsevere
impairment
manufactureradvisesavoidunlesspoten-
tialbenetoutweighsrisk
manufactureradvisesavoidunless
potentialbenetoutweighsrisk—noinformation
available
nausea,vomiting,constipation,sputum
Respiratorysystem
SimpleLinctus,Paediatric,BP
(=oralsolution),citricacidmonohydrate
HYDROCHLORIDE
Canbesoldtothepublicprovidednomorethan720mgof
pseudoephedrinesaltsaresupplied,andephedrinebase(or
Respiratorysystem
Centralnervoussystem
Hypnoticsandanxiolytics
Hypnotics
Anxiolytics
Barbiturates
Drugsusedinpsychosesand
relateddisorders
Antipsychoticdrugs
Antipsychoticdepotinjections
Antimanicdrugs
Antidepressantdrugs
Tricyclicantidepressantdrugs
Monoamine-oxidaseinhibitors
Selectiveserotoninre-uptake
inhibitors
Otherantidepressantdrugs
CNSstimulantsandotherdrugs
forattentiondeÞcithyperactiv-
itydisorder
Drugsusedinthetreatmentof
Drugsusedinnauseaand
vertigo
Analgesics
Non-opioidanalgesicsandcom-
poundanalgesicpreparations
Opioidanalgesics
Neuropathicpain
Antimigrainedrugs
Treatmentofacutemigraine
Prophylaxisofmigraine
Clusterheadacheandthetri-
geminalautonomiccephalalgias
Antiepileptics
Controloftheepilepsies
Drugsusedinstatusepilepticus
Febrileconvulsions
Drugsusedindystoniasand
relateddisorders
Dopaminergicdrugsusedin
dystonias
Antimuscarinicdrugsusedin
dystonias
Drugsusedinessentialtremor,
chorea,tics,andrelateddisor-
Drugsusedinsubstancedep-
Alcoholdependence
Nicotinedependence
Opioiddependence
Drugsfordementia
Hypnoticsandanxiolytics
Hypnotics
Anxiolytics
Barbiturates
Mostanxiolytics(‘sedatives’)willinducesleepwhen
givenatnightandmosthypnoticswillsedatewhen
givenduringtheday.Hypnoticsandanxiolyticsshould
bereservedforshortcoursestoalleviateacutecondi-
tionsaftercausalfactorshavebeenestablished.
Centralnervoussystem
Dentalprocedures
Someanxiouschildrenmayben-
etfromtheuseofahypnoticthenightbeforethedental
appointment.Hypnoticsdonotrelievepain,andifpain
interfereswithsleepanappropriateanalgesicshouldbe
Chloralandderivatives
Chloralhydrate
andderivativeswereformerlypopular
hypnoticsforchildren.
Chloralhydrateisnowmainlyusedforsedationduring
diagnosticprocedures(section15.1.4).Itaccumulates
onprolongeduse.
CHLORALHYDRATE
reducedoseindebilitated;avoidprolonged
use(andabruptwithdrawalthereafter);avoidcontact
withskinandmucousmembranes;
Appendix1(anxiolyticsandhypnotics)
Skilledtasks
Drowsinessmaypersistthenextdayand
affectperformanceofskilledtasks(e.g.driving);effectsof
alcoholenhanced
Contra-indications
severecardiacdisease;gastritis;
acuteporphyria(section9.8.2)
Hepaticimpairment
canprecipitatecoma;reduce
doseinmildtomoderatehepaticimpairment;avoidin
severeimpairment
Renalimpairment
avoidinsevereimpairment
avoid
riskofsedationininfant—avoid
gastricirritation(nauseaandvomiting
reported),abdominaldistention,atulence,headache,
tolerance,dependence,excitement,delirium(espe-
Centralnervoussystem
edationinintensivecare
Bymouthorbyslowintravenousinjectionorby
deepintramuscularinjection
Child1monthÐ12years
0.5–1mg/kg(max.
25mg)4timesdaily,adjustedaccordingto
hild12Ð18years
25–50mg4timesdaily,
adjustedaccordingtoresponse
llergyandurticaria
section3.4.1
auseaandvomiting
section4.6
Oralpreparations
Section3.4.1
Melatoninisapinealhormonethatmayaffectsleep
pattern.Clinicalexperiencesuggeststhatwhenappro-
priatebehaviouralsleepinterventionsfail,melatonin
MELATONIN
autoimmunedisease(manufactureradvises
avoid—noinformationavailable);
Appendix1(melatonin)
Hepaticimpairment
clearancereduced—manufac-
tureradvisesavoid
Renalimpairment
noinformationavailable—caution
noinformationavailable—avoid
presentinmilk—avoid
lesscommonly
abdominalpain,dys-
pepsia,drymouth,mouthulceration,weightgain,
hypertension,chestpain,malaise,dizziness,restless-
Centralnervoussystem
2.Bearinmindriskfactors,includingobesity.
3.Considerpotentialfordruginteractions—see
inter-
Appendix1(antipsychotics).
4.CarryoutECGtoexcludeuntowardabnormalities
suchasprolongedQTinterval;repeatECGperiodi-
callyandreducedoseifprolongedQTintervalor
otheradverseabnormalitydevelops.
5.Increasedoseslowlyandnotmoreoftenthanonce
weekly.
6.Carryoutregularpulse,bloodpressure,andtem-
peraturechecks;ensurethatpatientmaintainsade-
quateuidintake.
7.Considerhigh-dosetherapytobeforlimitedperiod
andreviewregularly;abandonifnoimprovement
Centralnervoussystem
Renalimpairment
Startwithsmalldosesofantipsy-
choticdrugsinsevererenalimpairmentbecauseof
increasedcerebralsensitivity.Pericyazineshouldbe
avoidedinrenalimpairment.
Extrapyramidaleffectshavebeenreported
occasionallyintheneonatewhenantipsychoticdrugs
aretakenduringthethirdtrimesterofpregnancy.
Thereislimitedinformationavailable
ontheshort-andlong-termeffectsofantipsychoticson
thebreast-fedinfant.
studiesindicatepossible
adverseeffectsofantipsychoticmedicinesonthedevel-
opingnervoussystem.Treatmentwithantipsychotics
whilstbreast-feedingshouldbeavoidedunlessabso-
lutelynecessary.
Extrapyramidalsymptomsarethemost
troublesome.Theyoccurmostfrequentlywiththe
piperazinephenothiazines(suchasperphenazine,pro-
chlorperazine,andtriuoperazine),thebutyrophenones
(suchashaloperidol),andthedepotpreparations.They
areeasytorecognisebutcannotbepredictedaccurately
becausetheydependonthedose,thetypeofdrug,and
onindividualsusceptibility.
Extrapyramidalsymptomsconsistof:
parkinsoniansymptoms
(includingtremor),which
mayappeargradually(butlesscommonlythanin
dystonia
(abnormalfaceandbodymovements)and
dyskinesia
,whichappearafteronlyafewdoses;
akathisia
(restlessness),whichcharacteristically
occursafterlargeinitialdosesandmayresemble
anexacerbationoftheconditionbeingtreated;and
tardivedyskinesia
(rhythmic,involuntarymove-
mentsoftongue,face,andjaw),whichusually
developsonlong-termtherapyorwithhighdosage,
butitmaydeveloponshort-termtreatmentwith
lowdoses—short-livedtardivedyskinesiamay
occurafterwithdrawalofthedrug.
Parkinsoniansymptoms
remitifthedrugiswithdrawn
andmaybesuppressedbytheadministrationof
muscarinic
drugs(section4.9.2).However,routine
administrationofsuchdrugsisnotjustiedbecause
notallchildrenareaffectedandbecausetheymay
unmaskorworsentardivedyskinesia.
Tardivedyskinesia
isofparticularconcernbecauseit
maybeirreversibleonwithdrawingtherapyandtreat-
mentisusuallyineffective.Inchildren,tardivedys-
kinesiaismorelikelytooccurwhentheantipsychotic
iswithdrawn.However,somemanufacturerssuggest
thatdrugwithdrawalattheearliestsignsoftardive
dyskinesia(nevermicularmovementsofthetongue)
mayhaltitsfulldevelopment.Tardivedyskinesiamay
occurandtreatmentmustbecarefullyandregularly
Hypotensionandinterferencewithtemperatureregula-
aredose-relatedside-effects.
Neurolepticmalignantsyndrome
(hyperthermia,uc-
tuatinglevelofconsciousness,musclerigidity,and
autonomicdysfunctionwithpallor,tachycardia,labile
bloodpressure,sweating,andurinaryincontinence)isa
rarebutpotentiallyfatalside-effectofsomeantipsy-
choticdrugs.Discontinuationoftheantipsychoticis
essentialbecausethereisnoproveneffectivetreatment,
butcooling,bromocriptine,anddantrolenehavebeen
used.Thesyndrome,whichusuallylastsfor5–7days
afterdrugdiscontinuation,maybeundulyprolongedif
depotpreparationshavebeenused.
Otherside-effectsinclude:
drowsiness;apathy;agitation,
excitementandinsomnia;convulsions;dizziness;head-
ache;confusion;gastro-intestinaldisturbances;nasal
congestion;antimuscarinicsymptoms(suchasdry
mouth,constipation,difcultywithmicturition,and
blurredvision;
veryrarely
angle-closureglaucoma);
cardiovascularsymptoms(suchashypotension,tachy-
cardia,andarrhythmias);ECGchanges(casesofsudden
deathhaveoccurred);venousthromboembolism;endo-
crineeffectssuchasmenstrualdisturbances,galacto-
rrhoea,gynaecomastia,impotence,andweightgain;
blooddyscrasias(suchasagranulocytosisandleuco-
penia),photosensitisation,contactsensitisationand
rashes,andjaundice(includingcholestatic);corneal
andlensopacities,andpurplishpigmentationofthe
Centralnervoussystem
Prescribingofmorethanoneantipsychoticdrugatthe
sametimeis
recommended;itmayconstitutea
hazardandthereisnosignicantevidencethatside-
effectsareminimised.
Chlorpromazine
isassociatedwithawiderangeof
adverseeffects,includingmarkedsedation.
islesssedatingthanchlorpromazine.
Althoughpimozideislicensedforuseinchildren,itis
notusedbecauseoftheriskofseriouscardiacside-
effects(seeECGMonitoring,p.176).
Sulpiride
inhighdosescontrolsoridpositivesymp-
toms,butinlowerdosesithasanalertingeffecton
CHLORPROMAZINE
HYDROCHLORIDE
Warning
Owingtotheriskofcontactsensitisation,pharma-
cists,nurses,andotherhealthworkersshouldavoiddirect
HALOPERIDOL
seenotesabove;alsosubarachnoid
Centralnervoussystem
Indicationanddose
chizophreniaandotherpsychoses,mania,
short-termadjunctivemanagementofpsycho-
motoragitation,excitementandviolentor
dangerouslyimpulsivebehaviour
(underspecia-
listsupervision)
Bymouth
Child12Ð18years
initially0.5–3mg2–3times
3–5mg2–3timesdailyinseverelyaffected
orresistantdisease;inresistantschizophreniaup
to30mgdailymaybeneeded;adjustedaccording
toresponsetolowesteffectivemaintenancedose
(aslowas5–10mgdaily)
PERICYAZINE
(Periciazine)
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;moresedating;hypo-
tensioncommonwhentreatmentinitiated;respir-
atorydepression
Licenseduse
Centralnervoussystem
seenotesabove;hypothyroidism
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;lesssedating;extra-
pyramidalsymptoms,especiallydystonia,morefre-
quent,particularlyathighdosage;
lupuserythematosus
Indicationanddose
chizophreniaandotherpsychoses,mania,
seenotesabove
ECGmonitoring
Followingreportsofsuddenunexplained
death,anECGisrecommendedbeforetreatment.Itisalso
recommendedthatpatientstakingpimozideshouldhavean
annualECG(iftheQTintervalisprolonged,treatment
shouldbereviewedandeitherwithdrawnordosereduced
underclosesupervision)andthatpimozideshould
givenwithotherantipsychoticdrugs(includingdepotpre-
parations),tricyclicantidepressantsorotherdrugswhich
prolongtheQTinterval,suchascertainantimalarials,anti-
arrhythmicdrugsandcertainantihistaminesandshould
begivenwithdrugswhichcauseelectrolytedisturbances
seenotesabove;alsoexcited,agitated,or
aggressivechildren(evenlowdosesmayaggravate
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsohepatitisand
venousthromboembolism
Licenseduse
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;extrapyramidalsymp-
tomsmorefrequent,especiallyatdosesexceeding
6mgdaily;anorexia;muscleweakness
4.2.1Antipsychoticdrugs
BNFC2011–
Centralnervoussystem
Indicationanddose
chizophreniaandotherpsychoses,short-term
adjunctivemanagementofpsychomotoragita-
tion,excitementandviolentordangerously
impulsivebehaviour
(underspecialistsupervision)
Bymouth
Child12Ð18years
initially5mgtwicedaily,
increasedby5mgdailyafter1week,thenat
intervalsof3days,accordingtoresponse
hort-termadjunctivemanagementofsevere
seenotesabove
Contra-indications
seenotesabove;phaeochromo-
cytoma,prolactin-dependenttumours
Renalimpairment
halvedoseifestimatedglomerular
ltrationrate30–60mL/minute/1.73m
;useone-
thirddoseifestimatedglomerularltrationrate10–
30mL/minute/1.73m
;noinformationavailableif
estimatedglomerularltrationratelessthan10mL/
minute/1.73m
avoid
avoid—noinformationavailable
Centralnervoussystem
Amisulpride
ARIPIPRAZOLE
seenotesabove;cerebrovasculardisease
Contra-indications
seenotesabove
Hepaticimpairment
usewithcautioninsevere
impairment
useonlyifpotentialbenetoutweighs
risk—noinformationavailable
avoid—presentinmilkin
seenotesabove;gastro-intestinaldistur-
bances;tachycardia;fatigue,insomnia,agitation,
akathesia,drowsiness,restlessness,tremor,headache,
asthenia;blurredvision;
lesscommonly
veryrarely
anorexia,dysphagia,oropharangeal
spasm,laryngospasm,hepatitis,jaundice,hypersali-
vation,pancreatitis,oedema,thromboembolism,
arrhythmias,bradycardia,hypertension,chestpain,
CLOZAPINE
seenotesabove;monitorleucocyteanddif-
ferentialbloodcounts(seeAgranulocytosis,below);
susceptibilitytoangle-closureglaucoma;taperoff
otherantipsychoticsbeforestarting;closemedical
supervisionduringinitiation(riskofcollapsebecause
ofhypotension);doseadjustmentmaybenecessaryif
smokingstartedorstoppedduringtreatment
Onplannedwithdrawalreducedoseover1–2
weekstoavoidriskofreboundpsychosis.Ifabruptwith-
drawalnecessaryobservechildcarefully
Neutropeniaandpotentiallyfatal
agranulocytosisreported.Leucocyteanddifferentialblood
countsmustbenormalbeforestarting;monitorcountsevery
weekfor18weeksthenatleastevery2weeksandifcloz-
apinecontinuedandbloodcountstableafter1yearatleast
every4weeks(and4weeksafterdiscontinuation);ifleuco-
cytecountbelow3000/mm
orifabsoluteneutrophilcount
below1500/mm
discontinuepermanentlyandreferto
haematologist.Patientswhohavealowwhitebloodcell
Centralnervoussystem
bocythaemia,hypertriglyceridaemia,hyper-
cholesterolaemia,hyperlipidaemia,fulminanthepatic
necrosis,angle-closureglaucoma,andskinreactions
Licenseduse
notlicensedforuseinchildrenunder
16years
Indicationanddose
chizophreniainchildrenunresponsiveto,or
intolerantof,conventionalantipsychoticdrugs
(underspecialistsupervision)
Bymouth
Child12Ð18years
12.5mgonceortwiceonrst
daythen25–50mgonseconddaythenincreased
gradually(ifwelltolerated)instepsof25–50mg
dailyover14–21daysupto300mgdailyindivided
doses(largerdoseatnight,upto200mgdailymay
betakenasasingledoseatbedtime);ifnecessary
maybefurtherincreasedinstepsof50–100mg
once(preferably)ortwiceweekly;usualdose200–
450mgdaily(max.900mgdaily)
intervalofmorethan2days
12.5mgonceortwiceonrstday(butmaybefeasibleto
increasemorequicklythanoninitiation)—extremecau-
tionifpreviousrespiratoryorcardiacarrestwithinitial
Clozaril
seenotesabove;alsosusceptibilitytoangle-
Centralnervoussystem
seenotesabove;alsodrowsiness,dys-
pepsia,constipation,drymouth,hypertension,mild
asthenia,rhinitis,tachycardia,irritability;leucopenia,
neutropeniaandoccasionallyeosinophiliareported;
elevatedplasma-triglycerideandcholesterolconcen-
trations,hypothyroidism;possibleQTintervalpro-
longation;restlesslegssyndrome;
rarely
veryrarely
Licenseduse
notlicensedforuseinchildren
Indicationanddose
chizophrenia
(underspecialistsupervision)
Bymouth
Child12Ð18years
initially25mgtwicedaily
adjustedinstepsof25–50mgaccordingto
response;max.750mgdaily
reatmentofmaniainbipolardisorder
specialistsupervision)
Bymouth
Child12Ð18years
25mgtwicedailyonday1,
50mgtwicedailyonday2,
100mgtwice
dailyonday3,
150mgtwicedailyonday4,
200mgtwicedailyonday5;thereafterdose
adjustedaccordingtoresponseinstepsnogreater
than100mgdaily,usualdose400–600mgdailyin
2divideddoses
(AstraZeneca)
ModiÞedrelease
(AstraZeneca)
seenotesabove;hyperprolactinaemia,pro-
lactin-dependenttumours;dehydration;familyhistory
ofsuddencardiacdeath(performECG);avoidinacute
porphyria(section9.8.2)
Hepaticimpairment
initialandsubsequentoraldoses
shouldbehalved
Renalimpairment
initialandsubsequentoraldoses
shouldbehalved
useonlyifpotentialbenetoutweighsrisk;
extrapyramidaleffectsreportedinneonatewhen
takeninthirdtrimester
useonlyifpotentialbenetoutweighs
risk—smallamountpresentinmilk
seenotesabove;alsogastro-intestinal
disturbances(includingdiarrhoea,constipation,
nauseaandvomiting,dyspepsia,abdominalpain),dry
mouth;dyspnoea;drowsiness,asthenia,tremor,sleep
Centralnervoussystem
Risperidone
Centralnervoussystem
Lithiumisusedtotreatacuteepisodesofmaniain
childrenwhohaverespondedtolithiumbeforeand
whosesymptomsarenotsevere.
Thedecisiontogiveprophylacticlithiumusually
requiresspecialistadvice,andmustbebasedoncareful
considerationofthelikelihoodofrecurrenceinthe
individualchild,andthebenetoftreatmentweighed
againsttherisks.Thefullprophylacticeffectoflithium
maynotoccurforsixtotwelvemonthsaftertheinitia-
tionoftherapy.Anatypicalantipsychoticorvalproate
(givenaloneorasadjunctivetherapywithlithium)are
alternativeprophylactictreatmentsinpatientswho
experiencefrequentrelapsesorcontinuingfunctional
impairment.Long-termuseoflithiumhasbeenasso-
ciatedwiththyroiddisordersandmildcognitiveand
memoryimpairment.Long-termtreatmentshould
thereforebeundertakenonlywithcarefulassessment
ofriskandbenet,andwithmonitoringofthyroid
functionatbaselineandevery6months(moreoftenif
LITHIUMCARBONATE
measureserum-lithiumconcentrationregu-
larly(every3monthsonstabilisedregimens),mea-
surerenalfunctionandthyroidfunctionevery6
monthsonstabilisedregimensandadvisechildren
andcarerstoseekattentionifsymptomsofhypo-
thyroidismdevelop(femalesareatgreaterrisk)e.g.
Centralnervoussystem
Indicationanddose
reatmentandprophylaxisofmania,bipolar
disorder,recurrentdepression(seealsonotes
above),aggressiveorself-mutilatingbehaviour
Bymouth
Seeunderpreparationsbelow,adjustedtoachieve
aserum-lithiumconcentrationof0.6–1mmol/litre
12hoursafteradoseondays4–7oftreatment,
theneveryweekuntildosagehasremainedcon-
stantfor4weeksandevery3monthsthereafter;
dosesareinitiallydividedthroughouttheday,but
oncedailyadministrationispreferredwhen
serum-lithiumconcentrationstabilised
Preparationsvarywidelyinbioavailability
changingthepreparationrequiresthesameprecautions
asinitiationoftreatment
Camcolit
Camcolit250
LITHIUMCITRATE
seeunderLithiumCarbonateandnotes
Counselling
Patientsshouldmaintainanadequateuid
Centralnervoussystem
Tricyclicantidepressantdrugsshouldbeavoidedforthe
treatmentofdepressioninchildren.
StJohnÕswort
Hypericumperforatum
)isapopular
herbalremedyonsaletothepublicfortreatingmild
depressioninadults.Itshouldnotbeusedforthe
treatmentofdepressioninchildrenbecauseStJohn’s
Tricyclicantidepressant
Studieshaveshownthattricyclicantidepressantsare
noteffectivefortreatingdepressioninchildren.
Forreferencetotheroleofsometricyclicantidepres-
santdrugsinsomeformsof
,seesection4.7.3,
andin
nocturnalenuresis
inchildren,seesection7.4.2.
Itisimportanttousedosesthataresufciently
highforeffectivetreatmentbutnotsohighastocause
toxiceffects.Lowdosesshouldbeusedforinitialtreat-
Inmostchildrenthelonghalf-lifeoftricyclicantidepres-
santdrugsallows
administration,usuallyat
night;theuseofmodied-releasepreparationsisthere-
foreunnecessary.
Tricyclicantidepressantdrugsshouldbe
usedwithcautioninchildrenwithcardiovasculardis-
ease(seealsoContra-indications,below);becauseofthe
riskofarrhythmias,childrenwithconcomitantcondi-
tionssuchashyperthyroidismandphaeochromocytoma
shouldbetreatedwithcare.Careisalsoneededin
Centralnervoussystem
isassociatedwithsomeofthetricyclicantidepressants.
Convulsions,hallucinations,delusions,mania,and
hypomaniamayoccur(seealsounderCautions,
above),and,
,extrapyramidalsymptomsincluding
tremoranddysarthria.
Antimuscarinicside-effectsincludedrymouth,blurred
vision(
veryrarely
precipitationofangle-closureglauc-
oma),constipation(
rarely
leadingtoparalyticileus),
AMITRIPTYLINEHYDROCHLORIDE
seenotesabove;
Appendix1
(antidepressants,tricyclic)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
useonlyifpotentialbenetoutweighsrisk
seenotesabove
seenotesabove;alsoabdominalpain,
stomatitis,palpitation,oedema,hypertension,rest-
lessness,fatigue,mydriasis,andincreasedintra-ocular
overdosage:
seeEmergencyTreatmentof
Poisoning,p.29(highrateoffatality—seeOverdo-
sage,above)
Licenseduse
notlicensedforuseinneuropathic
Indicationanddose
epression
(butseenotesabove)
Bymouth
Child16Ð18years
10–25mg3timesdaily(total
dailydosemayalternativelybegivenasasingle
doseatbedtime)increasedgraduallyasnecessary
to150–200mgdaily
europathicpain
Bymouth
Child2Ð12years
initially200–500micrograms/
kg(max.10mg)oncedailyatnight,increasedif
necessary;max.1mg/kgtwicedailyonspecialist
hild12Ð18years
initially10mgoncedailyat
night,increasedgraduallyifnecessarytousual
dose75mgatnight;higherdosesonspecialist
Amitriptyline
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
usewithcaution
usewithcaution—limitedinformation
available
seenotesabove;accumulationof
IMIPRAMINEHYDROCHLORIDE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
usewithcautioninsevereimpair-
colic,tachycardia,dyspnoea,irritability,
andmusclespasmsreportedinneonateswhenused
inthirdtrimester
seenotesabove
seenotesabove;alsopalpitation,ush-
ing,restlessness,headache,fatigue;
veryrarely
abdominalpain,stomatitis,diarrhoea,hypertension,
oedema,cardiacdecompensation,allergicalveolitis,
aggression,myoclonus,peripheralvasospasm,and
mydriasis
Licenseduse
notlicensedforuseforattentiondef-
icithyperactivitydisorder
BNFC2011–
4.3.1Tricyclicantidepressantdrugs
Centralnervoussystem
Indicationanddose
octurnalenuresis
Bymouth
Child6Ð8years
25mgatbedtime
hild8Ð11years
25–50mgatbedtime
hild11Ð18years
50–75mgatbedtime
Max.periodoftreatment(includinggradualwith-
drawal)3months—fullphysicalexaminationbefore
furthercourse,seealsosection7.4.2
ttentiondeÞcithyperactivitydisorder
specialistsupervision)
Bymouth
Child6Ð18years
10–30mgtwicedaily
Imipramine
NORTRIPTYLINE
seenotesabove;manufactureradvises
plasma-nortriptylineconcentrationmonitoringifdose
above100mgdaily,butevidenceofpracticalvalue
uncertain
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
useonlyifpotentialbenetoutweighsrisk
seenotesabove
seenotesabove;alsoabdominalpain,
stomatitis,diarrhoea,hypertension,oedema,ushing,
restlessness,fatigue,andmydriasis
Indicationanddose
epression
(butseenotesabove)
Bymouth
Child12Ð18years
lowdoseinitiallyincreasedas
necessaryto30–50mgdailyindivideddoses
asingledose(max.150mgdaily)
Contra-indications
SSRIsshouldnotbeusedifthe
childentersamanicphase.
ManufacturersadvisethatSSRIsshould
notbeusedduringpregnancyunlessthepotential
benetoutweighstherisk.Thereisasmallincreased
riskofcongenitalheartdefectswhenSSRIsaretaken
duringearlypregnancy.IfSSRIsareusedduringthe
thirdtrimesterthereisariskofneonatalwithdrawal
symptoms,andpersistentpulmonaryhypertensionin
thenewbornhasbeenreported.
SSRIsarelesssedatingandhavefewer
antimuscarinicandcardiotoxiceffectsthantricyclic
antidepressantdrugs(section4.3.1).Side-effectsofthe
SSRIsincludegastro-intestinaleffects(dose-relatedand
fairlycommon—includenausea,vomiting,dyspepsia,
abdominalpain,diarrhoea,constipation),anorexia
Centralnervoussystem
alsoreported)andhypersensitivityreactionsincluding
rash(considerdiscontinuation—maybesignofimpend-
ingserioussystemicreaction,possiblyassociatedwith
vasculitis),urticaria,angioedema,anaphylaxis,arthr-
algia,myalgiaandphotosensitivity;otherside-effects
CITALOPRAM
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
usedosesatlowerendofrange
Renalimpairment
noinformationavailableforesti-
matedglomerularltrationratelessthan20mL/
minute/1.73m
seenotesabove
presentinmilk—avoid
seenotesabove;alsohepatitis,palpita-
tion,tachycardia,oedema,bradycardia,postural
hypotension,coughing,yawning,confusion,impaired
concentration,aggression,malaise,amnesia,
migraine,paraesthesia,abnormaldreams,euphoria,
mydriasis,tastedisturbance,increasedsalivation,
rhinitis,tinnitus,polyuria,micturitiondisorders,and
pruritus
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ajordepression
(butseeDepressiveIllnessin
ChildrenandAdolescents,above)
FLUVOXAMINEMALEATE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
startwithlowdose
Renalimpairment
startwithlowdose
seenotesabove
presentinmilk—avoid
seenotesabove;palpitation,tachycardia,
lesscommonly
posturalhypotension,confu-
sion,ataxia;
abnormalliverfunction(usually
symptomatic—discontinuetreatment);
alsoreported
paraesthesia,tastedisturbance,neurolepticmalignant
syndrome-likeevent
Indicationanddose
bsessive-compulsivedisorder
Bymouth
Child8Ð18years
initially25mgdaily
increasedifnecessaryinstepsof25mgevery
BNFC2011–
4.3.3Selectiveserotoninre-uptakeinhibitors
Centralnervoussystem
4–7daysaccordingtoresponse(totaldailydoses
above50mgin2divideddoses);max.100mg
twicedaily
Ifnoimprovementinobsessive-compulsivedisor-
derwithin10weeks,treatmentshouldbereconsidered
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
reducedoseorincreasedose
intervalinmildormoderateimpairment;avoidin
severeimpairment
Renalimpairment
usewithcaution
seenotesabove
notknowntobeharmfulbutconsider
discontinuingbreast-feeding
seenotesabove;pancreatitis,hepatitis,
jaundice,liverfailure,stomatitis,palpitation,hyper-
tension,hypercholesterolaemia,tachycardia,postural
hypotension,bronchospasm,amnesia,paraesthesia,
aggression,hypoglycaemia,hypothyroidism,hyper-
prolactinaemia,urinaryincontinence,menstrualirre-
gularities,leucopenia,andtinnitusalsoreported
Licenseduse
notlicensedforuseinchildrenfor
Indicationanddose
bsessive-compulsivedisorder
Bymouth
Child6Ð12years
initially25mgdailyincreasedto
50mgdailyafter1week,furtherincreasedif
necessaryinstepsof50mgatintervalsofatleast1
week;max.200mgdaily
hild12Ð18years
initially50mgdailyincreased
ifnecessaryinstepsof50mgoverseveralweeks;
max.200mgdaily
ajordepression
(butseeDepressiveIllnessin
ChildrenandAdolescents,above)
Bymouth
Child12Ð18years
initially50mgoncedaily
increasedifnecessaryinstepsof50mgdailyat
intervalsofatleastaweek;max.200mgoncedaily
Sertraline
Centralnervoussystem
shouldbesoughtincaseofabdominalpain,unexplained
nausea,malaise,darkeningoftheurineorjaundice
Suicidalideation
Followingreportsofsuicidalthoughtsand
behaviour,childrenandcarersshouldbeinformedaboutthe
riskandtoldtoreportclinicalworsening,suicidalthoughtsor
behaviour,irritability,agitation,ordepression
Hepaticimpairment
halvedoseinmoderateimpair-
ment;quarterdoseinsevereimpairment;seealso
HepaticDisordersabove
noinformationavailable;avoidunless
potentialbenetoutweighsrisk
avoid—presentinmilkin
anorexia,drymouth,nausea,vomiting,
abdominalpain,constipation,dyspepsia,atulence;
palpitation,tachycardia,increasedbloodpressure,
posturalhypotension,hotushes;sleepdisturbance,
Centralnervoussystem
abnormalities;phaeochromocytoma;vasculitis;cere-
brovasculardisorders
limitedexperience—avoidunlesspotential
benetoutweighsrisk
limitedinformationavailable—avoid
abdominalpain,nausea,vomiting,diarr-
hoea,dyspepsia,drymouth,anorexia,reducedweight
gain;tachycardia,palpitation,arrhythmias,changesin
bloodpressure;tics(
veryrarely
ModiÞedrelease
Concerta
monitorbloodpressureandheartratein
hypertension(seeContra-indications);ECGrequired
beforeinitiation;possibilityofdependence;bipolar
disorderorhistoryofpsychiatricdisorders;alcoholor
drugabuse;
:Appendix1(modanil)
Contra-indications
moderatetosevereuncontrolled
hypertension,arrhythmia;historyofleftventricular
4.4CNSstimulantsandotherdrugsforADHD
BNFC2011–
Centralnervoussystem
hypertrophy,ofcorpulmonale,orofclinicallysignif-
icantstimulant-inducedmitral-valveprolapse
(includingischaemicECGchanges,chestpainand
arrhythmias)
Hepaticimpairment
halvedoseinsevereimpairment
Renalimpairment
usewithcaution—noinformation
available
avoid
avoid—presentinmilkin
ORLISTAT
mayimpairabsorptionoffat-solublevita-
Centralnervoussystem
Drugsusedinnauseaand
vertigo
Centralnervoussystem
Motionsickness
section3.4.1
Contra-indications
section3.4.1
Hepaticimpairment
section3.4.1
Renalimpairment
usewithcaution—noinformation
available
section3.4.1
section3.4.1
section3.4.1;also
rarely
weightgain,
sweating,lichenplanus,andlupus-likeskinreactions
Indicationanddose
eliefofsymptomsofvestibulardisorders
Bymouth
Child5Ð12years
15mg3timesdaily
hild12Ð18years
30mg3timesdaily
otionsickness
Bymouth
Child5Ð12years
15mg2hoursbeforetravelthen
7.5mgevery8hoursduringjourneyifnecessary
hild12Ð18years
30mg2hoursbeforetravel
then15mgevery8hoursduringjourneyif
necessary
section3.4.1;severeheartfailure;may
counteracthaemodynamicbenetsofopioids;
Appendix1(antihistamines)
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving);effectsofalcoholenhanced
Contra-indications
section3.4.1
Hepaticimpairment
section3.4.1
section3.4.1
noinformationavailable
section3.4.1
Licenseduse
Centralnervoussystem
Cyclizine
Section3.4.1
CHLORPROMAZINE
HYDROCHLORIDE
seeChlorpromazineHydrochloride,section
Contra-indications
seenotesinsection4.2.1
Hepaticimpairment
seenotesinsection4.2.1
Renalimpairment
seenotesinsection4.2.1
seenotesinsection4.2.1
seenotesinsection4.2.1
seeChlorpromazineHydrochloride,sec-
tion4.2.1
Indicationanddose
auseaandvomitingofterminalillness(where
otherdrugsareunsuitable)
Bymouth
Child1Ð6years
500micrograms/kgevery4–6
hours;max.40mgdaily
hild6Ð12years
500micrograms/kgevery4–6
hours;max.75mgdaily
hild12Ð18years
10–25mgevery4–6hours
Bydeepintramuscularinjection
Child1Ð6years
500micrograms/kgevery6–8
hours;max.40mgdaily
hild6Ð12years
500micrograms/kgevery6–8
hours;max.75mgdaily
hild12Ð18years
initially25mgthen25–50mg
every3–4hoursuntilvomitingstops
Section4.2.1
section4.2.1;alsochronicobstructive
pulmonarydiseaseorrespiratoryfailure;electrolyte
disturbances;historyofalcoholabuse;continuous
Centralnervoussystem
thatprolongQTinterval);hypokalaemia;hypo-
magnesaemia;bradycardia
Hepaticimpairment
max.625microgramsrepeated
every6hoursasrequired
Renalimpairment
max.625microgramsrepeated
every6hoursasrequired
section4.2.1
limitedinformationavailable—avoid
repeatedadministration
seenotesinsection4.2.1
Contra-indications
seenotesinsection4.2.1
Hepaticimpairment
seenotesinsection4.2.1
Renalimpairment
seenotesinsection4.2.1
seenotesinsection4.2.1
seenotesinsection4.2.1
seePerphenazine,section4.2.1
Indicationanddose
everenauseaandvomitingunresponsiveto
otherantiemetics
Bymouth
Child14Ð18years
4mg3timesdaily,adjusted
accordingtoresponse,max.24mgdaily
Section4.2.1
PROCHLORPERAZINE
seenotesinsection4.2.1;hypotensionmore
likelyafterintramuscularinjection
Contra-indications
seenotesinsection4.2.1
Hepaticimpairment
seenotesinsection4.2.1
Renalimpairment
seenotesinsection4.2.1
seenotesinsection4.2.1
seenotesinsection4.2.1
seenotesinsection4.2.1;respiratory
depressionmayoccurinsusceptiblechildren
Licenseduse
injectionnotlicensedforuseinchil-
Indicationanddose
reventionandtreatmentofnauseaandvomi-
Bymouth
Child1Ð12yearsandover10kg
250micr-
ograms/kg2–3timesdaily
hild12Ð18years
5–10mg,repeatedifneces-
saryupto3timesdaily
Byintramuscularinjection
Child2Ð5years,
1.25–2.5mg,repeatedifneces-
saryupto3timesdaily
hild5Ð12years
5–6.25mg,repeatedifneces-
saryupto3timesdaily
hild12Ð18years
12.5mg,repeatedifnecessary
upto3timesdaily
Dosesareexpressedasprochlorperazinemaleateor
mesilate;1mgprochlorperazinemaleate
1mgprochlor-
perazinemesilate
Prochlorperazine
Buccalpreparation
Buccastem
(Alliance)
seenotesinsection4.2.1
Contra-indications
seenotesinsection4.2.1
Hepaticimpairment
seenotesinsection4.2.1
Renalimpairment
seenotesinsection4.2.1
seenotesinsection4.2.1
seenotesinsection4.2.1
seeTriuoperazinesection4.2.1
Indicationanddose
everenauseaandvomitingunresponsiveto
otherantiemetics
Bymouth
Child3Ð5years
upto500microgramstwicedaily
hild6Ð12years
upto2mgtwicedaily
hild12Ð18years
1–2mgtwicedaily;max.3mg
twicedaily
Section4.2.1
Appendix1(dom-
Contra-indications
prolactinaemia;ifincreasedgas-
tro-intestinalmotilityharmful
BNFC2011–
4.6Drugsusedinnauseaandvertigo
Centralnervoussystem
Hepaticimpairment
avoid
Renalimpairment
reducedoseinrenalimpairment
useonlyifpotentialbenetoutweighsrisk
amounttoosmalltobeharmful
rarely
gastro-intestinaldisturbances
(includingcramps),andhyperprolactinaemia;
ventriculararrhythmias,agitation,drowsiness,
nervousness,seizures,extrapyramidaleffects,head-
ache,andrashes;alsoreportedQT-intervalprolon-
Indicationanddose
auseaandvomiting
Bymouth
Childover1monthandbody-weightupto
35kg
250–500micrograms/kg3–4timesdaily;
max.2.4mg/kgin24hours
ody-weight35kgandover
10–20mg3–4times
daily,max.80mgdaily
Byrectum
Body-weight15Ð35kg
30mgtwicedaily
ody-weightover35kg
60mgtwicedaily
astro-intestinalstasis
section1.2
malignantsyndrome,visualdisturbances,rashes,
pruritus,oedema;cardiacconductionabnormalities
reportedfollowingintravenousadministration;
Compoundpreparations(formigraine)
Section4.7.1
4.6Drugsusedinnauseaandvertigo
BNFC2011–
Centralnervoussystem
-receptorantagonists
Centralnervoussystem
Orallyophilisates
ZofranMelt
NABILONE
historyofpsychiatricdisorder;hypertension;
heartdisease;adverseeffectsonmentalstatecan
persistfor48–72hoursafterstopping;
Appendix1(nabilone)
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving);effectsofalcoholenhanced
Hepaticimpairment
avoidinsevereimpairment
avoidunlessessential
avoid—noinformationavailable
drowsiness,vertigo,euphoria,dry
mouth,ataxia,visualdisturbance,concentrationdif-
culties,sleepdisturbance,dysphoria,hypotension,
headacheandnausea;alsoconfusion,disorientation,
hallucinations,psychosis,depression,decreased
coordination,tremors,tachycardia,decreasedappe-
tite,andabdominalpain
Behaviouraleffects
Childrenandcarersshouldbemade
awareofpossiblechangesofmoodandotheradverse
behaviouraleffects
Licenseduse
notlicensedforuseinchildren
Indicationanddose
auseaandvomitingcausedbycytotoxic
chemotherapy,unresponsivetoconventional
antiemetics
(undercloseobservation,preferablyin
HYOSCINEHYDROBROMIDE
(ScopolamineHydrobromide)
section1.2;alsoepilepsy
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving)andmaypersistforupto24hoursor
longerafterremovalofpatch;effectsofalcoholenhanced
Contra-indications
section1.2
Hepaticimpairment
usewithcaution
Renalimpairment
usewithcaution
useonlyifpotentialbenetoutweighsrisk;
injectionmaydepressneonatalrespiration
amounttoosmalltobeharmful
section1.2
Licenseduse
notlicensedforuseinexcessive
Centralnervoussystem
ScopodermTTS
(NovartisConsumerHealth)
Patch
,self-adhesive,pink,releasinghyoscineapprox.
Centralnervoussystem
Compoundanalgesicpreparations
Compoundanalgesicpreparationsthatcontainasimple
Centralnervoussystem
ost-immunisationpyrexiaininfants
(seealso
p.600)
Bymouth
Child2Ð3months
60mgasasingledose
repeatedonceafter4–6hoursifnecessary
Withcodeine
Forprescribinginformationoncodeine,seep.204.
Withdihydrocodeinetartrate10mg
Forprescribinginformationondihydrocodeine,see
p.205
Seenotes,p.200
Canbesoldtothepublicprovidedpackscontainnomore
Centralnervoussystem
Withdihydrocodeinetartrate20or30mg
Seewarningsandnotes,p.200
Withtramadol
Forprescribinginformationontramadol,seesection
A
Centralnervoussystem
Respiratorydepressionandwithdrawal
symptomscanoccurintheneonateifopioidanalgesics
areusedduringdelivery;alsogastricstasisandinhala-
tionpneumoniahasbeenreportedinthemotherif
opioidanalgesicsareusedduringlabour.
Opioidanalgesicssharemanyside-
effects,althoughqualitativeandquantitativedifferences
exist.Themostcommonside-effectsincludenausea
andvomiting(particularlyininitialstages),constipation,
drymouthandbiliaryspasm;largerdosesproduce
musclerigidity,hypotensionandrespiratorydepression
(forreversalofopioid-inducedrespiratorydepression,
Centralnervoussystem
Opioidsarealsogivenepidurally[unlicensedroute]in
thepostoperativeperiodbutareassociatedwithside-
seenotesabove;alsoimpairedconscious-
ness;effectsonlypartiallyreversedbynaloxone
Contra-indications
seenotesabove;alsomyasthenia
gravis
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
presentinlowlevelsinbreastmilk—
monitorneonatefordrowsiness,adequateweight
gain,anddevelopmentalmilestones
seenotesabove;caninducemildwith-
drawalsymptomsinchildrendependentonopioids;
alsodiarrhoea,abdominalpain,anorexia,dyspepsia;
vasodilatation;dyspnoea;paraesthesia,asthenia,fati-
Indicationanddose
oderatetoseverepain
Bysublingualadministration
Childbody-weight16Ð25kg
100micrograms
every6–8hours
hildbody-weight25Ð37.5kg
100–200micr-
ogramsevery6–8hours
hildbody-weight37.5Ð50kg
200–300micr-
ogramsevery6–8hours
hildbody-weightover50kg
200–400micr-
ogramsevery6–8hours
Byintramuscularorbyslowintravenousinjec-
Child6monthsÐ12years
3–6micrograms/kg
every6–8hours,max.9micrograms/kg
hild12Ð18years
300–600microgramsevery6–
8hours
foradministration
bymouth
CODEINEPHOSPHATE
seenotesabove;alsocardiacarrhythmias;
myastheniagravis;acuteabdomen;gallstones
Centralnervoussystem
CodeinePhosphate
DIAMORPHINEHYDROCHLORIDE
(HeroinHydrochloride)
seenotesabove;alsoseverediarrhoea;toxic
psychosis,CNSdepression;severecorpulmonale
Contra-indications
seenotesabove;alsodelayed
gastricemptying;phaeochromocytoma
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
therapeuticdosesunlikelytoaffect
infant;withdrawalsymptomsininfantsofdependent
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
DIHYDROCODEINETARTRATE
seenotesabove;alsopancreatitis;severecor
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
useonlyifpotentialbenetoutweighs
seenotesabove;alsoparalyticileus,
abdominalpain,diarrhoea,seizures,andparaesthesia
Licenseduse
mostpreparationsnotlicensedforuse
inchildrenunder4years
Indicationanddose
oderatetoseverepain
Bymouthorbyintramuscularinjectionorby
subcutaneousinjection
Child1Ð4years
500micrograms/kgevery4–6
hours
hild4Ð12years
0.5–1mg/kg(max.30mg)
every4–6hours
hild12Ð18years
30mg(max.50mgbyintra-
muscularordeepsubcutaneousinjection)every4–
6hours
Centralnervoussystem
DF118Forte
ModiÞedrelease
DHCContinus
FENTANYL
doserequiredexceeds300micrograms/hour(
itmaytakeupto25hoursfortheplasma-fentanyl
concentrationtodecreaseby50%—replacementopioid
therapyshouldbeinitiatedatalowdoseandincreased
Longdurationofaction
Inviewofthelongdurationof
action,childrenwhohavehadsevereside-effectsshould
bemonitoredforupto24hoursafterpatchremoval
reakthroughpainandpremedicationanalge-
,seeunderpreparationbelow
eri-operativeanalgesia
section15.1.4.3
Conversion
(fromoralmorphinetotransdermalfentanyl),
seePrescribinginPalliativeCare,p.18
For
patches
,applytodry,non-irri-
tated,non-irradiated,non-hairyskinontorsoorupper
arm,removingafter72hoursandsitingreplacement
patchonadifferentarea(avoidusingthesamearea
forseveraldays).
,(withoromucosalapplicator),fentanyl(as
Patches
Transdermalfentanyl
Feverorexternalheat
Monitorpatientsusingpatches
forincreasedside-effectsiffeverpresent(increased
absorptionpossible);avoidexposingapplicationsiteto
externalheat,forexampleahotbathorsauna(may
alsoincreaseabsorption)
Respiratorydepression
Riskoffatalrespiratory
depression,particularlyinpatientsnotpreviously
treatedwithastrongopioidanalgesic;manufacturer
recommendsuseonlyinopioidtolerantpatients
Counselling
Patientsandcarersshouldbeinformed
aboutsafeuse,includingcorrectadministrationand
disposal,strictadherencetodosageinstructions,and
thesymptomsandsignsofopioidoverdosage.Patches
shouldberemovedimmediatelyincaseofbreathing
difculties,markeddrowsiness,confusion,dizziness,or
impairedspeech,andpatientsandcarersshouldseek
promptmedicalattention.
Prescriptionsforfentanylpatchescanbe
writtentoshowthestrengthintermsofthereleaserateand
itisacceptabletowrite‘
Fentanyl25patches
’toprescribe
patchesthatreleasefentanyl25microgramsperhour.The
Centralnervoussystem
=£17.76;‘25’patch(releasingapprox.25micr-
ograms/hourfor72hours),5=£25.38;‘50’patch
(releasingapprox.50micrograms/hourfor72hours),
5=£47.40;‘75’patch(releasingapprox.75micr-
ograms/hourfor72hours),5=£66.08;‘100’patch
(releasingapprox.100micrograms/hourfor72
hours),5=£81.45.Label:2,counselling,administra-
Brandsinclude
DurogesicDTrans
Patches
,self-adhesive,transparent,fentanyl,‘12’
patch(releasingapprox.12micrograms/hourfor72
HYDROCHLORIDE
seenotesabove;alsopancreatitis;toxic
psychosis
Contra-indications
seenotesabove;alsoacute
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
avoid—noinformationavailable
seenotesabove;alsoparalyticileus,
peripheraloedema,seizures,asthenia,dyskinesia,
agitation,andtremor
Indicationanddose
everepainincancer
Bymouth
Child12Ð18years
1.3mgevery4hours,
increasedifnecessaryaccordingtoseverityofpain
Swallowwholecapsuleorsprinkle
contentsonsoftfood
Capsules
,hydromorphonehydrochloride1.3mg
ModiÞedrelease
Capsules
,m/r,hydromorphonehydrochloride2mg
MORPHINESALTS
seenotesabove;alsopancreatitis,myas-
theniagravis,cardiacarrhythmias,severecorpulm-
Contra-indications
seenotesabove;alsodelayed
gastricemptying,acuteabdomen;heartfailuresec-
ondarytochroniclungdisease;phaeochromocytoma
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
therapeuticdosesunlikelytoaffect
infant;withdrawalsymptomsininfantsofdependent
Centralnervoussystem
reex,restlessness,seizures,paraesthesia,asthenia,
malaise,disorientation,excitation,agitation,delirium,
raisedintracranialpressure,amenorrhoea,myoclo-
nus,musclefasciculation,rhabdomyolysis,nystagmus
Licenseduse
solutionnotlicensedfor
useinchildrenunder1year;
unitdose
vialsnotlicensedforuseinchildrenunder6years;
Oralsolutions
Foradviceontransferfromoralsolutionsofmorphineto
modied-releasepreparationsofmorphine,seePrescribingin
PalliativeCare,p.17
MorphineOralSolutions
Oralsolutionsofmorphinecanbeprescribedbywritingthe
formula:
Morphinehydrochloride5mg
Chloroformwaterto5mL
Theproportionofmorphinehydrochloridemaybe
alteredwhenspeciedbytheprescriber;ifabove13mgper
5mLthesolutionbecomes
.Forsampleprescriptionsee
ControlledDrugsandDrugDependence,p.9.Itisusualto
adjustthestrengthsothatthedosevolumeis5or10mL.
(BoehringerIngelheim)
oralsolution
,morphinesulphate
Tablets
Centralnervoussystem
ModiÞed-release12-hourlyoralpreparations
MSTContinus
ModiÞed-release24-hourlyoralpreparations
Capsules
,m/r,morphinesulphate30mg(lightblue),
Morphine
MorphineSulphate
Injectionwithantiemetic
Forprescribinginformationoncyclizine,seesection
Caution
Notrecommended
inpalliativecare,seeNauseaand
Vomiting,p.19
Cyclimorph
Cyclimorph-10
,morphinetartrate10mg,
OXYCODONEHYDROCHLORIDE
seenotesabove;alsotoxicpsychosis;pan-
Contra-indications
seenotesabove;alsoacute
abdomen;delayedgastricemptying;chronicconsti-
pation;corpulmonale;acuteporphyria(section9.8.2)
Hepaticimpairment
avoidinmoderatetosevere
impairment;seealsonotesabove
Renalimpairment
avoidifestimatedglomerularl-
trationratelessthan10mL/minute/1.73m
;seealso
notesabove
seenotesabove
presentinmilk—avoid
seenotesabove;alsodiarrhoea,abdo-
minalpain,anorexia,dyspepsia;bronchospasm,dys-
Centralnervoussystem
beige),56-cappack=£22.73;20mg(pink/beige),56-
cappack=£45.47.Label:2
(=oralsolution),sugar-free,oxycodone
ModiÞedrelease
OxyContin
TRAMADOLHYDROCHLORIDE
seenotesabove;impairedconsciousness;
Centralnervoussystem
Byintravenousinjection(over2Ð3minutes)or
byintravenousinfusionorbyintramuscular
injection
Child12Ð18years
50–100mgevery4–6hours
ostoperativepain
Byintravenousinjection(over2Ð3minutes)
Child12Ð18years
100mginitiallythen50mg
every10–20minutesifnecessaryuptototalmax.
250mg(includinginitialdose)inrsthour,
50–100mgevery4–6hours;max.600mgdaily
intravenousinfusion
,dilutewith
Glucose5%
SodiumChloride0.9%
TramadolHydrochloride
ModiÞed-release12-hourlypreparations
A
Centralnervoussystem
pack=£18.26;150mg(beige),60-tabpack=£27.39;
200mg(orange),60-tabpack=£36.52.Label:2,25
Moderatetoseverepain
Bymouth
Child12Ð18years
50–100mgtwicedailyincreasedif
necessaryto150–200mgtwicedaily;totalofmorethan
400mgdailynotusuallyrequired
ModiÞed-release24-hourlypreparations
TradorecXL
4.7.4.1
Treatmentofacutemigraine
Treatmentofamigraineattackshouldbeguidedby
responsetoprevioustreatmentandtheseverityofthe
attacks.A
simpleanalgesic
Centralnervoussystem
naproxencanbeconsidered.
Sumatriptan
triptan
areusedformigraineinchildren.Theymayalso
beofvalueinclusterheadache(seealsosection4.7.4.3).
:Appendix1(5HT
SUMATRIPTAN
seeunder5HT
-receptoragonistsabove;
pre-existingcardiacdisease;historyofseizures;sen-
sitivitytosulfonamides;
Appendix1
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving)
Contra-indications
vasospasm;previouscerebro-
vascularaccidentortransientischaemicattack;per-
ipheralvasculardisease;moderateandsevere
Hepaticimpairment
reducedoseoforaltherapy;
avoidinsevereimpairment
Renalimpairment
usewithcaution
limitedexperience—avoidunlesspotential
benetoutweighsrisk
presentinmilkbutamountprobably
toosmalltobeharmful;withholdbreast-feedingfor
12hours
nausea,vomiting;sensationsoftingling,
heat,heaviness,pressure,ortightnessofanypartof
thebody(includingthroatandchest—discontinueif
intense,maybeduetocoronaryvasoconstrictionor
toanaphylaxis),transientincreaseinbloodpressure,
ushing;dyspnoea;drowsiness,dizziness,weakness;
myalgia;
alsoreported
diarrhoea,ischaemiccolitis,
hypotension,bradycardiaortachycardia,palpitation,
arrhythmias,myocardialinfarction,Raynaud’s
ZOLMITRIPTAN
seeunder5HT
-receptoragonistsabove;
shouldnotbetakenwithin12hoursofanyother
-receptoragonist;
:Appendix1
Contra-indications
vasospasm;Wolff-Parkinson-
Whitesyndromeorarrhythmiasassociatedwith
accessorycardiacconductionpathways;previous
cerebrovascularaccidentortransientischaemic
attack;ischaemicheartdisease;uncontrolledhyper-
Hepaticimpairment
max.5mgin24hoursinmod-
erateorsevereimpairment
limitedexperience—avoidunlesspotential
benetoutweighsrisk
usewithcaution—presentinmilkin
abdominalpain,drymouth,nausea,
vomiting;palpitation,sensationsoftingling,heat,
heaviness,pressure,ortightnessofanypartofthe
body(includingthroatandchest—discontinueif
intense,maybeduetocoronaryvasoconstrictionor
toanaphylaxis);dizziness,drowsiness,headache,
paraesthesia,asthenia;myalgia,muscleweakness;
commonly
tachycardia,transientincreaseinblood
pressure,polyuria;
urticaria;
veryrarely
intestinalandsplenicinfarction,ischaemiccolitis,
BNFC2011–
4.7.4Antimigrainedrugs
Centralnervoussystem
anginapectoris,myocardialinfarction;
withnasal
,tastedisturbance,andepistaxis
Licenseduse
notlicensedforuseinchildren
Indicationanddose
reatmentofacutemigraine
Bymouth
Child12Ð18years
2.5mg,repeatedafternotless
than2hoursifmigrainerecurs(ifresponseunsa-
tisfactoryafter3attacksconsiderincreasingdose
to5mgorswitchingtoalternativetreatment);
max.10mgin24hours
Child12Ð18years
5mg(1spray)into1nostril,
repeatedafternotlessthan2hoursifmigraine
recurs;max.10mgin24hours
reatmentofacuteclusterheadache
Child12Ð18years
5mg(1spray)into1nostril,
repeatedafternotlessthan2hoursifheadache
recurs;max.10mgin24hours
Zomig
(AstraZeneca)
4.7.4.2
Prophylaxisofmigraine
Wheremigraineattacksarefrequent,possibleprovok-
ingfactorssuchasstressshouldbesought;combined
oralcontraceptivesmayalsoprovokemigraine.Preven-
tivetreatmentshouldbeconsideredifmigraineattacks
interferewithschoolandsociallife,particularlyfor
childrenwho:
sufferatleasttwoattacksamonth;
sufferanincreasingfrequencyofheadaches;
suffersignicantdisabilitydespitesuitabletreat-
mentformigraineattacks;
cannottakesuitabletreatmentformigraineattacks.
Inchildrenitisoftenpossibletostopprophylaxisaftera
periodoftreatment.
Propranolol
(section2.4)maybeeffectiveinpreventing
migraineinchildrenbutitiscontra-indicatedinthose
withasthma.Side-effectssuchasdepressionandpos-
turalhypotensioncanfurtherlimititsuse.
,anantihistamineandserotoninantagonist,
takenatnightortwicedaily,mayalsobeusedbutits
efcacyinchildrenhasnotbeenclearlyestablished.
Commonside-effectsincludedrowsinessandweight
Topiramate
(section4.8.1)islicensedformigraine
prophylaxis.
PIZOTIFEN
4.7.4.3
Clusterheadacheandthe
trigeminalautonomic
cephalalgias
Clusterheadacherarelyrespondstostandardanal-
gesics.
Sumatriptan
givenbysubcutaneousinjection
isthedrugofchoiceforthe
treatment
ofclusterhead-
4.7.4Antimigrainedrugs
BNFC2011–
Centralnervoussystem
ache.Ifaninjectionisunsuitable,sumatriptannasal
sprayor
zolmitriptan
nasalspraymaybeused.Treat-
mentshouldbeinitiatedbyaspecialist.Alternatively,
oxygen
atarateof10–15litres/minutefor10–20
minutesisusefulinabortinganattack.
Theothertrigeminalautonomiccephalalgias,paroxys-
Centralnervoussystem
Centralnervoussystem
Youngwomenwhohaveseizuresinthesecondhalfof
pregnancyshouldbeassessedforeclampsiabeforeany
changeismadetoantiepileptictreatment.Statusepi-
lepticusshouldbetreatedaccordingtothestandard
protocol,seesection4.8.2.
RoutineinjectionofvitaminK(section9.6.6)atbirth
minimisestheriskofneonatalhaemorrhageassociated
withantiepileptics.
Withdrawaleffectsinthenewbornmayoccurwithsome
antiepilepticdrugs,inparticularbenzodiazepinesand
phenobarbital,andcantakeseveraldaystodiminish.
EpilepsyandPregnancyRegister
Epilepsysyndromes
Infantilespasms
Vigabatrin
isthedrugofchoicefor
infantilespasmsassociatedwithtuberoussclerosis.In
spasmsofothercauses,highdosesofcorticosteroids,
suchas
prednisolone
(section6.3.2)or
Centralnervoussystem
cardiacdisease(seealsoContra-indications);
skinreactions(seealsoBlood,Hepatic,orSkindis-
orders,belowandunderSide-effects);testforHLA-
B*1502alleleinindividualsofHanChineseorThai
origin(avoidunlessnoalternative—riskofStevens-
JohnsonsyndromeinthepresenceofHLA-B*1502
allele);historyofhaematologicalreactionstoother
drugs;manufacturerrecommendsbloodcountsand
hepaticandrenalfunctiontests(butevidenceof
practicalvalueuncertain);mayexacerbateabsence
andmyoclonicseizures;considervitaminDsupple-
mentationinpatientswhoareimmobilisedforlong
periodsorwhohaveinadequatesunexposureor
Centralnervoussystem
icalresponse(plasmaconcentrationmonitoringrecom-
mended);max.dose
byrectum
250mg4timesdaily
ModiÞedrelease
hypersensitivitytocarbamazepine;avoid
abruptwithdrawal;hyponatraemia(monitorplasma-
sodiumconcentrationinpatientsatrisk),heartfailure
(monitorbody-weight),cardiacconductiondisorders;
avoidinacuteporphyria(section9.8.2);
seep.215andAppendix1(oxcarbazepine)
Blood,hepatic,orskindisorders
Childrenortheircarers
shouldbetoldhowtorecognisesignsofblood,liver,orskin
disorders,andadvisedtoseekimmediatemedicalattentionif
responseinstepsofupto5mg/kgtwicedailyat
weeklyintervals(usualmaintenancedosefor
adjunctivetherapy15mg/kgtwicedaily);max.
23mg/kgtwicedaily
Inadjunctivetherapythedoseofconcomitantanti-
epilepticsmayneedtobereducedwhenusinghighdosesof
oxcarbazepine
Oxcarbazepine
Centralnervoussystem
Child6Ð18years
initially250mgtwicedaily,
increasedby250mgatintervalsof4–7daysto
usualdoseof500–750mgtwicedaily;occasionally
upto1gtwicedailymaybeneeded
Centralnervoussystem
LACOSAMIDE
riskofPR-intervalprolongation(including
conductionproblems,severecardiacdisease,and
concomitantuseofdrugsthatprolongPRinterval),
Appendix1(lacosamide)
Contra-indications
second-orthird-degreeAVblock
Hepaticimpairment
cautioninsevereimpairment—
noinformationavailable
Renalimpairment
titratedosewithcaution;max.
250mgdailyifestimatedglomerularltrationrateis
lessthan30mL/minute/1.73m
seePregnancy,p.216
manufactureradvisesavoid—present
inmilkin
studies;seealsoBreast-feeding,
p.217
nausea,vomiting,constipation,atu-
lence,dizziness,headache,impairedcoordination,
cognitivedisorder,drowsiness,tremor,depression,
fatigue,abnormalgait,blurredvision,nystagmus,
pruritus;
alsoreported
dyspepsia,drymouth,rst-
degreeAVblock,bradycardia,PR-intervalprolonga-
tion,confusion,hypoesthesia,dysarthria,irritability,
musclespasm,tinnitus,rash;suicidalideation
Indicationanddose
djunctivetreatmentoffocalseizureswithor
withoutsecondarygeneralisation
Byintravenousinfusionover15Ð60minutes
(forupto5days)orbymouth
Child16Ð18years
initially50mgtwicedaily,
increasedinstepsof50mgtwicedailyeveryweek;
max.200mgtwicedaily
intravenousinfusion
,giveundi-
lutedordilutewithGlucose5%
SodiumChloride
(UCBPharma)
closelymonitorandconsiderwithdrawalif
rash,fever,orsignsofhypersensitivitysyndrome
develop;avoidabruptwithdrawal(taperoffover2
weeksorlonger)unlessseriousskinreactionoccurs;
myoclonicseizures(maybeexacerbated);
seep.215andAppendix1(lamotrigine)
Blooddisorders
Childrenandtheircarersshouldbealertfor
symptomsandsignssuggestiveofbone-marrowfailure,such
asanaemia,bruising,orinfection.Aplasticanaemia,bone-
marrowdepression,andpancytopeniahavebeenassociated
rarelywithlamotrigine
Hepaticimpairment
halvedoseinmoderateimpair-
ment;quarterdoseinsevereimpairment
Renalimpairment
Centralnervoussystem
Child12Ð18years
initially25mgonalternate
daysfor14daysthen25mgdailyforfurther14
days,thereafterincreasedbymax.50mgevery7–
14days;usualmaintenance100–200mgdailyin
1–2divideddoses
Adjunctivetherapyofseizures(withenzyme
inducingdrugs)withoutvalproate
hild2Ð12years
initially300micrograms/kg
twicedailyfor14daysthen600micrograms/kg
twicedailyforfurther14days,thereafterincreased
bymax.1.2mg/kgevery7–14days;usualmain-
tenance2.5–7.5mg/kg(max.singledose200mg)
twicedaily
hild12Ð18years
initially50mgdailyfor14
daysthen50mgtwicedailyforfurther14days,
thereafterincreasedbymax.100mgevery7–14
days;usualmaintenance100–200mgtwicedaily
(upto700mgdailyhasbeenrequired)
Adjunctivetherapyofseizures(without
enzymeinducingdrugs)withoutvalproate
hild2Ð12years
initially300micrograms/kg
dailyin1–2divideddosesfor14daysthen
600micrograms/kgdailyin1–2divideddosesfor
further14days,thereafterincreasedbymax.
600micrograms/kgevery7–14days;usualmain-
tenance1–10mg/kgdailyin1–2divideddoses;
max.200mgdaily
hild12Ð18years
initially25mgdailyfor14
days,increasedto50mgdailyforfurther14days,
thenincreasedbymax.100mgevery7–14days;
usualmaintenance100–200mgdailyin1–2
divideddoses
Monotherapyofseizures
hild12Ð18years
initially25mgdailyfor14
days,increasedto50mgdailyforfurther14days,
thenincreasedbymax.100mgevery7–14days;
usualmaintenanceasmonotherapy,100–200mg
dailyin1–2divideddoses(upto500mgdailyhas
beenrequired)
onotherapyoftypicalabsenceseizures
Bymouth
Child2Ð12years
initially300micrograms/kg
dailyin1–2divideddosesfor14days,then
600micrograms/kgdailyin1–2divideddosesfor
further14days,thereafterincreasedbymax.
600micrograms/kgevery7–14days;usualmain-
tenance1–10mg/kgdailyin1–2divideddoses(up
to15mg/kgdailyhasbeenrequired)
Dosetitrationshouldberepeatedifrestartingafter
intervalofmorethan5days
SafePractice
Donotconfusethedifferentcombinations;seealso
notesabove
Lamotrigine
Centralnervoussystem
Child6monthsÐ18years,body-weightunder
50kg
initially10mg/kgoncedaily,increased
graduallybymax.10mg/kgtwicedailyevery2
weeks;max.30mg/kgtwicedaily
hild12Ð18years,body-weightover50kg
initially250mgtwicedaily,increasedgraduallyby
500mgtwicedailyevery2weeks;max.1.5gtwice
Byintravenousinfusion
PHENOBARBITAL
(Phenobarbitone)
seealsonotesabove;debilitated;respiratory
depression(avoidifsevere);avoidabruptwithdrawal
(dependencewithprolongeduse);historyofdrugand
alcoholabuse;considervitaminDsupplementationin
patientswhoareimmobilisedforlongperiodsorwho
Centralnervoussystem
Phenobarbital
seePhenobarbital;
seep.215
andAppendix1(primidone)
Hepaticimpairment
reducedose,mayprecipitate
Renalimpairment
seePhenobarbital
seePhenobarbital
seePhenobarbital
seePhenobarbital;alsonausea,visual
lesscommonly
vomiting,headache,
psychosis,lupuserythematosus,
arthralgia;
alsoreported
Dupuytren’scontracture
dosageincreasesinsomechildrenmayproducelarge
increasesinplasmaconcentrationwithacutetoxicside-
effects.Similarly,afewmisseddosesorasmallchange
indrugabsorptionmayresultinamarkedchangein
plasmaconcentration.Monitoringofplasmaconcentra-
tionimprovesdosageadjustment.Symptomsofpheny-
tointoxicityincludenystagmus,diplopia,slurred
speech,ataxia,confusion,andhyperglycaemia.
Phenytoinmaycausecoarseningofthefacialappear-
ance,acne,hirsutism,andgingivalhyperplasiaandso
maybeparticularlyundesirableinadolescentpatients.
Whenonlyparenteraladministrationispossible,
(section4.8.2),apro-drugofphenytoin,
maybeconvenienttogive.Whereasphenytoinshould
begivenintravenouslyonly,fosphenytoinmayalsobe
givenbyintramuscularinjection.
seenotesabove;cross-sensitivityreported
withcabamazepine;avoidabruptwithdrawal;HLA-B*
1502alleleinindividualsofHanChineseorThai
origin–avoidunlessessential(increasedriskofSte-
vens–Johnsonsyndrome);manufacturerrecommends
bloodcounts(butevidenceofpracticalvalueuncer-
tain);considervitaminDsupplementationinpatients
thatareimmobilisedforlongperiodsorwhohave
Centralnervoussystem
Child3months–18years,10–20mg/litre(40–
80micromol/litre)
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
llformsofepilepsyexceptabsenceseizures
Byintravenousinjection(over20Ð30minutes)
andbymouth
initialloadingdose
byslowintravenous
injection
(section4.8.2)18mg/kgthen
bymouth
2.5–5mg/kgtwicedailyadjustedaccordingto
responseandplasma-phenytoinconcentration
(usualmax.7.5mg/kgtwicedaily)
Bymouth
Child1monthÐ12years
initially1.5–2.5mg/kg
twicedaily,thenadjustedaccordingtoresponse
andplasma-phenytoinconcentrationto2.5–5mg/
kgtwicedaily(usualmax.7.5mg/kgtwicedaily
300mgdaily)
hild12Ð18years
initially75–150mgtwicedaily
thenadjustedaccordingtoresponseandplasma-
phenytoinconcentrationto150–200mgtwice
daily(usualmax.300mgtwicedaily)
tatusepilepticus,acutesymptomaticseizures
associatedwithheadtraumaorneurosurgery
section4.8.2
foradministration
bymouth
,interrupt
enteralfeedsforatleast1–2hoursbeforeandafter
givingphenytoin;givewithwatertoenhance
absorption
Foradministrationby
intravenousinjection
intravenousinfusion
,seep.235
Phenytoin
Parenteralpreparations
Section4.8.2
islicensedfortheadjunctivetreatmentof
seizuresinLennox-Gastautsyndrome.
ScottishMedicinesConsortium
(p.3)hasadvised
(October2008)thatrunamide(
Inovelon
)isaccepted
forrestrictedusewithinNHSScotlandasadjunctive
therapyinthetreatmentofseizuresassociatedwith
Lennox-Gastautsyndromeinpatients4yearsand
above.Itisrestrictedforusewhenalternativetraditional
antiepilepticdrugsareunsatisfactory.
closelymonitorandconsiderwithdrawalif
rash,fever,orothersignsofhypersensitivity
syndrome(seeSide-effects)develop;avoidabrupt
withdrawal;
seep.215andAppendix1
(runamide)
Hepaticimpairment
cautionandcarefuldosetitra-
tioninmildtomoderateimpairment;avoidinsevere
impairment
seePregnancy,p.216
manufactureradvisesavoid—no
informationavailable;seealsoBreast-feeding,p.217
nausea,vomiting,constipation,diarr-
hoea,dyspepsia,abdominalpain;rhinitis,epistaxis;
weightloss,anorexia,dizziness,headache,drowsi-
Centralnervoussystem
£61.77;400mg,60-tabpack=£102.96.Label:21,
counselling,driving(seenotesabove),hypersensi-
tivitysyndrome(seeabove)
Stiripentolislicensedforuseincombinationwithclob-
azamandvalproateasadjunctivetherapyofrefractory
generalisedtonic-clonicseizuresinchildrenwithsevere
performfullbloodcountandliverfunction
testspriortoinitiatingtreatmentandevery6months
thereafter;monitorgrowth;
Appendix1
Contra-indications
historyofpsychosis
Hepaticimpairment
avoid—noinformationavailable
Renalimpairment
avoid—noinformationavailable
seePregnancy,p.216
presentinmilkin
studies;see
alsoBreast-feeding,p.217
nausea,vomiting;aggression,anorexia,
ataxia,drowsiness,dystonia,hyperexcitability,hyper-
kinesia,hypotonia,irritability,sleepdisorders,weight
loss;neutropenia;
lesscommonly
fatigue,photo-
sensitivity,rash,andurticaria
Indicationanddose
everemyoclonicepilepsyininfancy
Bymouth
Child3Ð18years
initially10mg/kgin2–3
divideddoses;titratedoseoverminimumof3days
tomax.50mg/kg/dayin2–3divideddoses
(AlanPharmaceuticals)
Capsules
avoidinacuteporphyria(section9.8.2);
avoidabruptwithdrawal;
Appendix1
Mayimpairperformanceofskilledtasks(e.g.driv-
Hepaticimpairment
inmildtomoderateimpairment
reducedose,prolongthedoseinterval,orboth;avoid
insevereimpairment
seePregnancy,p.216
manufactureradvisesuseonlyif
potentialbenetoutweighsrisk;seealsoBreast-
feeding,p.217
diarrhoea;dizziness,tiredness,nervous-
ness,tremor,impairedconcentration,emotionallabi-
lity,speechimpairment;
rarely
confusion,depression,
drowsiness,psychosis,non-convulsivestatusepi-
lepticus,bruising,andvisualdisturbances;suicidal
ideation;leucopeniaalsoreported
Indicationanddose
djunctivetreatmentforfocalseizureswithor
withoutsecondarygeneralisationnotsatisfac-
torilycontrolledbyotherantiepileptics
Bymouth
Withenzyme-inducingdrugs
hild12Ð18years
initially5–10mgin1–2
divideddoses,increasedinstepsof5–10mgdaily
atweeklyintervals;usualmaintenancedose30–
45mgdailyin2–3divideddoses
Withoutenzyme-inducingdrugs
hild12Ð18years
initially5–10mgin1–2
divideddoses,increasedinstepsof5–10mgdaily
atweeklyintervals;initialmaintenancedose15–
30mgdailyin2–3divideddoses
(Cephalon)
TOPIRAMATE
Centralnervoussystem
nausea,diarrhoea,vomiting,constipa-
tion,dyspepsia,abdominalpain,drymouth,taste
SODIUMVALPROATE
seenotesabove;monitorliverfunction
beforetherapyandduringrst6monthsespeciallyin
childrenmostatrisk(seealsobelow);measurefull
bloodcountandensurenounduepotentialfor
bleedingbeforestartingandbeforesurgery;systemic
lupuserythematosus;false-positiveurinetestsfor
Centralnervoussystem
Contra-indications
familyhistoryofseverehepatic
dysfunction;acuteporphyria(section9.8.2)
Hepaticimpairment
avoidifpossible—hepatotoxi-
cityandhepaticfailuremayoccasionallyoccur
(usuallyinrst6months);avoidinactiveliverdisease;
seealsounderCautions
Renalimpairment
reducedose;adjustdosage
accordingtofreeserumvalproicacidconcentration
seePregnancy,p.216;neonatalbleeding
(relatedtohypobrinaemia)andneonatalhepato-
toxicityalsoreported
amounttoosmalltobeharmful;see
alsoBreast-feeding,p.217
nausea,gastricirritation,diarrhoea;
weightgain;hyperammonaemia,thrombocytopenia;
transienthairloss(regrowthmaybecurly);
lessfre-
quently
increasedalertness,aggression,hyperactivity,
behaviouraldisturbances,ataxia,tremor,andvascu-
hepaticdysfunction(seeunderCautions;
withdrawtreatmentimmediatelyifpersistentvomi-
tingandabdominalpain,anorexia,jaundice,oedema,
malaise,drowsiness,orlossofseizurecontrol),
SodiumValproate
ModiÞedrelease
EpilimChrono
Centralnervoussystem
,powderforreconstitution,sodiumval-
Valproicacid
Convulex
Capsules
Vigabatrincanbeprescribedincombinationwithother
antiepileptictreatmentforfocalepilepsywithorwithout
secondarygeneralisation.Itshouldnotbeprescribed
unlessallotherappropriatedrugcombinationsare
ineffectiveorhavenotbeentolerated,anditshould
beinitiatedandsupervisedbyanappropriatespecialist.
Vigabatrincanbeprescribedasmonotherapyinthe
managementofinfantilespasmsinWest’ssyndrome.
Aboutone-thirdofthosetreatedwithvigabatrinhave
sufferedvisualelddefects;counsellingand
monitoring
forthisside-effectarerequired(seealso
VisualFieldDefectsunderCautionsbelow).Vigabatrin
hasprominentbehaviouralside-effectsinsomechil-
VIGABATRIN
closelymonitorneurologicalfunction;avoid
suddenwithdrawal;historyofpsychosis,depression
orbehaviouralproblems;absenceseizures(maybe
seep.215andAppendix
1(vigabatrin)
VisualÞelddefects
Vigabatrinisassociatedwithvisualeld
Centralnervoussystem
Child1monthÐ2years
initially15–20mg/kg
twicedailyincreasedover2–3weekstousual
maintenancedose30–40mg/kgtwicedaily;max.
75mg/kgtwicedaily
hild2Ð12years
initially15–20mg/kg(max.
250mg)twicedailyincreasedover2–3weeksto
usualmaintenancedose30–40mg/kg(max.1.5g)
twicedaily
hild12Ð18years
initially250mgtwicedaily
increasedover2–3weekstousualmaintenance
dose1–1.5gtwicedaily
CLOBAZAM
seeDiazepam,section4.8.2
Contra-indications
seeDiazepam,section4.8.2
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seeDiazepam,section4.8.2
Licenseduse
notlicensedforuseinchildrenunder3
years
Indicationanddose
djunctivetherapyforepilepsy,monotherapy
underspecialistsupervisionforcatamenial
(menstruation)seizures(usuallyfor7Ð10days
eachmonth,justbeforeandduringmenstrua-
tion),clusterseizures
Bymouth
Child1monthÐ12years
initially125micr-
ograms/kgtwicedailyincreasedevery5daysto
usualmaintenancedoseof250micrograms/kg
twicedaily;max.500micrograms/kgtwicedaily,
notexceeding15mgtwicedaily
hild12Ð18years
initially10mgtwicedaily
increasedevery5daystousualmaintenancedose
of10–15mgtwicedaily;max.30mgtwicedaily
Clobazam
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
CLONAZEPAM
seenotesabove;respiratorydisease;spinal
orcerebellarataxia;myastheniagravis(avoidif
unstable);historyofalcoholordrugabuse,depression
orsuicidalideation;debilitatedpatients;avoidsudden
withdrawal;acuteporphyria(section9.8.2);
seep.215andAppendix1(anxiolyticsand
Drowsinessmayaffectperformanceofskilledtasks
(e.g.driving);effectsofalcoholenhanced
Contra-indications
respiratorydepression;acute
pulmonaryinsufciency;sleepapnoeasyndrome;
markedneuromuscularrespiratoryweaknessinclud-
ingunstablemyastheniagravis
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
drowsiness,fatigue,dizziness,muscle
hypotonia,coordinationdisturbances;alsopoorcon-
centration,restlessness,confusion,amnesia,depend-
ence,andwithdrawal;salivaryorbronchialhyperse-
Centralnervoussystem
ache,paradoxicaleffectsincludingaggressionand
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
NITRAZEPAM
avoidabruptwithdrawal;respiratorydis-
ease;acuteporphyria(section9.8.2);muscleweak-
nessandmyastheniagravis;
Appendix1
(anxiolyticsandhypnotics)
Contra-indications
respiratorydepression,acute
pulmonaryinsufciency,sleepapnoeasyndrome;
markedneuromuscularrespiratoryweaknessinclud-
ingmyastheniagravis
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
drowsiness,confusion,ataxia;seealso
underDiazepam(section4.8.2);
overdosage:
EmergencyTreatmentofPoisoning,p.30
Licenseduse
notlicensedforuseinchildren
Indicationanddose
nfantilespasms
Bymouth
Child1monthÐ2years
initially125micrograms/
kgtwicedaily,adjustedaccordingtoresponseover
2–3weeksto250micrograms/kgtwicedaily;max.
500micrograms/kg(notexceeding5mg)twice
daily;totaldailydosemayalternativelybegivenin
3divideddoses
Centralnervoussystem
occurs.Intramuscularphenytoinshouldnotbeused
(absorptionisslowanderratic).
Alternatively,
(apro-drugofphenytoin)
canbegivenmorerapidly,andwhengivenintrave-
nouslycausesfewerinjection-sitereactionsthanpheny-
toin.IntravenousadministrationrequiresECGmonitor-
ing.Althoughitcanalsobegivenintramuscularly,
absorptionistooslowbythisroutefortreatmentof
statusepilepticus.Dosesoffosphenytoinshouldbe
expressedintermsofphenytoinsodium.
Paraldehyde
givenrectallycauseslittlerespiratory
depressionandisthereforeusefulwherefacilitiesfor
resuscitationarepoor.
For
neonatalseizures
,seep.217.
Non-convulsivestatusepilepticus
Theurgencyto
treatnon-convulsivestatusepilepticusdependsonthe
CLONAZEPAM
seeClonazepam,section4.8.1;facilitiesfor
reversingrespiratorydepressionwithmechanical
ventilationmustbeathand(butseealsonotesabove)
Intravenousinfusion
Intravenousinfusionofclonazepamis
potentiallyhazardous(especiallyifprolonged),callingfor
closeandconstantobservationandbestcarriedoutin
specialistcentreswithintensivecarefacilities.Prolonged
infusionmayleadtoaccumulationanddelayrecovery
Contra-indications
seeClonazepam,section4.8.1;
avoidinjectionscontainingbenzylalcoholinneonates
(seeunderpreparationsbelow)
Hepaticimpairment
seeBenzodiazepines,section
Renalimpairment
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeClonazepam,section4.8.1;hypo-
tensionandapnoea
Indicationanddose
tatusepilepticus
Byintravenousinjectionoveratleast2minutes
100micrograms/kgrepeatedafter24
hoursifnecessary(avoidunlessthereisnosafer
alternative)
Child1monthÐ12years
50micrograms/kg
(max.1mg)repeatedifnecessary
hild12Ð18years
1mgrepeatedifnecessary
Byintravenousinfusion
Child1monthÐ12years
initially50micrograms/
kg(max.1mg)
byintravenousinjection
intravenousinfusion
10micrograms/kg/hour
adjustedaccordingtoresponse;max.60micr-
hild12Ð18years
initially1mg
byintravenous
injection
byintravenousinfusion
10micr-
ograms/kg/houradjustedaccordingtoresponse;
max.60micrograms/kg/hour
therformsofepilepsy
section4.8.1
intravenousinjection
,dilutetoa
concentrationof500micrograms/mLwithWaterfor
For
intravenousinfusion
,dilutetoaconcentrationof
12micrograms/mLwithGlucose5%
Chloride0.9%;incompatiblewithbicarbonate;
adsorbedonPVC—glassinfusionapparatuspreferred
Oralpreparations
Section4.8.1
DIAZEPAM
respiratorydisease,muscleweaknessand
myastheniagravis,historyofdrugoralcoholabuse,
markedpersonalitydisorder;avoidprolongeduse
(andabruptwithdrawalthereafter);whengivenpar-
enterally,closeobservationrequireduntilfullrecov-
eryfromsedation;whengivenintravenously,facilities
forreversingrespiratorydepressionwithmechanical
ventilationmustbeathand(butseealsonotesabove);
porphyria(section9.8.2);
Appendix1
(anxiolyticsandhypnotics)
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving);effectsofalcoholenhanced
Contra-indications
respiratorydepression;marked
neuromuscularrespiratoryweaknessincluding
unstablemyastheniagravis;acutepulmonaryinsuf-
ciency;sleepapnoeasyndrome;notforchronicpsy-
chosis;shouldnotbeusedaloneindepressionorin
Centralnervoussystem
Child1monthÐ12years
300–400micrograms/
kg(max.10mg)repeatedonceafter10minutesif
necessary
hild12Ð18years
10mgrepeatedonceafter10
minutesifnecessary
Byrectum(asrectalsolution)
1.25–2.5mgrepeatedonceafter10
minutesifnecessary
Child1monthÐ2years
5mgrepeatedonceafter
10minutesifnecessary
hild2Ð12years
5–10mgrepeatedonceafter10
minutesifnecessary
hild12Ð18years
10–20mgrepeatedonceafter
10minutesifnecessary
usclespasm
section10.2.2
Oralpreparations
Section10.2.2
FOSPHENYTOINSODIUM
Fosphenytoinisapro-drugofphenytoin
seePhenytoinSodium;resuscitationfacil-
itiesmustbeavailable;
seep.215and
Appendix1(phenytoin)
Contra-indications
seePhenytoinSodium
Hepaticimpairment
consider10–25%reductionin
doseorinfusionrate(exceptinitialdoseforstatus
Renalimpairment
consider10–25%reductionin
doseorinfusionrate(exceptinitialdoseforstatus
seePhenytoin(section4.8.1)and
Pregnancy,p.216
seePhenytoin(section4.8.1)
seePhenytoinSodium;alsodrymouth,
tastedisturbance,vasodilatation,asthenia,euphoria,
incoordination,chills,visualdisturbances,tinnitus,
pruritus,ecchymosis;
lesscommonly
hypoaesthesia,increasedordecreasedreexes,stu-
por,muscleweakness,pain,hypoacusis;
alsoreported
extrapyramidaldisorder,twitching,confusion,hyper-
glycaemia
Important
Intravenousinfusionoffosphenytoinhasbeen
associatedwithseverecardiovascularreactionsincluding
asystole,ventricularbrillation,andcardiacarrest.Hypo-
tension,bradycardia,andheartblockhavealsobeen
reported.Thefollowingarerecommended:
monitorheartrate,bloodpressure,andrespiratory
functionfordurationofinfusion;
observepatientforatleast30minutesafterinfusion;
ifhypotensionoccurs,reduceinfusionrateordiscon-
reducedoseorinfusionrateinrenalorhepaticimpair-
Indicationanddose
Expressedas
phenytoinsodiumequivalent
fosphenytoinsodium1.5mg
phenytoinsodium
1mg
tatusepilepticus
Byintravenousinfusion(atarateof2Ð
3mg(PE)/kg/minute,max.150mg(PE)/minute)
Child5Ð18years
initially20mg(PE)/kg,then(at
arateof1–2mg(PE)/kg/minute,max.
100mg(PE)/minute)4–5mg(PE)/kg;totaldaily
dosemaybegivenin1–4divideddoses;adjusted
accordingtoresponseandtroughplasma-pheny-
toinconcentration
rophylaxisortreatmentofseizuresassociated
withneurosurgeryorheadinjury
Byintravenousinfusion(atarateof1Ð
2mg(PE)/kg/minute,max.100mg(PE)/minute)
Child5Ð18years
initially10–15mg(PE)/kgthen
4–5mg(PE)/kgdaily;totaldailydosemaybegiven
in1–4divideddoses;adjustedaccordingto
responseandtroughplasma-phenytoinconcen-
emporarysubstitutionfororalphenytoin
Byintravenousinfusion(atarateof1Ð
2mg(PE)/kg/minute,max.100mg(PE)/minute)
Child5Ð18years
samedoseanddosingfre-
quencyasoralphenytointherapy
FosphenytoinsodiumdosesinBNFCmaydifferfrom
thoseinproductliterature
Prescriptionsforfosphenytoinsodiumshouldstate
thedoseintermsofphenytoinsodiumequivalent(PE)
intermittentintravenousinfusion
dilutetoaconcentrationof1.5–25mg(PE)/mLwith
Glucose5%
SodiumChloride0.9%
(Pzer)
,fosphenytoinsodium75mg/mL(equiva-
LORAZEPAM
seeDiazepam;facilitiesforreversingrespir-
atorydepressionwithmechanicalventilationmustbe
available
Contra-indications
seeDiazepam
Hepaticimpairment
seeBenzodiazepines,section
Renalimpairment
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeDiazepam;hypotensionandapnoea
Licenseduse
notlicensedforuseinfebrilecon-
vulsionsorconvulsionscausedbypoisoning
BNFC2011–
4.8.2Drugsusedinstatusepilepticus
Centralnervoussystem
Indicationanddose
tatusepilepticus,febrileconvulsions(section
4.8.3),convulsionscausedbypoisoning
Byslowintravenousinjection
100micrograms/kgasasingledose,
repeatedonceafter10minutesifnecessary
Child1monthÐ12years
100micrograms/kg
(max.4mg)asasingledose,repeatedonceafter
10minutesifnecessary
hild12Ð18years
4mgasasingledose,repeated
onceafter10minutesifnecessary
eri-operativeuse
Section15.1.4.1
intravenousinjection
,dilutewith
anequalvolumeofSodiumChloride0.9%(forneo-
nates,diluteinjectionsolutiontoaconcentrationof
100micrograms/mL)
Section15.1.4.1
seeMidazolam,section15.1.4.1
Contra-indications
seeMidazolam,section15.1.4.1
Hepaticimpairment
seeMidazolam,section15.1.4.1
Renalimpairment
seeMidazolam,section15.1.4.1
seeMidazolam,section15.1.4.1
seeMidazolam,section15.1.4.1
seeMidazolam,section15.1.4.1
Licenseduse
injectionnotlicensedforuseinstatus
epilepticusorfebrileconvulsions
Indicationanddose
tatusepilepticus,febrileconvulsions(section
Bybuccaladministration
300micrograms/kg,repeatedonceafter
10minutesifnecessary
Child1Ð6months
300micrograms/kg(max.
2.5mg),repeatedonceafter10minutesifneces-
sary
hild6monthsÐ1year
2.5mg,repeatedonce
after10minutesifnecessary
hild1Ð5years
5mg,repeatedonceafter10
minutesifnecessary
hild5Ð10years
7.5mg,repeatedonceafter10
minutesifnecessary
hild10Ð18years
10mg,repeatedonceafter10
minutesifnecessary
Byintravenousadministration
byintravenousinjection
200micrograms/kgfollowed
bycontinuousintra-
venousinfusion
of60micrograms/kg/hour
(increasedby60micrograms/kg/hourevery15
minutesuntilseizurecontrolled);max.300micr-
Child1monthÐ18years
byintravenous
injection
150–200micrograms/kgfollowed
continuousintravenousinfusion
of60micr-
ograms/kg/hour(increasedby60micrograms/
kg/hourevery15minutesuntilseizurecontrolled);
max.300micrograms/kg/hour
intravenousinjection
,dilutewith
Glucose5%
SodiumChloride0.9%;rapidintra-
venousinjection(lessthan2minutes)maycause
Section15.1.4
PARALDEHYDE
bronchopulmonarydisease;
Appendix1(paraldehyde)
Contra-indications
gastricdisorders;rectaladminis-
trationincolitis
Hepaticimpairment
usewithcaution
avoidunlessessential—crossesplacenta
avoidunlessessential—presentin
Licenseduse
notlicensedforuseinchildrenasan
Indicationanddose
tatusepilepticus
Byrectum(dosesexpressedasundilutedpar-
aldehyde)
0.4mL/kgasasingledose
Child1monthÐ18years
0.4mL/kg(max.10mL)
asasingledose
rectaladministration
,donot
administerparaldehydeundiluted
PHENOBARBITALSODIUM
Phenobarbitonesodium
seePhenobarbital,section4.8.1;
:seep.215andAppendix1(phenobarbital)
Hepaticimpairment
seePhenobarbital,section4.8.1
Renalimpairment
seePhenobarbital,section4.8.1
seePregnancy,p.216
seePhenobarbital,section4.8.1
seePhenobarbital,section4.8.1
Indicationanddose
tatusepilepticus
Byslowintravenousinjection(nofasterthan
1mg/kg/minute)
initially20mg/kgthen2.5–5mg/kg
onceortwicedaily
Child1monthÐ12years
initially20mg/kgthen
2.5–5mg/kgonceortwicedaily
hild12Ð18years
initially20mg/kg(max.1g)
then300mgtwicedaily
4.8.2Drugsusedinstatusepilepticus
BNFC2011–
Centralnervoussystem
therformsofepilepsy
section4.8.1
Fortherapeuticpurposesphenobarbitalandpheno-
barbitalsodiummaybeconsideredequivalentineffect
intravenousinjection
,dilutetoa
concentrationof20mg/mLwithWaterforInjections
Phenobarbital
Oralpreparations
Section4.8.1
PHENYTOINSODIUM
seenotesabove;respiratorydepression;
hypotensionandheartfailure;resuscitationfacilities
mustbeavailable;injectionsolutionsalkaline(irritant
totissues);seealsop.224;
seep.215
andAppendix1(phenytoin)
Contra-indications
sinusbradycardia,sino-atrial
block,andsecond-andthird-degreeheartblock;
Stokes-Adamssyndrome;acuteporphyria(section
Hepaticimpairment
seePhenytoin,section4.8.1
seePhenytoin,section4.8.1and
Pregnancy,p.216
seePhenytoin,section4.8.1
intravenousinjectionmaycausecardio-
vascularandCNSdepression(particularlyifinjection
toorapid)witharrhythmias,hypotension,andcardi-
ovascularcollapse;alterationsinrespiratoryfunction
(includingrespiratoryarrest);
alsoreported
seizures,purpleglovesyndrome;seealsop.224
Indicationanddose
tatusepilepticus,acutesymptomaticseizures
associatedwithtraumaorneurosurgery
Byslowintravenousinjectionorinfusion(with
blood-pressureandECGmonitoring)
initially20mg/kgasaloadingdosethen
2.5–5mg/kgtwicedaily
Child1monthÐ12years
initially20mg/kgasa
loadingdosethen2.5–5mg/kgtwicedaily
hild12Ð18years
initially20mg/kgasaloading
dosethenupto100mg3–4timesdaily
therformsofepilepsy
section4.8.1
PhenytoinsodiumdosesinBNFCmaydifferfrom
thoseinproductliterature
beforeandafteradministrationush
intravenouslinewithSodiumChloride0.9%.
For
intravenousinjection
,giveintoalargeveinatrate
notexceeding1mg/kg/minute(max.50mg/minute).
For
intravenousinfusion
,dilutetoaconcentrationnot
exceeding10mg/mLwithSodiumChloride0.9%and
giveintoalargeveinthroughanin-linelter(0.22–
0.50micron)ataratenotexceeding1mg/kg/minute
Phenytoin
Oralpreparations
Section4.8.1
Febrileconvulsions
Brieffebrileconvulsions
neednospecictreatment;
Centralnervoussystem
dihydrobiopterinreductasedeciency.Fortheuseof
CO-CARELDOPA
Amixtureofcarbidopaandlevodopa;theproportionsare
expressedintheform
arethestrengthsin
milligramsofcarbidopaandlevodoparespectively
seealsonotesabove;pulmonarydisease,
pepticulceration,cardiovasculardisease(including
historyofmyocardialinfarctionwithresidual
Centralnervoussystem
Antimuscarinicdrugs
usedindystonias
Theantimuscarinicdrugs
procyclidine
trihexy-
reducethesymptomsofdystonias,including
thoseinducedbyantipsychoticdrugs;thereisnojusti-
cationforgivingthemroutinelyintheabsenceof
dystonicsymptoms.Tardivedyskinesiaisnotimproved
byantimuscarinicdrugsandmaybemadeworse.
PROCYCLIDINEHYDROCHLORIDE
seenotesabove;
:Appendix1
(antimuscarinics)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
useonlyifpotentialbenetoutweighsrisk
noinformationavailable
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Bymouth
Child7Ð12years
1.25mg3timesdaily
hild12Ð18years
2.5mg3timesdaily
cutedystonia
Byintramuscularorintravenousinjection
Childunder2years
0.5–2mgasasingledose
hild2Ð10years
2–5mgasasingledose
hild10Ð18years
5–10mg(occasionallymore
than10mg)
Usuallyeffectivein5–10minutesbutmayneed30
minutesforrelief
HYDROCHLORIDE
(Benzhexolhydrochloride)
seenotesabove;
:Appendix1
(antimuscarinics)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
useonlyifpotentialbenetoutweighsrisk
avoid
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Bymouth
Child3monthsÐ18years
initially1–2mgdailyin
1–2divideddoses,increasedevery3–7daysby
1mgdaily;adjustedaccordingtoresponseand
side-effects;max.2mg/kgdaily
Trihexyphenidyl
Centralnervoussystem
BOTULINUMTOXINTYPEA
neurologicaldisorders(canleadtoincreased
sensitivityandexaggeratedmuscleweakness);
Centralnervoussystem
Nicotinereplacementtherapy
Nicotinereplacementtherapycanbeusedinplaceof
Centralnervoussystem
Chewthegumuntilthetastebecomes
NICOTINE
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
Seenotesabove
Centralnervoussystem
=£11.48,2
150-dosepack=£18.50.Counselling,
administration,seenotesabove
Centralnervoussystem
Antibacterialdrugs
Penicillins
Benzylpenicillinandphenoxy-
Infections
NotiÞablediseases
DoctorsmustnotifytheProperOfÞcerofthelocal
authority(usuallytheconsultantincommunicable
diseasecontrol)whenattendingapatientsuspected
ofsufferingfromanyofthediseaseslistedbelow;a
formisavailablefromtheProperOfÞcer.
Paratyphoidfever
Brucellosis
Poliomyelitis,acute
Diarrhoea(infectiousbloody)Rabies
Encephalitis,acute
Foodpoisoning
enteraladministrationisalsoappropriatewhenthe
oralroutecannotbeused(e.g.becauseofvomiting)
orifabsorptionisinadequate(e.g.inneonatesand
youngchildren).Wheneverpossiblepainfulintra-
muscularinjectionsshouldbeavoidedinchildren;
oftherapydependsonthenatureofthe
infectionandtheresponsetotreatment.Courses
shouldnotbeundulyprolongedbecausethey
encourageresistance,theymayleadtoside-effects
andtheyarecostly.However,incertaininfections
suchastuberculosisorosteomyelitisitmaybe
necessarytotreatforprolongedperiods.
Oralbacterialinfections
Antibacterialdrugsshould
onlybeprescribedforthe
treatment
oforalinfectionson
thebasisofdeÞnedneed.Theymaybeusedincon-
junctionwith(butnotasanalternativeto)otherappro-
priatemeasures,suchasprovidingdrainageorextract-
ingatooth.
TheÔblindÕprescribingofanantibacterialforunex-
plainedpyrexia,cervicallymphadenopathy,orfacial
swellingcanleadtodifÞcultyinestablishingthediag-
nosis.Asampleshouldalwaysbetakenforbacteriology
inthecaseofsevereoralinfection.
Oralinfectionswhichmayrequireantibacterialtreat-
mentincludeacuteperiapicalorperiodontalabscess,
cellulitis,acutelycreatedoral-antralcommunication
(andacutesinusitis),severepericoronitis,localised
osteitis,acutenecrotisingulcerativegingivitis,and
destructiveformsofchronicperiodontaldisease.Most
oftheseinfectionsarereadilyresolvedbytheearly
establishmentofdrainageandremovalofthecause
(typicallyaninfectednecroticpulp).Antibacterials
mayberequirediftreatmenthastobedelayed,in
immunocompromisedpatients,orinthosewithcondi-
Table1.Summaryofantibacterialtherapy
IftreatingapatientsuspectedofsufferingfromanotiÞabledisease,theconsultantincommunicabledisease
controlshouldbeinformed(seep.243)
Gastro-intestinalsystem
Gastro-enteritis
Frequentlyself-limitingandmaynotbebacterial.
Antibacterialnotusuallyindicated
5.1Antibacterialdrugs
BNFC2011–
Infections
Campylobacterenteritis
Frequentlyself-limiting;treatifimmunocompromisedorifsevereinfection.
Clarithromycin
,ciproßoxacin
Salmonella(non-typhoid)
Treatinvasiveorsevereinfection.Donottreatlesssevereinfectionunlessthereisariskofdevelopinginvasive
infection(e.g.immunocompromisedchildren,thosewithhaemoglobinopathy,orchildrenunder6monthsofage).
Ciproßoxacin
cefotaxime
Shigellosis
Antibacterialnotindicatedformildcases.
Azithromycin
ciproßoxacin
Alternativesifmicro-organismsensitive
,amoxicillin
Whereclarithromycinissuggestedazithromycinorerythromycinmaybeused
Wherecefotaximeissuggestedceftriaxonemaybeused
Whereamoxicillinissuggestedampicillinmaybeused
Wherevancomycinissuggestedteicoplaninmaybeused
BNFC2011–
5.1Antibacterialdrugs
Cardiovascularsystem
Endocarditis:initial‘blind’therapy
Flucloxacillin(
benzylpenicillinifsymptomslesssevere)+gentamicin
Wherevancomycinissuggestedteicoplaninmaybeused
Whereamoxicillinissuggestedampicillinmaybeused
5.1Antibacterialdrugs
BNFC2011–
Infections
Respiratorysystem
Haemophilusinßuenzae
epiglottitis
Ifhistoryofimmediatehypersensitivityreactiontopenicillinortocephalosporins
,chloram-
phenicol
Pneumonia:uncomplicatedcommunity-acquired
Neonateandchildunder6months
,treatasforseverecommunity-acquiredpneumoniaof
CysticÞbrosis
Staphylococcallunginfectionincysticbrosis
Ifchildalreadytakingßucloxacillinprophylaxisorifsevereexacerbation,addsodiumfusidateor
rifampicin;useßucloxacillinattreatmentdose
Ifpenicillin-allergicandifmicro-organismsensitive
,clarithromycin
Alternativeifpenicillin-allergic
,clindamycin
Haemophilusinßuenzae
lunginfectionincysticbrosis
abroad-spectrumcephalosporin
Insevereexacerbationuseathird-generationcephalosporin(e.g.cefotaxime)
Pseudomonallunginfectionincysticbrosis
Ciproßoxacin+
Wherecefotaximeissuggestedceftriaxonemaybeused
Whereamoxicillinissuggestedampicillinmaybeused
Whereclarithromycinissuggestedazithromycinorerythromycinmaybeused
BNFC2011–
5.1Antibacterialdrugs
Centralnervoussystem
Meningitis:initialempiricaltherapy
Transferpatienttohospitalurgently.
meningococcaldisease
(meningitiswithnon-blanchingrashormeningococcalsepticaemia)suspected,
benzylpenicillin(seep.258fordose)shouldbegivenbeforetransfertohospital,solongasthisdoesnotdelay
thetransfer.Ifapatientwithsuspectedbacterialmeningitiswithoutnon-blanchingrashcannotbetransferredto
hospitalurgently,benzylpenicillin(seep.258fordose)shouldbegivenbeforethetransfer.Cefotaxime(section
5.1.2)maybeanalternativeinpenicillinallergy;chloramphenicol(section5.1.7)maybeusedifhistoryof
immediatehypersensitivityreactiontopenicillinsortocephalosporins.
Wherecefotaximeissuggestedceftriaxonemaybeused
Whereamoxicillinissuggestedampicillinmaybeused
5.1Antibacterialdrugs
BNFC2011–
Infections
Urinarytract
Urinary-tractinfection
Childunder3monthsofage
,i/vamoxicillin
+gentamicin
i/vcephalosporinalone
Childover3monthsofagewithuncomplicatedlowerurinary-tractinfection
Genitalsystem
Neonatalcongenitalsyphilis
Benzylpenicillin
Alsoconsidertreatingneonateswithsuspectedcongenitalsyphiliswhosemothersweretreatedinade-
quatelyforsyphilis,orwhosemothersweretreatedforsyphilisinthe4weeksbeforedelivery,orwhose
mothersweretreatedwithnon-penicillinantibacterialsforsyphilis.
Suggesteddurationoftreatment
10days
Syphilis
Contacttracingrecommended.
Childunder12years
,benzylpenicillin
procainebenzylpenicillin[unlicensed]
Suggesteddurationoftreatment
10days
Child12–18years,earlysyphilis(infectionoflessthan2years)
,benzathinebenzylpenicillin
[unlicensed]
Suggesteddurationoftreatment
single-dose(repeatdoseafter7daysforfemalesinthethirdtrimesterof
Child12–18years,alternativesforearlysyphilis
,doxycycline
erythromycin
Suggesteddurationoftreatment
14days
Child12–18years,latelatentsyphilis(asymptomaticinfectionofmorethan2years)
benzathinebenzylpenicillin[unlicensed]
Suggesteddurationoftreatment
onceweeklyfor2weeks
Child12–18years,alternativeforlatelatentsyphilis
,doxycycline
Suggesteddurationoftreatment
28days
Child12–18yearswhoisanasymptomaticcontactofapatientwithinfectioussyphilis
doxycycline
Suggesteddurationoftreatment
14days
Gonorrhoea:uncomplicated
Contacttracingrecommended.Considerchlamydiaco-infection.Choiceofantibacterialdependsonlocalitywhere
infectionacquired.
Childunder12years
,ceftriaxone
Suggesteddurationoftreatment
Child12–18years
,ceÞxime
Suggesteddurationoftreatment
Child12–18years,alternativeifmicro-organismsensitive
,ciproßoxacin
Suggesteddurationoftreatment
Child12–18yearswithpharyngealinfection
,ceftriaxone
Suggesteddurationoftreatment
Whereamoxicillinissuggestedampicillinmaybeused
BNFC2011–
5.1Antibacterialdrugs
Septicaemia
Neonatelessthan48hoursold
,benzylpenicillin+gentamicin
amoxicillin
+cefotaxime
Neonatemorethan48hoursold
,ßucloxacillin+gentamicin
+cefotaxime
Child1month–18yearswithcommunity-acquiredsepticaemia
,aminoglycoside+
alone
Whereamoxicillinissuggestedampicillinmaybeused
Wherecefotaximeissuggestedceftriaxonemaybeused
Wherevancomycinissuggestedteicoplaninmaybeused
5.1Antibacterialdrugs
BNFC2011–
Infections
Purulentconjunctivitis
,chloramphenicol
neomycineyedrops
Seealsosection11.3.1
Child1month–18years
,chloramphenicoleye-drops
Seealsosection11.3.1
Congenitalchlamydialconjunctivitis
Erythromycin(bymouth)
Suggesteddurationoftreatment
14days
Congenitalgonococcalconjunctivitis
Suggesteddurationoftreatment
Ear,nose,andoropharynx
Pericoronitis
Antibacterialrequiredonlyinpresenceofsystemicfeaturesofinfection,oroftrismus,orpersistentswellingdespite
localtreatment.
Wherevancomycinissuggestedteicoplaninmaybeused
Wherecefotaximeissuggestedceftriaxonemaybeused
BNFC2011–
5.1Antibacterialdrugs
Gingivitis:acutenecrotisingulcerative
Antibacterialrequiredonlyifsystemicfeaturesofinfection.
Whereamoxicillinissuggestedampicillinmaybeused
Whereclarithromycinissuggestedazithromycinorerythromycinmaybeused
5.1Antibacterialdrugs
BNFC2011–
Infections
Impetigo:smallareasofskininfected
Seeklocalmicrobiologyadvicebeforeusingtopicaltreatmentinhospital.
Topicalfusidicacid
Suggesteddurationoftreatment
7daysisusuallyadequate(max.10days)
Whereclarithromycinissuggestedazithromycinorerythromycinmaybeused
BNFC2011–
5.1Antibacterialdrugs
Table2.Summaryofantibacterial
prophylaxis
Preventionofrecurrenceofrheumaticfever
Whereerythromycinissuggestedanothermacrolide(e.g.
azithromycinorclarithromycin)maybeused
Whereclarithromycinissuggestedazithromycinorery-
thromycinmaybeused
5.1Antibacterialdrugs
BNFC2011–
Infections
Preventionofpneumococcalinfectionin
aspleniaorinpatientswithsickle-cell
Intravenousantibacterialprophylaxisshouldbegivenupto
30minutesbeforetheprocedure
Additionalintra-operativeorpostoperativedosesofanti-
bacterialmaybegivenforprolongedproceduresorifthere
ismajorbloodloss
Whereteicoplaninissuggestedvancomycinmaybeused
Resectionsofcolonandrectum,andresectionsin
inammatoryboweldisease,andappendicectomy
Singledose
Intravenousantibacterialprophylaxisshouldbegivenupto
30minutesbeforetheprocedure
Additionalintra-operativeorpostoperativedosesofanti-
bacterialmaybegivenforprolongedproceduresorifthere
ismajorbloodloss
Patientsatriskofendocarditisincludethosewithvalve
replacement,acquiredvalvularheartdiseasewithstenosis
orregurgitation,structuralcongenitalheartdisease(in-
cludingsurgicallycorrectedorpalliatedstructuralcondi-
tions,butexcludingisolatedatrialseptaldefect,fully
repairedventricularseptaldefect,fullyrepairedpatent
ductusarteriosus,andclosuredevicesconsideredtobe
endothelialised),hypertrophiccardiomyopathy,orapre-
viousepisodeofinfectiveendocarditis
TheBritishAssociationofDermatologistsTherapyGuide-
linesandAuditSubcommitteeadvisethatsuchdermato-
logicalproceduresincludeskinbiopsiesandexcisionof
molesorofmalignantlesions
5.1Antibacterialdrugs
BNFC2011–
Infections
Jointprosthesesanddentaltreatment
Jointprosthesesanddentaltreatment
5.1.1.1
Benzylpenicillinand
BENZYLPENICILLINSODIUM
(PenicillinG)
historyofallergy;false-positiveurinaryglu-
cose(iftestedforreducingsubstances);
Appendix1(penicillins)
Contra-indications
penicillinhypersensitivity
Renalimpairment
neurotoxicityÑhighdosesmay
causeconvulsions.EstimatedglomerularÞltration
rate10Ð50mL/minute/1.73m
,usenormaldose
every8Ð12hours;estimatedglomerularÞltrationrate
lessthan10mL/minute/1.73m
usenormaldose
every12hours
notknowntobeharmful
traceamountsinmilkÑnotknownto
beharmful,butbealertforhypersensitivityininfant
hypersensitivityreactionsincludingurti-
caria,fever,jointpains,rashes,angioedema,anaphy-
laxis,serumsickness-likereactions;
CNStoxi-
cityincludingconvulsions(especiallywithhighdoses
orinsevererenalimpairment),interstitialnephritis,
haemolyticanaemia,leucopenia,thrombocytopenia
andcoagulationdisorders;alsoreporteddiarrhoea
(includingantibiotic-associatedcolitis)
Indicationanddose
ildtomoderatesusceptibleinfections
(includingthroatinfections,otitismedia,
pneumonia,cellulitis,neonatalsepsis,Table1,
section5.1)
Byintramuscularinjectionorbyslowintra-
venousinjectionorinfusion(intravenousroute
recommendedinneonatesandinfants)
eonateunder7days
25mg/kgevery12hours;
dosedoubledinsevereinfection
eonate7Ð28days
25mg/kgevery8hours;
dosedoubledinsevereinfection
Child1monthÐ18years
25mg/kgevery6hours;
increasedto50mg/kgevery4Ð6hours(max.2.4g
every4hours)insevereinfection
ndocarditis(combinedwithanotheranti-
bacterialifnecessary,seeTable1,section5.1)
Byslowintravenousinjectionorinfusion
Child1monthÐ18years
25mg/kgevery4hours,
increasedifnecessaryto50mg/kg(max.2.4g)
every4hours
eningitis,meningococcaldisease
Byslowintravenousinjectionorinfusion
75mg/kgevery8hours
Child1monthÐ18years
50mg/kgevery4Ð6
hours(max.2.4gevery4hours)
Important.
Ifmeningococcaldisease(meningitiswith
non-blanchingrashormeningococcalsepticaemia)is
suspected,asingledoseofbenzylpenicillinshouldbe
givenbeforetransferringthechildtohospitalurgently,so
longasthisdoesnotdelaythetransfer.Ifachildwith
suspectedbacterialmeningitiswithoutnon-blanching
rashcannotbetransferredtohospitalurgently,asingle
doseofbenzylpenicillinshouldbegivenbeforethetrans-
fer.Suitabledosesofbenzylpenicillinbyintravenous
injection(orbyintramuscularinjection)are:
under1year
300mg;
Child1–9years
600mg,
10years
andover
1.2g.Inpenicillinallergy,cefotaxime(section
5.1.2)maybeanalternative;chloramphenicol(section
5.1.7)maybeusedifthereisahistoryofanaphylaxisto
rovenorsuspectedneonatalgroupBstrep-
tococcusinfection
Byslowintravenousinjectionorinfusion
eonateunder7days
50mg/kgevery12hours
eonate7Ð28days
50mg/kgevery8hours
rophylaxisinlimbamputation
Table2,section
Intravenousrouterecommendedin
neonatesandinfants.For
intravenousinfusion
,dilute
withGlucose5%
SodiumChloride0.9%;giveover
15Ð30minutes.Longeradministrationtimeisparti-
cularlyimportantwhenusingdosesof50mg/kg(or
greater)toavoidCNStoxicity
Safepractice
Intrathecalinjectionofbenzylpenicillinis
Crystapen
,powderforreconstitution,benzylpenicillin
Infections
Child6Ð12years
250mg4timesdaily;increased
upto12.5mg/kg4timesdailyinsevereinfection
hild12Ð18years
500mg4timesdaily;
increasedinsevereinfectionupto1g4timesdaily
reventionofpneumococcalinfectionin
aspleniaorsicklecelldisease
,seeTable2,sec-
tion5.1
reventionofrecurrenceofrheumaticfever
,see
Table2,section5.1
reventionofgroupAstreptococcalinfection
seeTable2,section5.1
5.1.1.2
Penicillinase-resistant
Moststaphylococciarenowresistanttobenzylpenicillin
becausetheyproducepenicillinases.
Flucloxacillin
however,isnotinactivatedbytheseenzymesandis
thuseffectiveininfectionscausedbypenicillin-resistant
staphylococci,whichisthemainindicationforitsuse.
Flucloxacillinisacid-stableandcan,therefore,begiven
bymouthaswellasbyinjection.
Flucloxacilliniswellabsorbedfromthegut.Fora
warningonhepaticdisordersseeunderFlucloxacillin.
Infectionfrom
Staphylococcusaureus
glycopeptide
canbeusedfor
pneumonia
withMRSA.
shouldbereservedforhospital-
acquiredpneumoniathathasnotrespondedtoother
antibacterialsorforchildrenwhocannottolerateother
antibacterials.
FLUCLOXACILLIN
seeunderBenzylpenicillin(section5.1.1.1);
riskofkernicterusinjaundicedneonateswhenhigh
dosesgivenparenterally;
Appendix1
Hepaticdisorders
Cholestaticjaundiceandhepatitismayoccurvery
rarely,uptotwomonthsaftertreatmentwithßuclox-
acillinhasbeenstopped.Administrationformorethan
2weeksandincreasingageareriskfactors.Healthcare
professionalsareremindedthat:
ßucloxacillinshouldnotbeusedinpatientswithahistory
ofhepaticdysfunctionassociatedwithßucloxacillin;
ßucloxacillinshouldbeusedwithcautioninpatientswith
hepaticimpairment;
carefulenquiryshouldbemadeabouthypersensitivity
Indicationanddose
5.1.1.3
Broad-spectrumpenicillins
isactiveagainstcertainGram-positiveand
Gram-negativeorganismsbutisinactivatedbypeni-
cillinasesincludingthoseproducedby
Staphylococcus
andbycommonGram-negativebacillisuchas
Escherichiacoli
.Ampicillinisalsoactiveagainst
spp.andenterococci.Almostallstaphylococci,
approx.60%of
E.coli
strainsandapprox.20%of
Haemophilusinuenzae
strainsarenowresistant.The
likelihoodofresistanceshouldthereforebeconsidered
beforeusingampicillinfortheÔblindÕtreatmentofinfec-
tions;inparticular,itshouldnotbeusedforhospital
patientswithoutcheckingsensitivity.
Ampicillincanbegivenbymouth,butlessthanhalfthe
doseisabsorbedandabsorptionisfurtherdecreasedby
thepresenceoffoodinthegut.Ampicilliniswell
Infections
Staph.aureus
E.coli
,and
H.inuenzae
,aswellas
Bacteroides
Klebsiella
spp.Co-amoxiclav
shouldbereservedforinfectionslikely,orknown,to
seeunderAmpicillin;maintainadequate
hydrationwithhighdoses(particularlyduringpar-
enteraltherapy);
Appendix1(penicil-
Contra-indications
seeunderAmpicillin
Renalimpairment
riskofcrystalluriawithhighdoses
(particularlyduringparenteraltherapy).Reducedose
insevereimpairment;rashesmorecommon
notknowntobeharmful
traceamountsinmilkÑnotknownto
beharmfulbutbealertforhypersensitivityininfant
seeunderAmpicillin
Indicationanddose
usceptibleinfectionsincludingurinary-tract
infections,sinusitis,uncomplicatedcommu-
nity-acquiredpneumonia,oralinfections(Table
1,section5.1),Lymedisease(seenotes
above),salmonellosis
Bymouth
eonate7Ð28days
30mg/kg(max.62.5mg)3
timesdaily;dosedoubledinsevereinfection
Child1monthÐ1year
62.5mg3timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,salmonellosis,orLymedisease
hild1Ð5years
125mg3timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,salmonellosis,orLymedisease
hild5Ð18years
250mg3timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,salmonellosis,orLymedisease
Byintravenousinjectionorinfusion
eonateunder7days
30mg/kgevery12hours;
dosedoubledinsevereinfection,community-
acquiredpneumonia,orsalmonellosis
eonate7Ð28days
30mg/kgevery8hours;
dosedoubledinsevereinfection,community-
acquiredpneumonia,orsalmonellosis
Child1monthÐ18years
20Ð30mg/kg(max.
500mg)every8hours;dosedoubledinsevere
infection(max.4gdaily)
titismedia(butseeTable1,section5.1)
Bymouth
Child1monthÐ18years
40mg/kgdailyin3
divideddoses(max.1.5gdailyin3divideddoses)
isterialmeningitis(incombinationwith
anotherantibacterial,Table1,section5.1),
groupBstreptococcalinfection,enterococcal
(incombinationwithanotherantibio-
Byintravenousinfusion
eonateunder7days
50mg/kgevery12hours;
dosemaybedoubledinmeningitis
eonate7Ð28days
50mg/kgevery8hours;
dosemaybedoubledinmeningitis
Child1monthÐ18years
50mg/kgevery4Ð6
hours(max.2gevery4hours)
ysticÞbrosis(treatmentofasymptomatic
carriageormildexacerbations)
Bymouth
Child1monthÐ1year
125mg3timesdaily
hild1Ð7years
250mg3timesdaily
hild7Ð18years
500mg3timesdaily
elicobacterpylori
section1.3
AmoxicillindosesinBNFCmaydifferfromthosein
productliterature
DisplacementvaluemaybesigniÞ-
cantwhenreconstitutinginjection,consultlocal
guidelines.Diluteintravenousinjectiontoaconcen-
trationof50mg/mL(100mg/mLforneonates).May
befurtherdilutedwithGlucose5%
Glucose10%
Sodiumchloride0.9%
0.45%forintravenousinfu-
sion.Giveintravenousinfusionover30minuteswhen
usingdosesover30mg/kg
100mL=£1.22;250mg/5mL,100mL=£1.39.
Label:9
Sugar-freeversionsareavailableandcanbeorderedby
specifyingÔsugar-freeÕontheprescription
Brandsinclude
DentalprescribingonNHS
AmoxicillinOralSuspension
maybeprescribed
,powderforreconstitution,amoxicillin(as
historyofallergy;erythematousrashes
commoninglandularfever(seenotesabove);
increasedriskoferythematousrashesincyto-
megalovirusinfection,andacuteorchroniclympho-
cyticleukaemia(seenotesabove);
Appendix1(penicillins)
Contra-indications
penicillinhypersensitivity
Renalimpairment
ifestimatedglomerularÞltration
ratelessthan10mL/minute/1.73m
reducedoseor
frequencyÑrashesmorecommon
notknowntobeharmful
traceamountsinmilkÑnotknownto
beharmfulbutbealertforhypersensitivityininfant
nausea,vomiting,diarrhoea;rashes(dis-
continuetreatment);rarely,antibiotic-associatedcol-
itis;seealsounderBenzylpenicillin(section5.1.1.1)
Indicationanddose
usceptibleinfectionsincludingurinary-tract
infections,otitismedia,sinusitis,uncompli-
catedcommunity-acquiredpneumonia,oral
infections(Table1,section5.1),salmonellosis
Bymouth
eonateunder7days
30mg/kg(max.62.5mg)
twicedaily;dosedoubledinsevereinfection
eonate7Ð21days
30mg/kg(max.62.5mg)3
timesdaily;dosedoubledinsevereinfection
eonate21Ð28days
30mg/kg(max.62.5mg)4
timesdaily;dosedoubledinsevereinfection
Child1monthÐ1year
62.5mg4timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,orsalmonellosis
hild1Ð5years
125mg4timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,orsalmonellosis
hild5Ð12years
250mg4timesdaily;dose
doubledinsevereinfection,community-acquired
pneumonia,orsalmonellosis
hild12Ð18years
250Ð500mg4timesdaily;
dosedoubledinsevereinfection
Byintravenousinjectionorinfusion
eonateunder7days
30mg/kgevery12hours;
dosedoubledinsevereinfection,community-
acquiredpneumonia,orsalmonellosis
eonate7Ð21days
30mg/kgevery8hours;
dosedoubledinsevereinfection,community-
acquiredpneumonia,orsalmonellosis
eonate21Ð28days
30mg/kgevery6hours;
dosedoubledinsevereinfection,community-
acquiredpneumonia,orsalmonellosis
Child1monthÐ18years
25mg/kg(max.500mg)
every6hours;dosedoubledinsevereinfection
isterialmeningitis,groupBstreptococcal
infection,enterococcalendocarditis
(incombi-
nationwithanotherantibacterial,seeTable1,sec-
tion5.1)
Byintravenousinfusion
eonateunder7days
50mg/kgevery12hours;
dosedoubledinmeningitis
eonate7Ð21days
50mg/kgevery8hours;
dosedoubledinmeningitis
eonate21Ð28days
50mg/kgevery6hours;
dosedoubledinmeningitis
Child1monthÐ18years
50mg/kgevery4Ð6
hours(max.2gevery4hours)
:administeratleast30minutes
beforefood
:displacementvaluemaybesigniÞcantwhen
reconstitutinginjection,consultlocalguidelines.
Diluteintravenousinjectiontoaconcentrationof50Ð
100mg/mL.Maybefurtherdilutedwithglucose5%
or10%orsodiumchloride0.9%or0.45%forinfusion.
Giveover30minuteswhenusingdosesofgreater
than50mg/kgtoavoidCNStoxicityincludingcon-
vulsions.
Infections
Withßucloxacillin
Co-ßuampicil
CO-AMOXICLAV
Amixtureofamoxicillin(asthetrihydrateorasthe
sodiumsalt)andclavulanicacid(aspotassiumcla-
vulanate);theproportionsareexpressedintheform
arethestrengthsinmilligramsof
amoxicillinandclavulanicacidrespectively
seeunderAmpicillinandnotesabove;
maintainadequatehydrationwithhighdoses(parti-
cularlyduringparenteraltherapy);
Appendix1(penicillins)
Cholestaticjaundice
Cholestaticjaundicecanoccureither
duringorshortlyaftertheuseofco-amoxiclav.Anepide-
miologicalstudyhasshownthattheriskofacuteliver
toxicitywasabout6timesgreaterwithco-amoxiclavthan
withamoxicillin;thesereactionshaveonlyrarelybeen
reportedinchildren.Jaundiceisusuallyself-limitingand
veryrarelyfatal.Thedurationoftreatmentshouldbe
appropriatetotheindicationandshouldnotusuallyexceed
14days
Contra-indications
penicillinhypersensitivity,history
ofco-amoxiclav-associatedorpenicillin-associated
jaundiceorhepaticdysfunction
Hepaticimpairment
monitorliverfunctioninliver
disease.SeealsoCholestaticJaundiceabove
Renalimpairment
riskofcrystalluriawithhighdoses
(particularlyduringparenteraltherapy).
Co-amoxiclav125/31suspension,250/62suspen-
bleedingtime,dizziness,headache,convulsions(par-
ticularlywithhighdosesorinrenalimpairment);
Oralsuspension
,co-amoxiclav250/62(amoxicillin
250mgastrihydrate,clavulanicacid62.5mgas
potassiumsalt)/5mLwhenreconstitutedwithwater,
Twicedailyoralpreparations
Co-amoxiclav
5.1.1.4
Antipseudomonalpenicillins
,aureidopenicillin,isonlyavailableincom-
PIPERACILLINWITHTAZOBACTAM
seeunderBenzylpenicillin(section5.1.1.1);
Appendix1(penicillins)
Contra-indications
seeunderBenzylpenicillin(sec-
tion5.1.1.1)
Renalimpairment
doseexpressedasacombination
ofpiperacillinandtazobactam(bothassodiumsalts).
Childunder12years
90mg/kg(max.4.5g)every8
hoursifestimatedglomerularÞltrationrate20Ð
40mL/minute/1.73m
;90mg/kg(max.4.5g)every
12hoursifestimatedglomerularÞltrationrateless
than20mL/minute/1.73m
Child12–18years
4.5gevery8hoursifestimatedglomerularÞltration
rate20Ð80mL/minute/1.73m
;max.4.5gevery12
hoursifestimatedglomerularÞltrationratelessthan
20mL/minute/1.73m
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
presentinmilkÑmanufacturer
advisesuseonlyifpotentialbeneÞtoutweighsrisk
seeunderBenzylpenicillin(section
5.1.1.1);alsonausea,vomiting,diarrhoea;
lesscom-
stomatitis,dyspepsia,constipation,jaundice,
hypotension,headache,insomnia,andinjection-site
abdominalpain,hepatitis,oedema,
fatigueandeosinophilia;
veryrarely
hypoglycaemia,
hypokalaemia,pancytopenia,Stevens-Johnson
syndrome,andtoxicepidermalnecrolysis
Licenseduse
notlicensedforuseinchildrenunder
12years(exceptforchildrenwithneutropeniaand
complicatedappendicitis)
5.1.1Penicillins
BNFC2011–
Infections
Indicationanddose
Expressedasacombinationofpiperacillinand
tazobactam(bothassodiumsalts)inaratioof8:1
owerrespiratorytract,urinary-tract,intra-
abdominalandskininfections,andbacterial
Byintravenousinjectionover3Ð5minutesor
byintravenousinfusion
90mg/kgevery8hours
Child1monthÐ12years
90mg/kgevery6Ð8
hours;(max4.5gevery6hours)
hild12Ð18years
2.25Ð4.5gevery6Ð8hours,
usually4.5gevery8hours
nfectionsinchildrenwithneutropenia
incom-
binationwithanaminoglycoside
Byintravenousinjectionover3Ð5minutesor
byintravenousinfusion
Child1monthÐ18years
90mg/kg(max.4.5g)
every6hours
omplicatedappendicitis
Byintravenousinjectionover3Ð5minutesor
byintravenousinfusion
Child2Ð12years
112.5mg/kg(max.4.5g)every
8hoursfor5Ð14days
displacementvaluemaybesigniÞcant
whenreconstitutinginjection,consultlocalguide-
lines.For
intravenousinfusion
,dilutereconstituted
solutiontoaconcentrationof15Ð90mg/mLwith
Glucose5%
SodiumChloride0.9%;giveover20Ð
30minutes
Piperacillinwithtazobactam
TICARCILLINWITHCLAVULANIC
seeunderBenzylpenicillin(section5.1.1.1);
Appendix1(penicillins)
CholestaticJaundice
Forawarningoncholestaticjaundice
possiblyassociatedwithclavulanicacid,seeunderCo-
amoxiclav
Contra-indications
seeunderBenzylpenicillin(sec-
tion5.1.1.1)
Hepaticimpairment
manufactureradvisescautionin
severeimpairment;alsocholestaticjaundice,see
underCo-amoxiclav
Renalimpairment
reducedoseif
estimatedglomerularÞltrationratelessthan
60mL/minute/1.73m
Child1month–18years
normaldoseevery8hoursifestimatedglomerular
Þltrationrate30Ð60mL/minute/1.73m
;usehalf
normaldoseevery8hoursifestimatedglomerular
Þltrationrate10Ð30mL/minute/1.73m
;usehalf
normaldoseevery12hoursifestimatedglomerular
Þltrationratelessthan10mL/minute/1.73m
notknowntobeharmful
traceamountspresentinmilkÑnot
knowntobeharmful,butbealertforhypersensitivity
intheinfant
seeunderBenzylpenicillin(section
5.1.1.1);alsonausea,vomiting,coagulationdisorders,
haemorrhagiccystitis(morefrequentinchildren),
injection-sitereactions,Stevens-Johnsonsyndrome,
toxicepidermalnecrolysis,hypokalaemia,eosino-
Indicationanddose
Expressedasacombinationofticarcillin(assodium
salt)andclavulanicacid(aspotassiumsalt)inaratioof
nfectionsdueto
Pseudomonas
seenotesabove
Byintravenousinfusion
5.1.1.5
Mecillinams
Pivmecillinam
hassigniÞcantactivityagainstmany
Gram-negativebacteriaincluding
Escherichiacoli
,kleb-
siella,enterobacter,andsalmonellae.Itisnotactive
Pseudomonasaeruginosa
orenterococci.
Pivmecillinamishydrolysedtomecillinam,whichis
theactivedrug.
PIVMECILLINAMHYDROCHLORIDE
seeunderBenzylpenicillin(section5.1.1.1);
alsoliverandrenalfunctiontestsrequiredinlong-
termuse;avoidinacuteporphyria(section9.8.2);
Appendix1(penicillins)
Contra-indications
seeunderBenzylpenicillin(sec-
tion5.1.1.1);alsocarnitinedeÞciency,oesophageal
BNFC2011–
5.1.1Penicillins
strictures,gastro-intestinalobstruction,infantsunder
3months
notknowntobeharmful,butmanufacturer
advisesavoid
traceamountsinmilk
seeunderBenzylpenicillin(section
5.1.1.1);nausea,vomiting,dyspepsia;alsoreduced
serumandtotalbodycarnitine(especiallywithlong-
termorrepeateduse)
Licenseduse
notlicensedforuseinchildrenunder3
Indicationanddose
cuteuncomplicatedcystitis
Bymouth
Childbody-weightover40kg
initially400mg
then200mgevery8hoursfor3days
hronicorrecurrentbacteriuria
hildbody-weightover40kg
400mgevery6Ð8
hours
rinary-tractinfections
hildbody-weightunder40kg
5Ð10mg/kg
every6hours;totaldailydosemayalternativelybe
givenin3divideddoses
notrecommendedthereforenodose
Counselling
5.1.2.1
Cephalosporins
Thecephalosporinsarebroad-spectrumantibacterials
whichareusedforthetreatmentofsepticaemia,pneu-
monia,meningitis,biliary-tractinfections,peritonitis,
andurinary-tractinfections.Thepharmacologyofthe
cephalosporinsissimilartothatofthepenicillins,excre-
Infections
whichbecomeresistanttopenicillinareusuallyalso
resistanttocephalosporins.Thisisofimportanceinthe
caseofchildrenwhohavehadrheumaticfeverandare
onlong-termpenicillintherapy.Cefalexinandcefradine
havebeenusedinthetreatmentoforalinfections.
CEFACLOR
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan50mL/minute/1.73m
notknowntobeharmful
presentinmilkinlowconcentrations
seeunderCefaclor
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
butseenotesabove
Bymouth
Child6Ð18years
ody-weightunder40kg
500mgtwicedaily;
ody-weightover40kg
0.5Ð1gtwicedaily(1g
oncedailyforskin,soft-tissueanduncomplicated
urinary-tractinfections)
Cefadroxil
(Cephalexin)
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reducedoseinmoderateimpair-
notknowntobeharmful
presentinmilkinlowconcentrations,
consideredcompatiblewithbreast-feeding
seeunderCefaclor
BNFC2011–
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
butseenotesabove
Bymouth
eonateunder7days
25mg/kg(max.125mg)
twicedaily
eonate7Ð21days
25mg/kg(max.125mg)3
timesdaily
eonate21Ð28days
25mg/kg(max.125mg)4
timesdaily
Child1monthÐ12years
12.5mg/kgtwicedaily;
dosedoubledinsevereinfection;max.25mg/kg4
timesdaily(max.1g4timesdaily)
hild1monthÐ1year
125mgtwicedaily
hild1Ð5years
125mg3timesdaily
hild5Ð12years
250mg3timesdaily
hild12Ð18years
500mg2Ð3timesdaily,
increasedto1Ð1.5g3Ð4timesdailyforsevere
rophylaxisofrecurrenturinary-tractinfection
Bymouth
Child1monthÐ18years
12.5mg/kgatnight
(max.125mgatnight)
Cefalexin
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan20mL/minute/1.73m
notknowntobeharmful
manufactureradvisesavoidÑno
informationavailable
seeunderCefaclor
Indicationanddose
cuteinfectionsduetosensitiveGram-positive
andGram-negativebacteria,butseenotes
Bymouth
Child6monthsÐ1year
75mgdaily
hild1Ð5years
100mgdaily
hild5Ð10years
200mgdaily
hild10Ð18years
200Ð400mgdaily
200mgtwicedaily
ncomplicatedgonorrhoea
[unlicensedindica-
tion,seealsoTable1,section5.1]
Bymouth
Child12Ð18years
400mgasasingledose
CEFOTAXIME
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
usualinitialdose,thenusehalf
normaldoseifestimatedglomerularÞltrationrateless
than5mL/minute/1.73m
notknowntobeharmful
presentinmilkinlowconcentration,
consideredcompatiblewithbreast-feeding
seeunderCefaclor;rarelyarrhythmias
followingrapidinjectionreported
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria,surgicalprophylaxis,
Haemophilusepiglottitisandmeningitis(Table
1,section5.1)
seealsonotesabove
Byintramuscularorbyintravenousinjectionor
intravenousinfusion
eonateunder7days
25mg/kgevery12hours;
dosedoubledinsevereinfectionandmeningitis
eonate7Ð21days
25mg/kgevery8hours;
dosedoubledinsevereinfectionandmeningitis
eonate21Ð28days
25mg/kgevery6Ð8hours;
dosedoubledinsevereinfectionandmeningitis
Infections
Child1monthÐ18years
50mg/kgevery8Ð12
hours;increasetoevery6hoursinverysevere
infectionsandmeningitis(max.12gdaily)
Important
.Ifmeningococcaldisease(meningitiswith
non-blanchingrashormeningococcalsepticaemia)is
suspected,andthechildcannotbegivenbenzylpenicillin
(e.g.becauseofanallergy),asingledoseofcefotaxime
canbegiven(ifavailable)beforeurgenttransferto
hospital,solongasthisdoesnotdelaythetransfer.Ifa
childwithsuspectedbacterialmeningitiswithoutnon-
blanchingrashcannotbetransferredtohospitalurgently
andcannotbegivenbenzylpenicillin,asingledoseof
cefotaximecanbegivenbeforetransfer.Suitabledosesof
cefotaximebyintravenousinjection(orbyintramuscular
injection)are
Childunder12years
50mg/kg;
Childover
12years
1g;chloramphenicol(section5.1.7)maybe
usedifthereisahistoryofanaphylaxistopenicillinsor
ongenitalgonococcalconjunctivitis
Byintramuscularinjection
100mg/kg(max.1g)asasingledose
ncomplicatedgonorrhoea
Byintramuscularorbyintravenousinjectionor
intravenousinfusion
Child12Ð18years
500mgasasingledose
evereexacerbationsof
Haemophilusinßu-
infectionincysticÞbrosis
Byintravenousinjectionorintravenousinfu-
Child1monthÐ18years
50mg/kgevery6Ð8
hours(max.12gdaily)
DisplacementvaluemaybesigniÞ-
cant,consultlocalguidelines.Forintermittentintra-
venousinfusiondiluteinglucose5%
chloride0.9%;administerover20Ð60minutes;
incompatiblewithalkalinesolutions
Cefotaxime
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
increasedoseintervaltoevery24
hoursifestimatedglomerularÞltrationrate10Ð
40mL/minute/1.73m
.Increasedoseintervalto
every48hoursifestimatedglomerularÞltrationrate
lessthan10mL/minute/1.73m
notknowntobeharmful
presentinmilkinlowconcentration
seeunderCefaclor
Indicationanddose
pperrespiratory-tractinfections(butin
pharyngitisandtonsillitisreservedforinfec-
tionswhicharerecurrent,chronic,orresistant
tootherantibacterials),lowerrespiratory-tract
infections(includingbronchitisandpneu-
monia),skinandsofttissueinfections,
uncomplicatedurinary-tractinfections
Bymouth
Child15daysÐ6months
4mg/kgtwicedaily
hild6monthsÐ2years
40mgtwicedaily
hild3Ð8years
80mgtwicedaily
hild9Ð12years
100mgtwicedaily
hild12Ð18years
100mgtwicedaily(increased
to200mgtwicedailyinsinusitis,skinandsoft
tissueinfections,uncomplicatedupperurinary
tractinfectionsandifnecessaryinlowerrespir-
atorytractinfections)
Orelox
(Cephradine)
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan20mL/minute/1.73m
notknowntobeharmful
presentinmilkinlowconcentrations
seeunderCefaclor
Licenseduse
notlicensedforuseinchildrenfor
preventionof
Staphylococcusaureus
lunginfection
incysticÞbrosis
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
butseenotesabove
Bymouth
Child7Ð12years
12.5Ð25mg/kgtwicedaily
(totaldailydosemayalternativelybegivenin3Ð4
divideddoses)
hild12Ð18years
0.5Ð1gtwicedaily
500mg4timesdaily;upto1g4timesdailyin
severeinfections
reventionof
Staphylococcusaureus
infectionincysticÞbrosis
Bymouth
Child7Ð18years
2gtwicedaily
Cefradine
CEFTAZIDIME
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan50mL/minute/1.73m
notknowntobeharmful
BNFC2011–
presentinmilkinlowconcentration,
consideredcompatiblewithbreast-feeding
seeunderCefaclor
Licenseduse
nebulisedrouteunlicensed
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
butseenotesabove
Byintravenousinjectionorinfusion
eonateunder7days
25mg/kgevery24hours;
dosedoubledinsevereinfectionandmeningitis
eonate7Ð21days
25mg/kgevery12hours;
dosedoubledinsevereinfectionandmeningitis
eonate21Ð28days
25mg/kgevery8hours;
dosedoubledinsevereinfectionandmeningitis
Child1monthÐ18years
25mg/kgevery8hours;
dosedoubledinsevereinfection,febrileneutro-
peniaandmeningitis(max.6gdaily)
seudomonallunginfectionincysticÞbrosis
Byintravenousinjectionorinfusionorbydeep
intramuscularinjection
Child1monthÐ18years
50mg/kgevery8hours
(max.9gdaily)
Burkholderiacepacia
infectionincystic
Byinhalationofnebulisedsolution
Child1monthÐ18years
1gtwicedaily
Forparenteraladministration,intra-
venousrouterecommendedinchildren.Displace-
mentvaluemaybesigniÞcant,consultlocalguide-
lines.Forintermittentintravenousinfusiondilute
reconstitutedsolutionfurthertoaconcentrationof
notmorethan40mg/mLinGlucose5%orGlucose
10%orSodiumchloride0.9%;giveover20Ð30min-
Fornebulisation,dissolvedosein3mLofwaterfor
Ceftazidime
seeunderCefaclor;neonates;maydisplace
bilirubinfromserumalbumin,administerover60
minutesinneonates(seealsoContra-indications);
treatmentlongerthan14days,renalfailure,dehy-
drationÑriskofceftriaxoneprecipitationingall
Appendix1(cephalosporins)
Contra-indications
seeunderCefaclor;neonatesless
than41weekspostmenstrualage;neonatesover41
weekspostmenstrualagewithjaundice,hypoalbumi-
naemia,oracidosis;concomitanttreatmentwith
intravenouscalcium(includingtotalparenteralnutri-
tioncontainingcalcium)inneonatesover41weeks
postmenstrualageÑriskofprecipitationinurineand
Hepaticimpairment
ifhepaticimpairmentisaccom-
paniedbysevererenalimpairment,reducedoseand
monitorplasmaconcentration
Renalimpairment
max.50mg/kgdaily(max.2g
daily)insevererenalimpairment;alsomonitor
plasmaconcentrationifhepaticimpairmentaccom-
paniedbysevererenalimpairment
notknowntobeharmful
presentinmilkinlowconcentration,
consideredcompatiblewithbreast-feeding
seeunderCefaclor;calciumceftriaxone
precipitatesinurine(particularlyinveryyoung,
dehydratedorthosewhoareimmobilised)oringall
bladderÑconsiderdiscontinuationifsymptomatic;
rarelyprolongationofprothrombintime,pancreatitis
Licenseduse
notlicensedforcongenitalgonococcal
conjunctivitisorearlysyphilis;notlicensedforuse
inchildrenunder12yearsofageforuncomplicated
gonorrhoeaorpelvicinßammatorydisease
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
Byintravenousinfusionover60minutes
20Ð50mg/kgoncedaily
Bydeepintramuscularinjection,orbyintra-
venousinjectionover2Ð4minutes,orby
intravenousinfusion
Child1monthÐ12years
ody-weightunder50kg
50mg/kgoncedaily;
upto80mg/kgdailyinsevereinfectionsand
meningitis;dosesof50mg/kgandoverbyintra-
venousinfusiononly
ody-weight50kgandover
doseasforchild12Ð
18years
hild12Ð18years
1gdaily;2Ð4gdailyinsevere
infectionsandmeningitis;intramusculardoses
Infections
arlysyphilis
Bydeepintramuscularinjection
Child12Ð18years
500mgdailyfor10days
urgicalprophylaxis
Bydeepintramuscularinjectionorbyintra-
venousinjectionoveratleast2Ð4minutes,or
(forcolorectalsurgery)byintravenousinfusion
Child12Ð18years
1gupto30minutesbeforethe
procedure;colorectalsurgery,2gupto30minutes
beforetheprocedure;intramusculardosesover1g
seeunderCefaclor;
Appendix
1(cephalosporins)
Contra-indications
seeunderCefaclor
Renalimpairment
reduceparenteraldoseifesti-
matedglomerularÞltrationratelessthan20mL/
minute/1.73m
notknowntobeharmful
presentinmilkinlowconcentration
seeunderCefaclor
Licenseduse
notlicensedfortreatmentofLyme
diseaseinchildrenunder12years
Indicationanddose
nfectionsduetosensitiveGram-positiveand
Gram-negativebacteria
Bymouth(ascefuroximeaxetil)
Child3monthsÐ2years
10mg/kg(max.125mg)
twicedaily
hild2Ð12years
15mg/kg(max.250mg)twice
hild12Ð18years
250mgtwicedaily;dose
doubledinseverelowerrespiratory-tractinfec-
tions,orifpneumoniasuspected;dosereducedto
125mgtwicedailyinlowerurinary-tractinfection
Byintravenousinjectionorinfusionorby
intramuscularinjection
eonateunder7days
25mg/kgevery12hours;
dosedoubledinsevereinfection,intravenous
routeonly
eonate7Ð21days
25mg/kgevery8hours;
dosedoubledinsevereinfection,intravenous
routeonly
eonate21Ð28days
25mg/kgevery6hours;
dosedoubledinsevereinfection,intravenous
routeonly
Child1monthÐ18years
20mg/kg(max.750mg)
every8hours;increaseto50Ð60mg/kg(max.
1.5g)every6Ð8hoursinsevereinfectionand
cysticÞbrosis
ymedisease
(seealsosection5.1.1.3)
Bymouth
Child3monthsÐ12years
15mg/kg(max.
500mg)twicedailyfor14Ð21days(for28daysin
Lymearthritis)
hild12Ð18years
500mgtwicedailyfor14Ð21
days(for28daysinLymearthritis)
urgicalprophylaxis
Byintravenousinjection
Child1monthÐ18years
50mg/kg(max.1.5g)
upto30minutesbeforetheprocedure;upto3
furtherdosesof30mg/kg(max.750mg)maybe
givenby
intramuscularorintravenousinjection
every8hoursforhigh-riskprocedures
Singledosesover750mgshouldbe
administeredbytheintravenousrouteonly.
DisplacementvaluemaybesigniÞcantwhenrecon-
stitutinginjection,consultlocalguidelines.Forinter-
mittentintravenousinfusion,dilutereconstituted
solutionfurtheringlucose5%
sodiumchloride
0.9%;giveover30minutes.
Cefuroxime
5.1.2.2
Carbapenems
ERTAPENEM
peritonitis,renalimpairment,musclecramp,scleral
disorder,blooddisorders(includingneutropenia,
thrombocytopenia,haemorrhage),hypoglycaemia,
electrolytedisturbances;alsoreportedhallucinations,
Indicationanddose
bdominalinfections,acutegynaecological
infections,community-acquiredpneumonia
Byintravenousinfusion
Child3monthsÐ13years
15mg/kgevery12
hours(max.1gdaily)
hild13Ð18years
1goncedaily
reconstitute1gwith10mLWaterfor
InjectionsorSodiumChloride0.9%;for
intermittent
intravenousinfusion
,diluterequisitedoseinSodium
Chloride0.9%toaÞnalconcentrationnotexceeding
20mg/mL;incompatiblewithglucosesolutions
Intravenousinfusion
,powderforreconstitution,
IMIPENEMWITHCILASTATIN
CNSdisorders(e.g.epilepsy);hypersensi-
Infections
Child3monthsÐ18years
ody-weightunder40kg
15mg/kg(max.
500mg)every6hours
ody-weightover40kg
250Ð500mgevery6
hours;lesssensitiveorganismsupto12.5mg/kg
(max.1g)every6hours;totaldailydosemay
alternativelybegivenin3divideddoses
ysticÞbrosis
Byintravenousinfusion
Child1monthÐ18years
ody-weightunder40kg
22.5mg/kgevery6
hours
ody-weightover40kg
1gevery6Ð8hours
forintermittentintravenousinfusion
dilutetoaconcentrationof5mg(asimipenem)/mLin
sodiumchloride0.9%
sodiumchlorideandglucose;
giveupto500mgover20Ð30minutes;give1gover
40Ð60minutes
Intravenousinfusion
,powderforreconstitution,
imipenem(asmonohydrate)500mgwithcilastatin(as
5.1.2.3
minute/1.73m
;usualinitialdose,thenone-quarter
normaldoseifestimatedglomerularÞltrationrateless
than10mL/minute/1.73m
noinformationavailableÑmanufacturer
advisesavoid
amountinmilkprobablytoosmallto
beharmful
nausea,vomiting,diarrhoea,abdominal
cramps;mouthulcers,alteredtaste;jaundiceand
hepatitis;ßushing;hypersensitivityreactions;blood
disorders(includingthrombocytopeniaandneutro-
penia);rashes,injection-sitereactions;
tension,seizures,asthenia,confusion,dizziness,
headache,halitosis,andbreasttenderness;
veryrarely
antibiotic-associatedcolitis,gastro-intestinalbleed-
ing,andtoxicepidermalnecrolysis
Licenseduse
notlicensedforuseinchildrenunder7
Indicationanddose
ram-negativeinfectionsincluding
monasaeruginosa
Haemophilusinßuenzae
Neisseriameningitidis
Byintravenousinjectionover3Ð5minutesor
byintravenousinfusion
eonateunder7days
30mg/kgevery12hours
eonate7Ð28days
30mg/kgevery6Ð8hours
Child1monthÐ2years
30mg/kgevery6Ð8
hours
hild2Ð12years
30mg/kgevery6Ð8hours
increasedto50mg/kgevery6Ð8hoursinsevere
infectionandcysticÞbrosis(max.2gevery6
hours)
hild12Ð18years
1gevery8hoursor2gevery
12hours;2gevery6Ð8hoursforsevereinfections
(includingsystemic
Ps.aeruginosa
andlung
infectionsincysticÞbrosis)
DisplacementvaluemaybesigniÞ-
cant,consultlocalguidelines.Forintermittentintra-
venousinfusion,dilutereconstitutedsolutionfurther
inGlucose5%
Sodiumchloride0.9%toacon-
centrationoflessthan20mg/mL;tobegivenover
20Ð60minutes
Infections
DEMECLOCYCLINEHYDROCHLORIDE
seenotesabove,butphotosensitivitymore
common(avoidexposuretosunlightorsunlamps)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;max.1gdaily
individeddoses
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsoreversiblenephro-
DOXYCYCLINE
seenotesabove;alcoholdependence;
photosensitivityreported(avoidexposuretosunlight
orsunlamps)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
usewithcaution(avoidexcessive
seenotesabove
seenotesabove
seenotesabove;alsoanorexia,dry
djuncttogingivalscalingandrootplaningfor
periodontitis
section12.3.1
Counselling
Capsulesshouldbeswallowedwholewith
plentyofßuidduringmealswhilesittingorstanding
DoxycyclinedosesinBNFforChildrenmaydifferfrom
thoseinproductliterature
LYMECYCLINE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
usceptibleinfections
seenotesabove
Bymouth
Child12Ð18years
408mgtwicedaily,increased
to1.224Ð1.632gdailyinsevereinfections
Bymouth
Child12Ð18years
408mgdailyforatleast8
seenotesabove;iftreatmentcontinuedfor
longerthan6months,monitorevery3monthsfor
hepatotoxicity,pigmentationandforsystemiclupus
erythematosusÑdiscontinueifthesedeveloporif
pre-existingsystemiclupuserythematosusworsens
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
usewithcaution(avoidexcessive
seenotesabove
seenotesabove
seenotesabove;alsodizzinessand
vertigo(morecommoninwomen);
tinnitus,impairedhearing,hyperaesthesia,paraes-
ModiÞedrelease
Minocyclinem/rpreparations
Capsules
,m/r,minocycline(ashydrochloride)
Infections
Mostside-effectsofthisgroupofantibioticsaredose-
related;thereforecaremustbetakenwithdosageand
wheneverpossibletreatmentshouldnotexceed7days.
Theimportantside-effectsareototoxicity,andnephro-
toxicity;theyoccurmostcommonlyinchildrenwith
renalfailure.
Aminoglycosidesmayimpairneuromusculartransmis-
sionandshouldnotbegiventochildrenwithmyas-
theniagravis;largedosesgivenduringsurgeryhave
beenresponsibleforatransientmyasthenicsyndrome
inpatientswithnormalneuromuscularfunction.
Aminoglycosidesshouldpreferablynotbegivenwith
centrationsthuspreventingtoxicityandensuringefÞ-
cacy.Inchildrenwithnormalrenalfunction,
aminoglycosideconcentrationshouldbemeasurediniti-
allyafter3or4dosesofamultipledailydoseregimen;
childrenwithrenalimpairmentmayrequireearlierand
morefrequentmeasurementofaminoglycosideconcen-
Bloodsamplesshouldbetakenjustbeforethenextdose
isadministered(ÔtroughÕconcentration).Ifthepre-dose
Thereisariskofauditoryorvestibular
nervedamagewhenaminoglycosidesareusedinthe
secondandthirdtrimestersofpregnancy.Theriskis
greatestwithstreptomycin(section5.1.9).Theriskis
probablyverysmallwithgentamicinandtobramycin,
buttheiruseshouldbeavoidedunlessessential(ifgiven,
serum-aminoglycosideconcentrationmonitoringis
GENTAMICIN
neonates,infants(adjustdoseandmonitor
Infections
A
seeunderGentamicin;
Appendix1(aminoglycosides)
Contra-indications
seeunderGentamicin
Renalimpairment
seenotesabove
seenotesabove
seeunderGentamicin
TOBRAMYCIN
seeunderGentamicin;
Appendix1(aminoglycosides)
SpeciÞccautionsforinhaledtreatment
Otherinhaled
drugsshouldbeadministeredbeforetobramycin;monitorfor
bronchospasmwithinitialdose,measurepeakßowbefore
andafternebulisationÑifbronchospasmoccurs,repeattest
usingbronchodilator;monitorrenalfunctionbeforetreat-
mentandthenannually;severehaemoptysis
Contra-indications
seeunderGentamicin
Renalimpairment
seenotesabove
seenotesabove
seeunderGentamicin;
oninhalation
mouthulcers,tastedisturbances,voicealteration,
cough,bronchospasm(seeCautions)
Child12Ð18years
1mg/kgevery8hours;in
severeinfectionsupto5mg/kgdailyindivided
dosesevery6Ð8hours(reducedto3mg/kgdaily
assoonasclinicallyindicated)
Oncedailydoseregimenbyintravenousinfu-
Child1monthÐ18years
initially7mg/kg,then
adjustedaccordingtoserum-tobramycinconcen-
seudomonallunginfectionincysticÞbrosis
Multipledailydoseregimenbyslowintra-
venousinjectionover3Ð5minutes
Child1monthÐ18years
8Ð10mg/kg/dailyin3
divideddoses
Oncedailydoseregimenbyintravenousinfu-
sionover30minutes
Child1monthÐ18years
initially10mg/kg(max.
660mg),thenadjustedaccordingtoserum-tobra-
mycinconcentration
hronicpulmonary
Pseudomonasaeruginosa
infectioninpatientswithcysticÞbrosis
Byinhalationofnebulisedsolution
Child6Ð18years
300mgevery12hoursfor28
days,subsequentcoursesrepeatedafter28-day
intervalwithouttobramycinnebulisersolution
Localdosageguidelinesmayvary
intravenousinfusion
,dilutewith
Glucose5%
SodiumChloride0.9%;giveover20Ð
60minutes
Tobramycin
Nebulisersolution
seenotesabove;
Appendix1
(macrolides)
Hepaticimpairment
manufacturersadviseavoidin
severeliverdiseaseÑnoinformationavailable
Renalimpairment
usewithcautionifestimated
glomerularÞltrationratelessthan10mL/minute/
1.73m
manufacturersadviseuseonlyifadequate
alternativesnotavailable
presentinmilk;useonlyifnosuitable
alternative
seenotesabove;alsoanorexia,dys-
pepsia,ßatulence,syncope,dizziness,headache,
drowsiness,convulsions,arthralgia,anddisturbances
intasteandsmell;
constipation,hypotension,
Infections
mia,insterstitialnephritis,acuterenalfailure,photo-
sensitivity,toothandtonguediscoloration
Licenseduse
notlicensedfortyphoidfever,Lyme
disease,chronic
Pseudomonasaeruginosa
incysticÞbrosis,orprophylaxisofgroupAstrep-
tococcalinfection
Indicationanddose
espiratory-tractinfections,otitismedia,skin
andsoft-tissueinfections
Bymouth
Childover6months
10mg/kgoncedaily(max.
500mgoncedaily)for3days
ody-weight15Ð25kg
200mgoncedailyfor3
ody-weight26Ð35kg
300mgoncedailyfor3
ody-weight36Ð45kg
400mgoncedailyfor3
ody-weightover45kg
500mgoncedailyfor3
nfectionincysticÞbrosis
Bymouth
Child6monthsÐ18years
10mg/kgoncedaily
(max.500mgoncedaily)for3days;course
repeatedafter1week,thenrepeatasnecessary
Pseudomonasaeruginosa
infectionin
cysticÞbrosis
Bymouth
Child6Ð18years
ody-weight25Ð40kg
250mg3timesaweek
ody-weightover40kg
500mg3timesaweek
ncomplicatedgenitalchlamydialinfections
seenotesabove;
Appendix1
(macrolides)
Hepaticimpairment
hepaticdysfunctionincluding
jaundicereported
Renalimpairment
usehalfnormaldoseifestimated
glomerularÞltrationratelessthan30mL/minute/
1.73m
;avoid
KlaricidXL
ifestimatedglomerular
Þltrationratelessthan30mL/minute/1.73m
manufactureradvisesavoidunlesspoten-
tialbeneÞtoutweighsrisk
manufactureradvisesavoidunless
potentialbeneÞtoutweighsriskÑpresentinmilk
seenotesabove;alsodyspepsia,tooth
andtonguediscoloration,smellandtastedistur-
bances,stomatitis,glossitis,andheadache;
lesscom-
arthralgiaandmyalgia;
rarely
very
ymedisease
(seealsosection5.1.1.3)
Bymouth
Child1monthÐ12years
7.5mg/kg(max.
500mg)twicedailyfor14Ð21days
hild12Ð18years
500mgtwicedailyfor14Ð21
elicobacterpylori
section1.3
reventionofpertussis
Table2,section5.1
forintermittentintravenousinfusion
dilutereconstitutedsolutionfurtherinGlucose5%
Sodiumchloride0.9%toaconcentrationof2mg/mL;
giveintolargeproximalveinover60minutes
Clarithromycin
seenotesabove;neonateunder2weeks(risk
ofhypertrophicpyloricstenosis);acuteporphyria
(section9.8.2);
Appendix1(macrolides)
Hepaticimpairment
maycauseidiosyncratic
hepatotoxicity
Renalimpairment
reducedoseinsevererenal
impairment(ototoxicity)
notknowntobeharmful
onlysmallamountsinmilkÑnot
knowntobeharmful
seenotesabove;alsomyasthenia-like
Indicationanddose
usceptibleinfectionsinpatientswithpeni-
cillinhypersensitivity,oralinfections(see
notesabove),campylobacterenteritis,respir-
atory-tractinfections(includingLegionella
infection),skininfections,chlamydialophthal-
mia,preventionandtreamentofpertussis(see
alsoTable2,section5.1)
Bymouth
12.5mg/kgevery6hours
Child1monthÐ2years
125mg4timesdaily;
dosedoubledinsevereinfections
hild2Ð8years
250mg4timesdaily;dose
doubledinsevereinfections
hild8Ð18years
250Ð500mg4timesdaily;dose
doubledinsevereinfections
Totaldailydosemaybegivenintwodivideddoses
Byintravenousinfusion
10Ð12.5mg/kgevery6hours
Child1monthÐ18years
12.5mg/kg(max.1g)
every6hours
arlysyphilis
Bymouth
Child12Ð18years
500mg4timesdailyfor14
ncomplicatedgenitalchlamydia,non-gono-
Infections
Erythromycin
CLINDAMYCIN
discontinueimmediatelyifdiarrhoeaorcol-
itisdevelops;monitorliverandrenalfunctionif
treatmentexceeds10days,andinneonatesand
infants;avoidrapidintravenousadministration;avoid
inacuteporphyria(section9.8.2);
Appendix1(clindamycin)
Contra-indications
diarrhoealstates;avoidinjections
containingbenzylalcoholinneonates(seeunder
preparationsbelow)
notknowntobeharmful
amountprobablytoosmalltobe
harmful;bloodydiarrhoeareportedin1infant
diarrhoea(discontinuetreatment),
abdominaldiscomfort,oesophagitis,oesophageal
ulcers,tastedisturbances,nausea,vomiting,antibio-
tic-associatedcolitis;jaundice;leucopenia,eosino-
philia,andthrombocytopeniareported;polyarthritis
reported;rash,pruritus,urticaria,anaphylactoid
reactions,Stevens-Johnsonsyndrome,toxicepider-
malnecrolysis,exfoliativeandvesiculobullous
dermatitisreported;pain,induration,andabscess
afterintramuscularinjection;thrombophlebitisafter
intravenousinjection
Indicationanddose
taphylococcalboneandjointinfections,peri-
seenotesabove
Bymouth
eonateunder14days
3Ð6mg/kg3timesdaily
eonate14Ð28days
3Ð6mg/kg4timesdaily
Child1monthÐ12years
3Ð6mg/kg4timesdaily
(body-weightunder10kg,minimumdose37.5mg
3timesdaily)
hild12Ð18years
150Ð300mg4timesdaily;in
severeinfections450mg4timesdaily
Bydeepintramuscularinjectionorbyintra-
venousinfusion
Child1monthÐ12years
3.75Ð6.25mg/kg4
timesdaily;increasedupto10mg/kg4timesdaily
insevereinfections;totaldailydosemayalterna-
tivelybegivenin3divideddoses
hild12Ð18years
150Ð675mg4timesdaily;
totaldailydosemayalternativelybegivenin2Ð3
divideddoses;inlife-threateninginfectionupto
1.2g4timesdaily;singledosesabove600mgby
intravenousinfusiononly;singledosesbyintra-
venousinfusionnottoexceed1.2g
BNFC2011–
5.1.6Clindamycin
taphylococcallunginfectionincysticÞbrosis
Bymouth
Child1monthÐ18years
5Ð7mg/kg(max.
600mg)4timesdaily
reatmentoffalciparummalaria
,seep.330
intravenousinfusion
,dilutetoa
concentrationofnotmorethan18mg/mLwithGlu-
cose5%
SodiumChloride0.9%;giveover10Ð60
minutesatamax.rateof20mg/kg/hour
CHLORAMPHENICOL
avoidrepeatedcoursesandprolonged
treatment;bloodcountsrequiredbeforeandperiodi-
callyduringtreatment;monitorplasma-chloram-
phenicolconcentrationinneonates(seebelow);
Appendix1(chloramphenicol)
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
avoidifpossibleÑincreasedrisk
ofbone-marrowdepression;reducedoseandmonitor
plasma-chloramphenicolconcentration
Renalimpairment
avoidinsevereimpairmentunless
noalternative;dose-relateddepressionofhaemato-
manufactureradvisesavoid;neonatal
grey-babysyndromeifusedinthirdtrimester
manufactureradvisesavoid;use
anotherantibiotic;maycausebone-marrowtoxicityin
infant;concentrationinmilkusuallyinsufÞcientto
causeÔgrey-babysyndromeÕ
blooddisordersincludingreversibleand
irreversibleaplasticanaemia(withreportsofresulting
leukaemia),peripheralneuritis,opticneuritis,head-
ache,depression,urticaria,erythemamultiforme,
nausea,vomiting,diarrhoea,stomatitis,glossitis,dry
mouth;nocturnalhaemoglobinuriareported;grey
syndrome(abdominaldistension,pallidcyanosis,cir-
culatorycollapse)mayfollowexcessivedosesin
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Kemicetine
,powderforreconstitution,chloramphenicol
Infections
causedbypenicillin-resistantstaphylococci,especially
osteomyelitis,astheyarewellconcentratedinbone;
theyarealsousedforstaphylococcalendocarditis.A
secondantistaphylococcalantibioticisusuallyrequired
topreventemergenceofresistanceduringtreatment.
SODIUMFUSIDATE
monitorliverfunctionwithhighdosesoron
prolongedtherapy;eliminationmaybereducedin
hepaticimpairmentorbiliarydiseaseorbiliary
obstruction;
Appendix1(fusidicacid)
Hepaticimpairment
VANCOMYCIN
avoidrapidinfusion(riskofanaphylactoid
reactions,seeSide-effects);rotateinfusionsites;avoid
ifhistoryofdeafness;allpatientsrequireplasma-
vancomycinmeasurement(after3or4dosesifrenal
functionnormal,earlierifrenalimpairment),blood
counts,urinalysis,andrenalfunctiontests;monitor
auditoryfunctioninrenalimpairment;teicoplanin
sensitivity;systemicabsorptionmayfolloworal
administrationespeciallyininßammatoryboweldis-
ordersorfollowingmultipledoses;
Appendix1(vancomycin)
Renalimpairment
reducedoseÑmonitorplasma-
vancomycinconcentrationandrenalfunctionregu-
larly;seealsoCautionsabove
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑplasma-vancomycinconcen-
afterparenteraladministration:nephro-
toxicityincludingrenalfailureandinterstitialnephri-
tis;ototoxicity(discontinueiftinnitusoccurs);blood
disordersincludingneutropenia(usuallyafter1week
orhighcumulativedose),rarelyagranulocytosisand
thrombocytopenia;nausea;chills,fever;eosinophilia,
anaphylaxis,rashes(includingexfoliativedermatitis,
Stevens-Johnsonsyndrome,toxicepidermalnecro-
lysis,andvasculitis);phlebitis(irritanttotissue);on
rapidinfusion,severehypotension(includingshock
andcardiacarrest),wheezing,dyspnoea,urticaria,
pruritus,ßushingoftheupperbody(ÔredmanÕ
syndrome),painandmusclespasmofbackandchest
TEICOPLANIN
vancomycinsensitivity;bloodcountsand
liverandkidneyfunctiontestsrequiredÑmonitor
renalandauditoryfunctiononprolongedadminis-
trationduringrenalimpairmentorifothernephro-
toxicorneurotoxicdrugsgiven;monitorplasma-
teicoplaninconcentrationifseveresepsisorburns,
deep-seatedstaphylococcalinfection(includingbone
andjointinfection),endocarditis,renalimpairment,
andinintravenousdrugabusers;
Appendix1(teicoplanin)
Renalimpairment
reducedoseonday4:usehalf
normaldoseifestimatedglomerularÞltrationrate40Ð
60mL/minute/1.73m
anduseone-thirdnormal
doseifestimatedglomerularÞltrationratelessthan
40mL/minute/1.73m
;seealsoCautionsabove
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
noinformationavailable
rash,pruritus;
lesscommonly
vomiting,diarrhoea,bronchospasm,dizziness,head-
ache,fever,leucopenia,thrombocytopenia,eosino-
philia,tinnitus,mildhearingloss,vestibulardisorders,
thrombophlebitis;
alsoreported
renalfailure,exfol-
iativedermatitis,Stevens-Johnsonsyndrome,toxic
epidermalnecrolysis
Infections
Licenseduse
notlicensedforuseinchildren
Indicationanddose
neumonia,complicatedskinandsoft-tissue
infectionscausedbyGram-positivebacteria
(initiatedunderexpertsupervision)
Bymouthorbyintravenousinfusionover30Ð
120minutes
eonateunder7days
10mg/kgevery12hours,
increasetoevery8hoursifpoorresponse
eonateover7days
10mg/kgevery8hours
Child1monthÐ12years
10mg/kg(max.600mg)
every8hours
hild12Ð18years
600mgevery12hours
Zyvox
presentinmilkbutpoorlyabsorbed
fromgut;manufacturersadviseavoid(oruseonlyif
potentialbeneÞtoutweighsrisk)
Side-effects
SpeciÞcside-effectsforparenteraltreatment
neurotoxi-
cityreportedespeciallywithexcessivedoses(including
apnoea,perioralandperipheralparaesthesia,vertigo,head-
ache,muscleweakness;rarelyvasomotorinstability,slurred
speech,confusion,psychosis,visualdisturbances),nephro-
toxicity;rash
SpeciÞcside-effectsforinhaledtreatment
sorethroat,
soremouth,cough,bronchospasm
Infections
Sulfonamidesand
CO-TRIMOXAZOLE
1ampoule(5mL)to125mL,2ampoules(10mL)to
250mLor3ampoules(15mL)to500mL;suggested
durationofinfusion60Ð90minutes(butmaybe
adjustedaccordingtoßuidrequirements);ifßuid
restrictionnecessary,1ampoule(5mL)maybe
dilutedwith75mLglucose5%andtherequireddose
infusedovermax.60minutes;checkcontainerfor
hazeorprecipitantduringadministration.Insevere
ßuidrestrictionmaybegivenundilutedviaacentral
venousline
Co-trimoxazole
Treatmentshouldbestartedwithoutwaitingforculture
resultsifclinicalfeaturesorhistologyresultsarecon-
sistentwithtuberculosis;treatmentshouldbecontinued
evenifinitialcultureresultsarenegative.Theinitial
phasedrugsshouldbecontinuedfor2months.Wherea
positiveculturefor
M.tuberculosis
hasbeenobtained,
butsusceptibilityresultsarenotavailableafter2
months,treatmentwithrifampicin,isoniazid,pyrazin-
5.1.9Antituberculosisdrugs
BNFC2011–
Infections
Forpreventionoftuberculosisinsusceptibleclosecon-
tactsorthosewhohavebecometuberculin-positive,see
Table2,section5.1.Foradviceonimmunisationagainst
tuberculosisandtuberculintesting,seesection14.4.
Monitoring
Sinceisoniazid,rifampicinandpyrazin-
amideareassociatedwithlivertoxicity,
hepaticfunction
shouldbecheckedbeforetreatmentwiththesedrugs.
Thosewithpre-existingliverdiseaseshouldhavefre-
quentchecksparticularlyintheÞrst2months.Ifthereis
noevidenceofliverdisease(andpre-treatmentliver
functionisnormal),furtherchecksareonlynecessaryif
thepatientdevelopsfever,malaise,vomiting,jaundice
CYCLOSERINE
monitorhaematological,renal,andhepatic
Appendix1(cycloserine)
5.1.9Antituberculosisdrugs
BNFC2011–
Infections
Contra-indications
epilepsy,depression,severe
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seeMonitoringinnotesabove;alsoslow
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
monitorhepaticfunctionÑidio-
syncratichepatotoxicitymorecommon;avoidin
severehepaticimpairment;seealsoHepaticDisor-
dersabove
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk;seealsonotesabove
amounttoosmalltobeharmful;see
alsop.291
hepatotoxicityincludingfever,anorexia,
hepatomegaly,splenomegaly,jaundice,liverfailure;
nausea,vomiting,dysuria,arthralgia,sideroblastic
anaemia,thrombocytopenia,rashandoccasionally
photosensitivity
Licenseduse
notlicensed
Indicationanddose
uberculosisincombinationwithotherdrugs
seenotesabove
Pyrazinamide
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seeunderRifampicin;acuteporphyria(sec-
tion9.8.2)
Hepaticimpairment
reducedoseinsevereimpair-
Renalimpairment
usehalfnormaldoseifestimated
glomerularÞltrationratelessthan30mL/minute/
1.73m
manufactureradvisesavoidÑnoinforma-
tionavailable
manufactureradvisesavoidÑno
informationavailable
nausea,vomiting;leucopenia,thrombo-
cytopenia,anaemia,rarelyhaemolysis;raisedliver
enzymes,jaundice,rarelyhepatitis;uveitisfollowing
highdosesoradministrationwithdrugswhichraise
plasmaconcentrationÑseealso
Appendix1(rifamycins);arthralgia,myalgia,inßu-
enza-likesyndrome,dyspnoea;alsohypersensitivity
reactionsincludingfever,rash,eosinophilia,bron-
chospasm,shock;skin,urine,salivaandotherbody
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seeMonitoringinnotesabove;alsoliver
functiontestsandbloodcountsinhepaticdisorders,
andonprolongedtherapy,seealsobelow;acute
porphyria(section9.8.2);
important:
effectivenessof
hormonalcontraceptivesisreducedandalternative
familyplanningadviceshouldbeoffered(seealso
section7.3.1);discolourssoftcontactlenses;seealso
notesabove;
Appendix1(rifamycins)
Iftreatmentinterruptedre-introducewithlowdosage
andincreasegradually;discontinuepermanentlyifserious
side-effectsdevelop
Hepaticdisorders
Childrenandtheircarersshouldbetold
howtorecognisesignsofliverdisorder,andadvisedto
discontinuetreatmentandseekimmediatemedicalattention
ifsymptomssuchaspersistentnausea,vomiting,malaiseor
jaundicedevelop
Contra-indications
Hepaticimpairment
impairedelimination;monitor
liverfunction;avoidordonotexceed8mg/kgdaily;
seealsoCautionsabove
Renalimpairment
usewithcautionifdoseabove
10mg/kgdaily
manufacturersadviseveryhighdosester-
atogenicin
studiesinÞrsttrimester;riskof
neonatalbleedingmaybeincreasedinthirdtrimester;
seealsonotesabove
amounttoosmalltobeharmful;see
alsop.291
gastro-intestinalsymptomsincluding
anorexia,nausea,vomiting,diarrhoea(antibiotic-
associatedcolitisreported);headache,drowsiness;
thoseoccurringmainlyonintermittenttherapy
includeinßuenza-likesymptoms(withchills,fever,
dizziness,bonepain),respiratorysymptoms(includ-
ingshortnessofbreath),collapseandshock,haemo-
lyticanaemia,disseminatedintravascularcoagulation
andacuterenalfailure,thrombocytopenicpurpura;
alterationsofliverfunction,jaundice;ßushing,urti-
caria,andrashes;otherside-effectsreportedinclude
oedema,psychoses,adrenalinsufÞciency,muscular
weaknessandmyopathy,exfoliativedermatitis,toxic
epidermalnecrolysis,Stevens-Johnsonsyndrome,
pemphigoidreactions,leucopenia,eosinophilia,
menstrualdisturbances;urine,saliva,andotherbody
5.1.9Antituberculosisdrugs
BNFC2011–
Infections
Combinedpreparations
Seenotesabove
Rifater
STREPTOMYCIN
seeunderAminoglycosides,section5.1.4;
measureplasma-concentrationinrenalimpairment;
Appendix1(aminoglycosides)
Contra-indications
seeunderAminoglycosides,sec-
tion5.1.4
Renalimpairment
seeunderAminoglycosides,sec-
tion5.1.4
seeunderAminoglycosides,section5.1.4
seeunderAminoglycosides,section
5.1.4;alsohypersensitivityreactions,paraesthesiaof
Byrectum
Child1monthÐ1year
125mg3timesdailyfor3
days,thentwicedailythereafter
hild1Ð5years
250mg3timesdailyfor3days,
thentwicedailythereafter
hild5Ð10years
500mg3timesdaily,for3days,
thentwicedailythereafter
hild10Ð18years
1g3timesdailyfor3days,
thentwicedailythereafter
Byintravenousinfusionover20Ð30minutes
7.5mg/kgevery12hours
Child1Ð2months
7.5mg/kgevery12hours
hild2monthsÐ18years
7.5mg/kg(max.
500mg)every8hours
elvicinßammatorydisease
(seealsoTable1,
section5.1)
Bymouth
Child12Ð18years
400mgtwicedailyfor14days
cuteulcerativegingivitisandotheracute
dentalinfections
Bymouth
Child1Ð3years
50mgevery8hours
hild3Ð7years
100mgevery12hours
hild7Ð10years
100mgevery8hours
hild10Ð18years
200Ð250mgevery8hours
elicobacterpylori
section1.3
urgicalprophylaxis
Bymouth
Child1monthÐ12years
30mg/kg(max.500mg)
2hoursbeforetheprocedure
hild12Ð18years
400Ð500mg2hoursbefore
theprocedure;upto3furtherdosesof400Ð500mg
maybegivenevery8hoursforhigh-riskproce-
Byintravenousinfusion
eonateunder40weekspostmenstrualage
10mg/kgupto30minutesbeforetheprocedure
eonateover40weekspostmenstrualage
30mg/kgupto30minutesbeforetheprocedure
Child1monthÐ12years
30mg/kg(max.500mg)
upto30minutesbeforetheprocedure
hild12Ð18years
500mgupto30minutes
beforetheprocedure;upto3furtherdosesof
500mgmaybegivenevery8hoursforhigh-risk
procedures
Byrectum
Child5Ð10years
500mg2hoursbeforesurgery;
upto3furtherdosesof500mgmaybegivenevery
8hoursforhigh-riskprocedures
hild10Ð18years
1g2hoursbeforesurgery;up
to3furtherdosesof1gmaybegivenevery8
hoursforhigh-riskprocedures
Infections
Contra-indications
Quinolonehypersensitivity.
Quinolonesshouldbeavoidedin
pregnancybecausetheyhavebeenshowntocause
arthropathyin
animal
studies;saferalternativesare
available.
Side-effectsofthequinolonesinclude
nausea,vomiting,dyspepsia,abdominalpain,diarrhoea
(rarelyantibiotic-associatedcolitis),headache,dizzi-
ness,rash(veryrarelyStevens-Johnsonsyndromeand
toxicepidermalnecrolysis).Lessfrequentside-effects
includeanorexia,sleepdisturbances,asthenia,confu-
CIPROFLOXACIN
seenotesabove;avoidexcessivealkalinityof
urineandensureadequateßuidintake(riskofcrys-
Appendix1(quinolones)
Skilledtasks
Mayimpairperformanceofskilledtasks(e.g.
Contra-indications
seenotesabove
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan30mL/minute/
1.73m
Ñconsultproductliterature
seenotesabove
amountprobablytoosmalltobe
harmfulbutmanufactureradvisesavoid
seenotesabove;alsoßatulence,painand
phlebitisatinjectionsite;
dysphagia,pancreat-
itis,chestpain,tachycardia,syncope,oedema,hot
ßushes,abnormaldreams,sweating,hyperglycaemia,
anderythemanodosum;
veryrarely
movementdis-
orders,tinnitus,vasculitis,andtenosynovitis
Licenseduse
licensedforuseinchildrenover1year
forcomplicatedurinary-tractinfections,forpseu-
domonallowerrespiratory-tractinfectionsincystic
Þbrosis,forprophylaxisandtreatmentofinhala-
tionalanthrax;licensedforuseinchildrenover1
yearforotherinfectionswherethebeneÞtiscon-
sideredtooutweighthepotentialrisks;notlicensed
foruseinchildrenforgastro-intestinalanthrax;not
licensedforuseinchildrenforprophylaxisof
meningococcalmeningitis;notlicensedforusein
childrenunder1yearofage
Indicationanddose
omplicatedurinary-tractinfections
Bymouth
10mg/kgtwicedaily
Child1monthÐ18years
10mg/kgtwicedaily;
dosedoubledinsevereinfection(max.750mg
twicedaily)
Byintravenousinfusionover60minutes
6mg/kgevery12hours
Child1monthÐ18years
6mg/kgevery8hours;
increasedto10mg/kgevery8hoursinsevere
infection(max.400mgevery8hours)
evererespiratory-tractinfections,gastro-
intestinalinfections;seenotesabove
Bymouth
15mg/kgtwicedaily
Child1monthÐ18years
20mg/kg(max.750mg)
twicedaily
Byintravenousinfusionover60minutes
10mg/kgevery12hours
Child1monthÐ18years
10mg/kg(max.400mg)
every8hours
seudomonallowerrespiratory-tractinfection
incysticÞbrosis
Bymouth
Child1monthÐ18years
20mg/kg(max.750mg)
twicedaily
Byintravenousinfusionover60minutes
Child1monthÐ18years
10mg/kg(max.400mg)
every8hours
Bymouth
Child12Ð18years
500mgasasingledose
nthrax(treatmentandpost-exposureprophy-
laxis,seenotesabove)
Bymouth
Child1monthÐ18years
15mg/kg(max.500mg)
twicedaily
Byintravenousinfusionover60minutes
Child1monthÐ18years
10mg/kg(max.400mg)
every12hours
yeinfections
section11.3.1
rophylaxisofmeningococcalmeningitis
Table
2,section5.1
Ciproßoxacin
Infections
Intravenousinfusion
,ciproßoxacin(aslactate)
NALIDIXICACID
seenotesabove;avoidinacuteporphyria
(section9.8.2);falsepositiveurinaryglucose(iftested
forreducingsubstances);monitorbloodcounts,renal
andliverfunctioniftreatmentexceeds2weeks;
Appendix1(quinolones)
Contra-indications
seenotesabove
Hepaticimpairment
manufactureradvisescautionin
liverdisease
Renalimpairment
usewithcaution;avoidifesti-
matedglomerularÞltrationratelessthan20mL/
minute/1.73m
seenotesabove
risktoinfantverysmallbutonecase
ofhaemolyticanaemiareported
seenotesabove;alsoreportedtoxic
psychosis,increasedintracranialpressure,cranial
ModiÞedrelease
Capsules
,m/r,blue/yellow,nitrofurantoin100mg
(asnitrofurantoinmacrocrystalsandnitrofurantoin
Infections
(section5.2.1)isanalternativefor
Candida
albicans
infectioninclinicallystablechildrenwhohave
notreceivedanazoleantifungalrecently.Amphotericin
shouldbeconsideredfortheinitialtreatmentofCNS
candidiasis.
Voriconazole
(section5.2.1)canbeused
forinfectionscausedbyßuconazole-resistant
Candida
spp.whenoraltherapyisrequired,orinchildrenintol-
erantofamphotericinoranechinocandin.Inrefractory
cases,
ucytosine
(section5.2.5)canbeusedwith
intravenousamphotericin.
Cryptococcosis
Cryptococcosisisuncommonbut
infectionintheimmunocompromised,especiallyHIV-
positivechildren,canbelife-threatening;cryptococcal
meningitisisthemostcommonformoffungalmening-
itis.Thetreatmentofchoiceincryptococcalmeningitis
amphotericin
(section5.2.3)byintravenousinfusion
ucytosine
(section5.2.5)byintravenousinfusion
for2weeks,followedby
uconazole
(section5.2.1)by
mouthfor8weeksoruntilculturesarenegative.In
FLUCONAZOLE
concomitantusewithhepatotoxicdrugs,
monitorliverfunctionwithhighdosesorextended
coursesÑdiscontinueifsignsorsymptomsofhepatic
disease(riskofhepaticnecrosis);susceptibilitytoQT
intervalprolongation;
Appendix1
(antifungals,triazole)
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
toxicitywithrelateddrugs
Renalimpairment
usualinitialdosethenhalvesub-
sequentdosesifestimatedglomerularÞltrationrate
lessthan50mL/minute/1.73m
BNFC2011–
5.2.1Triazoleantifungals
manufactureradvisesavoidÑmultiple
congenitalabnormalitiesreportedwithlong-term
highdoses
presentinmilkbutamountprobably
toosmalltobeharmful
nausea,abdominaldiscomfort,diarr-
hoea,ßatulence,headache,rash(discontinuetreat-
mentormonitorcloselyifinfectioninvasiveorsys-
temic);lessfrequentlydyspepsia,vomiting,taste
disturbance,hepaticdisorders,angioedema,anaphy-
laxis,dizziness,seizures,alopecia,pruritus,toxicepi-
dermalnecrolysis,Stevens-Johnsonsyndrome
(severecutaneousreactionsmorelikelyinAIDS
patients),hyperlipidaemia,leucopenia,thrombocyto-
penia,andhypokalaemiareported
Licenseduse
notlicensedfortineainfectionsin
children,orforvaginalcandidiasisingirlsunder16
years,orforpreventionofrelapseofcryptococcal
Capsulescanbesoldtothepublicforvaginalcandidiasis
andassociatedcandidalbalanitisinthoseaged16Ð18
years,inacontainerorpackagingcontainingnotmore
than150mgandlabelledtoshowamax.doseof150mg
5.2.1Triazoleantifungals
BNFC2011–
Infections
35mL=£16.61;200mg/5mL,35mL=£66.42.
Label:9
DentalprescribingonNHS
MaybeprescribedasFlucon-
azoleOralSuspension50mg/5mL
Intravenousinfusion
,ßuconazole2mg/mLinsod-
ITRACONAZOLE
absorptionreducedinAIDSandneutropenia
(monitorplasma-itraconazoleconcentrationand
increasedoseifnecessary);susceptibilitytoconges-
tiveheartfailure(seealsoHeartFailure,below);
Appendix1(antifungals,triazole)
Hepatotoxicity
Potentiallylife-threateninghepatotoxicity
reportedveryrarelyÑdiscontinueifsignsofhepatitis
develop.Avoidorusewithcautionifhistoryofhepatotoxi-
citywithotherdrugsorinactiveliverdisease.Monitorliver
functioniftreatmentcontinuesforlongerthanonemonth,if
receivingotherhepatotoxicdrugs,ifhistoryofhepatotoxicity
withotherdrugs,orinhepaticimpairment
Counselling
Childrenortheircarersshouldbetoldhowto
recognisesignsofliverdisorderandadvisedtoseekprompt
medicalattentionifsymptomssuchasanorexia,nausea,
vomiting,fatigue,abdominalpainordarkurinedevelop
Heartfailure
Followingreportsofheartfailure,cautionisadvised
whenprescribingitraconazoletopatientsathighrisk
ofheartfailure.Thoseatriskinclude:
patientsreceivinghighdosesandlongertreatment
courses;
thosewithcardiacdisease;
patientsreceivingtreatmentwithnegativeinotropicdrugs,
e.g.calciumchannelblockers.
Itraconazoleshouldbeavoidedinpatientswithventri-
culardysfunctionorahistoryofheartfailureunless
theinfectionisserious.
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
useonlyifpotentialbeneÞtout-
weighsriskofhepatotoxicity(seeHepatotoxicity
above);dosereductionmaybenecessary
Renalimpairment
riskofcongestiveheartfailure;
bioavailabilityoforalformulationspossiblyreduced;
useintravenousinfusionwithcautionifestimated
glomerularÞltrationrate30Ð80mL/minute/1.73m
(monitorrenalfunction);avoidintravenousinfusionif
estimatedglomerularÞltrationratelessthan30mL/
minute/1.73m
manufactureradvisesuseonlyinlife-
threateningsituations(toxicityathighdosesin
ani-
studies);ensureeffectivecontraceptionduring
treatmentanduntilthenextmenstrualperiodfol-
lowingendoftreatment
smallamountspresentinmilkÑmay
accumulate;manufactureradvisesavoid
nausea,abdominalpain,rash;
lesscom-
vomiting,dyspepsia,tastedisturbances,ßatu-
lence,diarrhoea,constipation,oedema,headache,
dizziness,paraesthesia(discontinuetreatmentif
neuropathy),menstrualdisorder,andalopecia;
rarely
pancreatitis,hypoaesthesia,urinaryfrequency,leuco-
penia,visualdisturbances,andtinnitus;alsoreported,
heartfailure(seeCautionsabove),hypertriglyceri-
daemia,hepatitis(seeHepatotoxicityabove),erectile
dysfunction,thrombocytopenia,hypokalaemia,myal-
gia,arthralgia,photosensitivity,toxicepidermal
necrolysis,andStevens-JohnsonSyndrome;
intravenousinjection
hypertensionandhyperglyc-
Licenseduse
capsulesand
arenotlicensedforuseinchildrenunder12
years;
liquidand
arenotlicensedforuseinchildren(agerangenot
speciÞedbymanufacturer)
Indicationanddose
ropharyngealcandidiasis
Bymouth
Child1monthÐ12years
3Ð5mg/kgoncedaily;
max.100mgdaily(200mgdailyinAIDSorneu-
tropenia)for15days
hild12Ð18years
100mgoncedaily(200mg
oncedailyinAIDSorneutropenia)for15days
ityriasisversicolor
Bymouth
Child1monthÐ12years
3Ð5mg/kg(max.
200mg)oncedailyfor7days
hild12Ð18years
200mgoncedailyfor7days
ineacorporisandtineacruris
Bymouth
Child1monthÐ12years
3Ð5mg/kg(max.
100mg)oncedailyfor15days
hild12Ð18years
100mgoncedailyfor15
200mgoncedailyfor7days
ineapedisandtineamanuum
Bymouth
Child1monthÐ12years
3Ð5mg/kg(max.
100mg)oncedailyfor30days
hild12Ð18years
100mgoncedailyfor30
200mgtwicedailyfor7days
ineacapitis
Bymouth
Child1Ð18years
3Ð5mg/kg(max.200mg)daily
for2Ð6weeks
nychomycosis
Bymouth
Child1Ð12years
course(ÔpulseÕ)of5mg/kg
(max.200mg)dailyfor7days;subsequentcourses
repeatedafter21dayintervals;Þngernails2
courses,toenails3courses
hild12Ð18years
200mgoncedailyfor3
course(ÔpulseÕ)of200mgtwicedailyfor
7days,subsequentcoursesrepeatedafter21-day
intervals;Þngernails2courses,toenails3courses
ystemicaspergillosis,candidiasisand
cryptococcosisincludingcryptococcalmening-
itiswhereotherantifungaldrugsinappropriate
orineffective
(limitedinformationavailable)
Bymouth
Child1monthÐ18years
5mg/kg(max.200mg)
oncedaily;increasedininvasiveordisseminated
diseaseandincryptococcalmeningitisto5mg/kg
(max.200mg)twicedaily
BNFC2011–
5.2.1Triazoleantifungals
Byintravenousinfusion
Child1monthÐ18years
2.5mg/kg(max.
200mg)every12hoursfor2days,then2.5mg/kg
(max.200mg)oncedailyformax.12days
istoplasmosis
Bymouth
Child1monthÐ18years
5mg/kg(max.200mg)
1Ð2timesdaily
aintenanceinHIV-infectedpatientstoprevent
relapseofunderlyingfungalinfectionand
prophylaxisinneutropeniawhenstandard
therapyinappropriate
Bymouth
Child1monthÐ18years
5mg/kg(max.200mg)
oncedaily,increasedto5mg/kg(max.200mg)
twicedailyiflowplasma-itraconazoleconcentra-
tion(seeCautions)
rophylaxisofdeepfungalinfections(when
standardtherapyinappropriate)inpatients
withhaematologicalmalignancyorundergoing
bone-marrowtransplantationwhoareexpected
tobecomeneutropenic
Bymouth(liquidpreparationonly)
Child1monthÐ18years
2.5mg/kgtwicedaily
startingbeforetransplantationorbeforechemo-
therapy(takingcaretoavoidinteractionwith
cytotoxicdrugs)andcontinueduntilneutrophil
countrecovers
For
intravenousinfusion
,dilute
250mgwith50mLSodiumChloride0.9%andgive
requisitedosethroughanin-lineÞlter(0.2micron)
over60minutes
VORICONAZOLE
electrolytedisturbances,cardiomyopathy,
bradycardia,symptomaticarrhythmias,historyofQT
intervalprolongation,concomitantusewithother
drugsthatprolongQTinterval;avoidexposureto
sunlight;patientsatriskofpancreatitis;monitorliver
functionbeforetreatmentandduringtreatment;hae-
matologicalmalignancy(increasedriskofhepatic
reactions);monitorrenalfunction;
Appendix1(antifungals,triazole)
Contra-indications
acuteporphyria(section9.8.2)
Hepaticimpairment
inmildtomoderatehepatic
cirrhosisuseusualinitialdosethenhalvesubsequent
doses;noinformationavailableforseverehepatic
cirrhosisÑmanufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
Renalimpairment
intravenousvehiclemayaccumu-
lateifestimatedglomerularÞltrationratelessthan
50mL/minute/1.73m
Ñuseintravenousinfusion
onlyifpotentialbeneÞtoutweighsrisk,andmonitor
Infections
Byintravenousinfusion
Child2Ð12years
7mg/kgevery12hours
(reducedto4mg/kgevery12hoursifnottoler-
ated)formax.6months
hild12Ð18years
6mg/kgevery12hoursfor2
doses,then4mg/kgevery12hours(reducedto
3mg/kgevery12hoursifnottolerated)formax.6
For
intravenousinfusion
,reconstitute
each200mgwith19mLWaterforInjectionstopro-
ducea10mg/mLsolution;dilutedosetoconcentra-
tionof0.5Ð5mg/mLwithGlucose5%
Chloride0.9%andgiveataratenotexceeding3mg/
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Polyeneantifungals
Thepolyeneantifungalsincludeamphotericinandnys-
tatin;neitherdrugisabsorbedwhengivenbymouth.
Nystatinisusedfororal,oropharyngeal,andperioral
infectionsbylocalapplicationinthemouth(section
12.3.2).Nystatinisalsousedfor
Candidaalbicans
infectionoftheskin(section13.10.2)
Amphotericin
byintravenousinfusionisusedforthe
treatmentofsystemicfungalinfectionsandisactive
againstmostfungiandyeasts.Itishighlyproteinbound
(AmphotericinB)
whengivenparenterally,toxicitycommon
(closesupervisionnecessaryandcloseobservation
requiredforatleast30minutesaftertestdose;see
Anaphylaxisbelow);hepaticandrenalfunctiontests,
bloodcountsandplasmaelectrolyte(including
plasma-potassiumandmagnesiumconcentration)
monitoringrequired;corticosteroids(avoidexceptto
BNFC2011–
5.2.2Imidazoleantifungals
controlreactions);avoidrapidinfusion(riskofarrhy-
Appendix1(amphotericin)
Anaphylaxisoccursrarelywithanyintra-
venousamphotericinproductandatestdoseisadvisable
beforetheÞrstinfusioninchildrenover1monthofage;the
patientshouldbecarefullyobservedforatleast30minutes
Lipidformulations
Infections
effectiveagainstfungalinfectionsoftheCNS.Forthe
roleofechinocandinantifungalsinthepreventionand
systemictreatmentoffungalinfections,seep.300.
Appendix1(caspofungin)
Hepaticimpairment
usualinitialdose,thenuse70%
ofnormalmaintenancedoseinmoderateimpairment;
noinformationavailableforsevereimpairment
manufactureradvisesavoidunlessessen-
tialÑtoxicityin
animal
presentinmilkin
manufactureradvisesavoid
nausea,diarrhoea,vomiting;tachycardia,
hypotension,ßushing;dyspnoea;headache;hypokal-
aemia,hypomagnesaemia;arthralgia;rash,pruritus,
sweating,injection-sitereactions;
lesscommonly
abdominalpain,dyspepsia,dysphagia,drymouth,
tastedisturbances,anorexia,constipation,ßatulence,
cholestasis,hepaticdysfunction,ascites,palpitation,
arrhythmia,chestpain,heartfailure,thrombophleb-
itis,hypertension,bronchospasm,cough,dizziness,
fatigue,paraesthesia,hypoaesthesia,sleepdistur-
monitorrenalfunction;
Appendix1(micafungin)
Hepatotoxicity
Potentiallylife-threateninghepatotoxicity
reported.MonitorliverfunctionÑdiscontinueifsigniÞcant
andpersistentabnormalitiesinliverfunctiontestsdevelop.
Usewithcautioninhepaticimpairment(avoidifsevere)orif
receivingotherhepatotoxicdrugs.Riskofhepaticside-
effectsgreaterinchildrenunder1yearofage
Hepaticimpairment
usewithcautioninmildto
moderateimpairment;avoidinsevereimpairment;
seealsoHepatotoxicityabove
Renalimpairment
Intravenousinfusion
,powderforreconstitution,
FLUCYTOSINE
blooddisorders;liver-andkidney-function
testsandbloodcountsrequired(weeklyinblood
Appendix1(ßucytosine)
Renalimpairment
liver-andkidney-functiontests
andbloodcountsrequiredweekly;usenormaldose
every12hoursifcreatinineclearance20Ð40mL/
minute;usenormaldoseevery24hoursifcreatinine
clearance10Ð20mL/minute;useinitialnormaldoseif
creatinineclearancelessthan10mL/minuteandthen
adjustdoseaccordingtoplasma-ßucytosineconcen-
teratogenicin
studies;manufac-
tureradvisesuseonlyifpotentialbeneÞtoutweighs
manufactureradvisesavoid
nausea,vomiting,diarrhoea,rashes;less
frequentlycardiotoxicity,confusion,hallucinations,
convulsions,headache,sedation,vertigo,alterations
inliverfunctiontests(hepatitisandhepaticnecrosis
reported),andtoxicepidermalnecrolysis;blooddis-
ordersincludingthrombocytopenia,leucopenia,and
aplasticanaemiareported
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
GRISEOFULVIN
Appendix1(griseofulvin)
Skilledtasks
Mayimpairperformanceofskilledtasks;
effectsofalcoholenhanced
Contra-indications
systemiclupuserythematosus
(riskofexacerbation);acuteporphyria(section9.8.2)
Hepaticimpairment
avoidinsevereliverdisease
Infections
ineacapitiscausedby
Trichophytontonsurans
Bymouth
Child1monthÐ12years
15Ð20mg/kg(max.1g)
oncedailyorindivideddoses
hild12Ð18years
1goncedailyorindivided
Griseofulvin
psoriasis(riskofexacerbation);autoimm-
munedisease(riskoflupus-erythematosus-likeeffect)
Appendix1(terbinaÞne)
Hepaticimpairment
manufactureradvisesavoidÑ
eliminationreduced
Renalimpairment
usehalfnormaldoseifestimated
glomerularÞltrationratelessthan50mL/minute/
1.73m
andnosuitablealternativeavailable
manufactureradvisesuseonlyifbeneÞt
outweighsriskÑnoinformationavailable
avoidÑpresentinmilk
abdominaldiscomfort,anorexia,nausea,
diarrhoea;headache;rashandurticariaoccasionally
witharthralgiaormyalgia;
lesscommonly
tastedis-
rarely
livertoxicity(includingjaundice,
cholestasisandhepatitis)Ñdiscontinuetreatment,
angioedema,dizziness,malaise,paraesthesia,
hypoaesthesia,photosensitivity,seriousskinreactions
(includingStevens-Johnsonsyndromeandtoxicepi-
dermalnecrolysis)Ñdiscontinuetreatmentifpro-
gressiveskinrash;
veryrarely
psychiatricdistur-
bances,blooddisorders(includingincidenceof
leucopeniahigherandthrombocytopenia),lupus
erythematosus-likeeffect,andexacerbationofpsor-
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ermatophyteinfectionsofthenails,ringworm
infections(includingtineapedis,cruris,cor-
poris,andcapitis)whereoraltherapyappro-
priate(duetosite,severityorextent)
Bymouth
Childover1year;body-weight10Ð20kg
62.5mgoncedaily
hildbody-weight20Ð40kg
125mgoncedaily
hildbody-weightover40kg
250mgoncedaily
treatmentusuallyfor4weeksintineacapitis,2Ð6
weeksintineapedis,2Ð4weeksintineacruris,4weeksin
tineacorporis,6weeksÐ3monthsinnailinfections
(occasionallylongerintoenailinfections)
ungalskininfections
section13.10.2
TerbinaÞne
Association(CHIVA)
www.chiva.org.uk
;andfurther
establishedbeforestartingtreatmentorbeforeswitch-
ingdrugsiftheinfectionisnotresponding.
Initiationoftreatment
Treatmentisstartedinall
HIVinfectedchildrenunder1yearofageregardlessof
intheUK.Thesedrugsmayinteractwithanumberof
Infections
linresistanceandhyperglycaemiaoccuronlyrarelyin
Fatredistribution(withlossofsubcutaneousfat,
increasedabdominalfat,ÔbuffalohumpÕandbreast
enlargement)isassociatedwithregimenscontaining
proteaseinhibitorsandnucleosidereversetranscriptase
inhibitors.Stavudine,andtoalesserextentzidovudine,
areassociatedwithahigherriskoflipoatrophyand
shouldbeusedonlyifalternativeregimensarenot
suitable.
ABACAVIR
seenotesabove;alsotestforHLA-B*5701
allelebeforetreatment(orifre-startingtreatmentand
HLA-B*5701statusnotknown)Ñincreasedriskof
hypersensitivityreactioninpresenceofHLA-B*5701
Appendix1(abacavir)
Hypersensitivityreactions
Life-threateninghypersensi-
tivityreactionsreportedÑcharacterisedbyfeverorrashand
possiblynausea,vomiting,diarrhoea,abdominalpain,dys-
A
Withlamivudine
Forcautions,contra-indicationsandside-effectssee
underindividualdrugs
Withlamivudineandzidovudine
useonlyifchildisstabilised(for6Ð8weeks)onthe
individualcomponentsinthesameproportions.Forcau-
tions,contra-indicationsandside-effectsseeunderindivi-
dualdrugs
Trizivir
(ddI,DDI)
seenotesabove;alsohistoryofpancreatitis
(preferablyavoid,otherwiseextremecaution,seealso
below);peripheralneuropathyorhyperuricaemia(see
underSide-effects);ophthalmologicalexamination
(includingvisualacuity,colourvision,anddilated
fundusexamination)recommendedannuallyorif
visualchangesoccur;
Appendix1
Ifsymptomsofpancreatitisdeveloporifserum
lipaseisraisedandpancreatitisisconÞrmed,discontinue
treatment.Wheneverpossibleavoidconcomitanttreatment
withotherdrugsknowntocausepancreatictoxicity(e.g.
seenotesabove;alsopancreatitis(less
commoninchildren,seealsounderCautions),liver
failure,anaphylacticreactions,peripheralneuropathy
EMTRICITABINE
seenotesabove;alsoondiscontinuation,
monitorpatientswithhepatitisB(riskofexacerbation
ofhepatitis);
Appendix1(emtricitabine)
Hepaticimpairment
seenotesaboveandCautions
Renalimpairment
reducedoseorincreasedosage
intervalifestimatedglomerularÞltrationrateless
than50mL/minute/1.73m
;consultproductlitera-
manufactureradvisesuseonlyifessen-
tialÑnoinformationavailable
seep.310
seenotesabove;alsoabnormaldreams,
pruritus,andhyperpigmentation
Indicationanddose
Seepreparations
5.3.1HIVinfection
BNFC2011–
Infections
Capsules
Withtenofovir
SeeunderTenofovir
Withefavirenzandtenofovir
SeeunderTenofovir
seenotesabove;
Appendix1
(lamivudine)
ChronichepatitisB
Recurrenthepatitisinpatientswith
chronichepatitisBmayoccurondiscontinuationoflami-
vudine.WhentreatingchronichepatitisBwithlamivudine,
monitorliverfunctiontestsevery3months,andviraland
serologicalmarkersofhepatitisBevery3Ð6months,more
frequentlyinpatientswithadvancedliverdiseaseorfollow-
ingtransplantation(monitoringtocontinueforatleast1year
afterdiscontinuation)
Hepaticimpairment
seenotesaboveandCautions
Renalimpairment
reducedoseifestimatedglom-
erularÞltrationratelessthan50mL/minute/1.73m
consultproductliterature
seep.310
canbeusedwithcautioninwomen
infectedwithchronichepatitisBalone,providing
adequatemeasuresaretakentopreventhepatitisB
infectionininfants;forwomeninfectedwithHIV,see
p.310
seenotesabove;alsoperipheralneuro-
pathy,muscledisordersincludingrhabdomyolysis,
nasalsymptoms,alopecia
Licenseduse
notlicensedforuseinchil-
drenunder3months;
notlicensedforusein
Indicationanddose
Seepreparations
Oralsolution
,banana-andstrawberry-ßavoured,
Withabacavir
SeeunderAbacavir
Withzidovudine
SeeunderZidovudine
Withabacavirandzidovudine
SeeunderAbacavir
STAVUDINE
seenotesabove;alsohistoryofperipheral
neuropathy,excessivealcoholintake,concomitant
useofisoniazidÑriskofperipheralneuropathy(see
underSide-effects);historyofpancreatitisorconco-
mitantusewithotherdrugsassociatedwithpan-
Appendix1(stavudine)
Hepaticimpairment
seenotesabove
Renalimpairment
riskofperipheralneuropathy;
reducedoseto50%ifestimatedglomerularÞltration
rate25Ð50mL/minute/1.73m
;reducedoseto25%
ifestimatedglomerularÞltrationratelessthan25mL/
minute/1.73m
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
seep.310
BNFC2011–
5.3.1HIVinfection
seenotesabove;alsoperipheralneuro-
TENOFOVIRDISOPROXIL
seenotesabove;alsotestrenalfunctionand
serumphosphatebeforetreatment,thenevery4
weeks(morefrequentlyifatincreasedriskofrenal
impairment)for1yearandthenevery3months,
Withemtricitabine
For
,and
side-effects
seeunderindividualdrugs
Truvada
Withefavirenzandemtricitabine
For
,and
side-effects
seeunderindividualdrugs
(Azidothymidine,AZT)
Infections
Indicationanddose
IVinfectionincombinationwithotheranti-
Withlamivudine
For
,and
side-effects
seeunderindividualdrugs
Combivir
Withabacavirandlamivudine
SeeunderAbacavir
Proteaseinhibitors
Proteaseinhibitorsshouldbeusedwith
ATAZANAVIR
seenotesabove;concomitantusewithdrugs
thatprolongPRinterval;cardiacconductiondisor-
ders;predispositiontoQTintervalprolongation
(includingelectrolytedisturbances,concomitantuse
ofdrugsthatprolongQTinterval);
Appendix1(atazanavir)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsousewith
cautioninmildimpairment;avoidinmoderateto
severeimpairment
manufactureradvisesuseonlyifpotential
Indicationanddose
IVinfectionincombinationwithotheranti-
DARUNAVIR
seenotesabove;alsosulfonamidesensitiv-
ity;monitorliverfunctionbeforeandduringtreat-
Appendix1(daruanvir)
Mildtomoderaterashoccurscommonly,usually
withintheÞrst4weeksoftherapyandresolveswithout
stoppingtreatment.Severeskinrash(includingStevens-
Johnsonsyndromeandtoxicepidermalnecrolysis)occurs
lessfrequentlyandmaybeaccompaniedbyfever,malaise,
arthralgia,myalgia,orallesions,conjunctivitis,hepatitis,or
eosinophilia;treatmentshouldbestoppedifsevererash
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsomanufac-
tureradvisescautioninmildtomoderateimpairment;
avoidinsevereimpairmentÑnoinformationavailable
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑnoinformationavailable
seep.310
seenotesabove;alsohaematemesis,
myocardialinfarction,chestpain,QTintervalpro-
longation,syncope,bradycardia,tachycardia,palpi-
tation,hypertension,ßushing,peripheraloedema,
240-tabpack=£446.70;400mg(lightorange),60-tab
pack=£297.80;600mg(orange),60-tabpack=
£446.70.Label:21
FOSAMPRENAVIR
Fosamprenavirisapro-drugofamprenavir
seenotesabove;
Appendix1
(fosamprenavir)
Rashmayoccur,usuallyinthesecondweekoftherapy;
discontinuepermanentlyifsevererashwithsystemicor
allergicsymptomsor,mucosalinvolvement;ifrashmildor
moderate,maycontinuewithoutinterruptionÑusually
resolveswithin2weeksandmayrespondtoantihistamines
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsomanufac-
tureradvisescautioninmildimpairment;reducedose
inmoderatetosevereimpairment
toxicityin
animal
studies;manufacturer
advisesuseonlyifpotentialbeneÞtoutweighsrisk
seep.310
seenotesabove;alsoreported,rash
includingrarelyStevens-Johnsonsyndrome(seealso
Rashabove)
Indicationanddose
IVinfectionincombinationwithotheranti-
LOPINAVIRWITHRITONAVIR
seenotesabove;concomitantusewithdrugs
thatprolongQTorPRinterval;cardiacconduction
disorders,structuralheartdisease;pancreatitis(see
Appendix1(lopinavir,ritonavir)
Signsandsymptomssuggestiveofpancreatitis
(includingraisedserumlipase)shouldbeevaluatedÑdis-
continueifpancreatitisdiagnosed
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsoavoidoral
solutionÑhighpropyleneglycolcontent;manufac-
Infections
seenotesandCautionsabove;also
electrolytedisturbances;
lesscommonly
NELFINAVIR
seenotesabove;
Appendix1
(nelÞnavir)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsomanufac-
tureradvisescaution
Renalimpairment
manufactureradvisescaution
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑnoinformationavailable
seep.310
seenotesabove;alsoreported,fever
Licenseduse
notlicensedforuseinchildrenunder3
years
Indicationanddose
IVinfectionincombinationwithotheranti-
RITONAVIR
seenotesabove;concomitantusewithdrugs
thatprolongPRinterval;cardiacconductiondisor-
ders,structuralheartdisease;pancreatitis(seebelow);
Appendix1(ritonavir)
Signsandsymptomssuggestiveofpancreatitis
(includingraisedserumlipase)shouldbeevaluatedÑdis-
continueifpancreatitisdiagnosed
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsoavoidin
decompensatedliverdisease;insevereimpairment
withoutdecompensation,useÔboosterÕdoseswith
caution(avoidtreatmentdoses)
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑtoxicityin
animal
seep.310
seenotesandCautionsabove;also
diarrhoea(mayimpairabsorptionÑclosemonitoring
required),vasodilatation,cough,throatirritation,
ow-doseritonavirtoincreasetheeffectof
Bymouth
Child2Ð12years
150mg/m
(max.200mg)
twicedaily
hild12Ð18years
200mgtwicedaily
Norvir
Withlopinavir
SeeunderLopinavirwithritonavir
SAQUINAVIR
seenotesabove;monitorECGbeforestart-
ingtreatmentandthenonday3or4oftreatmentÑ
discontinueifQTintervalover480milliseconds,ifQT
intervalmorethan20millisecondsabovebaseline,or
ifprolongationofPRinterval;concomitantuseof
garlic(avoidgarliccapsulesÑreducesplasma-saqui-
navirconcentration);
Appendix1
(saquinavir)
Counselling
Childrenandtheircarersshouldbetoldhowto
recognisesignsofarrhythmiaandadvisedtoseekmedical
attentionifsymptomssuchaspalpitationorsyncope
Contra-indications
seenotesabove;predispositionto
cardiacarrhythmias(includingcongenitalQTpro-
longation,bradycardia,historyofsymptomatic
arrhythmias,heartfailurewithreducedleftventricular
ejectionfraction,electrolytedisturbances,concomi-
tantuseofdrugsthatprolongQTorPRinterval);
concomitantuseofdrugsthatincreaseplasma-
saquinavirconcentration(avoidunlessnoalternative
treatmentavailable)
Hepaticimpairment
seenotesabove;alsomanufac-
tureradvisescautioninmoderateimpairment;avoid
indecompensatedliverdisease
Renalimpairment
usewithcautionifestimated
glomerularÞltrationratelessthan30mL/minute/
1.73m
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
seep.310
seenotesabove;alsodyspnoea,
IVinfectionincombinationwithotheranti-
TIPRANAVIR
seenotesabove;alsopatientsatriskof
increasedbleedingfromtrauma,surgery,orother
pathologicalconditions;concomitantuseofdrugs
thatincreaseriskofbleeding;
Appendix
1(tipranavir)
Hepatotoxicity
Potentiallylife-threateninghepatotoxicity
reported;monitorliverfunctionbeforetreatmentthenevery
2weeksfor1month,thenevery3months.Discontinueif
signsorsymptomsofhepatitisdeveloporifliver-function
abnormalitydevelops(consultproductliterature)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove;alsomanufac-
tureradvisescautioninmildimpairment;avoidin
moderateorsevereimpairmentÑnoinformation
available
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑtoxicityin
animal
seep.310
seenotesabove;alsodyspnoea,ano-
rexia,peripheralneuropathy,inßuenza-likesymp-
toms,renalimpairment,andphotosensitivity;
dehydration
Indicationanddose
IVinfectionresistanttootherproteaseinhi-
Infections
Non-nucleosidereversetranscriptase
EFAVIRENZ
historyofmentalillnessorseizures;monitor
liverfunctionifreceivingotherhepatotoxicdrugs;
Appendix1(efavirenz)
Rash,usuallyintheÞrst2weeks,isthemostcommon
side-effect;discontinueifsevererashwithblistering,des-
quamation,mucosalinvolvementorfever;ifrashmildor
moderate,maycontinuewithoutinterruptionÑusually
resolveswithin1month
Psychiatricdisorders
Childrenortheircarersshouldbe
advisedtoseekimmediatemedicalattentionifsymptoms
suchasseveredepression,psychosisorsuicidalideation
Contra-indications
acuteporphyria(butseesection
Hepaticimpairment
inmildtomoderateliverdis-
ease,monitorfordose-relatedside-effects(e.g.CNS
effects)andliverfunction;avoidinsevereimpair-
ment;greaterriskofhepaticside-effectsinchronic
hepatitisBorC
Renalimpairment
manufactureradvisescautionin
severerenalfailureÑnoinformationavailable
manufactureradvisesavoid(effective
contraceptionrequiredduringtreatmentandfor12
weeksaftertreatment);useefavirenzonlyifnoalter-
nativeavailable
seep.310
rashincludingStevens-Johnson
syndrome(seeRashabove);abdominalpain,diarr-
Withemtricitabineandtenofovir
SeeunderTenofovir
strophySyndrome,p.310);renalfailure;anaemia;
commonly
pancreatitis,haematemesis,hepatitis,
chestpain,bronchospasm,drowsiness,malaise,
gynaecomastia,blurredvision,drymouth,and
sweating;alsoreported,haemorrhagicstroke;seealso
Osteonecrosis,p.311
Licenseduse
notlicensedforuseinchildren
Indicationanddose
chronichepatitisBorC,highCD4cellcount,
andfemales(allatgreaterriskofhepaticside-effects);
Appendix1(nevirapine)
Hepaticdisease
Potentiallylife-threateninghepatotoxicity
includingfatalfulminanthepatitisreportedusuallyinÞrst6
weeks;closemonitoringrequiredduringÞrst18weeks;
monitorliverfunctionbeforetreatmentthenevery2weeks
for2monthsthenafter1monthandthenregularly;dis-
continuepermanentlyifabnormalitiesinliverfunctiontests
accompaniedbyhypersensitivityreaction(rash,fever,
arthralgia,myalgia,lymphadenopathy,hepatitis,renal
impairment,eosinophilia,granulocytopenia);suspendif
severeabnormalitiesinliverfunctiontestsbutnohyper-
sensitivityreactionÑdiscontinuepermanentlyifsigniÞcant
liverfunctionabnormalitiesrecur;monitorpatientcloselyif
mildtomoderateabnormalitiesinliverfunctiontestswithno
hypersensitivityreaction
Rash,usuallyinÞrst6weeks,ismostcommonside-
effect;incidencereducedifintroducedatlowdoseanddose
increasedgradually;monitorcloselyforskinreactionsduring
Þrst18weeks;discontinuepermanentlyifsevererashorif
rashaccompaniedbyblistering,orallesions,conjunctivitis,
facialoedema,generalmalaiseorhypersensitivityreactions;
ifrashmildormoderatemaycontinuewithoutinterruption
butdoseshouldnotbeincreaseduntilrashresolves
Counselling
Childrenandcarersshouldbetoldhowto
recognisehypersensitivityreactionsandadvisedtodiscon-
tinuetreatmentandseekimmediatemedicalattentionif
severeskinreaction,hypersensitivityreactionsorsymptoms
ofhepatitisdevelop
Contra-indications
acuteporphyria(butseesection
9.8.2);post-exposureprophylaxis
Hepaticimpairment
manufactureradvisescautionin
moderateimpairment;avoidinsevereimpairment;
seealsoHepaticDisease,above
althoughmanufactureradvisescaution,
maybeappropriatetouseifclearlyindicated;seealso
p.310
seep.310
rashincludingStevens-Johnson
syndromeandrarely,toxicepidermalnecrolysis(see
alsoCautionsabove);nausea,hepatitis(seealso
HepaticDiseaseabove),headache;
lesscommonly
vomiting,abdominalpain,fatigue,fever,andmyalgia;
diarrhoea,angioedema,anaphylaxis,hyper-
sensitivityreactions(mayinvolvehepaticreactions
andrash,seeHepaticDiseaseabove),arthralgia,
anaemia,andgranulocytopenia;
veryrarely
psychiatricreactions;seealsoOsteonecrosis,p.311
Licenseduse
Hypersensitivityreactions
Hypersensitivityreactions
includingrash,fever,nausea,vomiting,chills,rigors,low
bloodpressure,respiratorydistress,glomerulonephritis,and
raisedliverenzymesreported;discontinueimmediatelyif
anysignsorsymptomsofsystemichypersensitivitydevelop
anddonotrechallenge
Counselling
Childrenandcarersshouldbetoldhowto
recognisesignsofhypersensitivity,andadvisedtodiscon-
tinuetreatmentandseekpromptmedicalattentionif
symptomsdevelop
Hepaticimpairment
manufactureradvisescautionÑ
noinformationavailable;chronichepatitisBorC
(possiblygreaterriskofhepaticside-effects)
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
seep.310
injection-sitereactions;pancreatitis,
gastro-oesophagealreßuxdisease,anorexia,weight
loss;hypertriglyceridaemia;peripheralneuropathy,
Infections
Indicationanddose
IVinfectionincombinationwithotheranti-
MARAVIROC
cardiovasculardisease;chronichepatitisB
orC;
Appendix1(maraviroc)
Hepaticimpairment
usewithcaution
Renalimpairment
ifestimatedglomerularÞltration
ratelessthan80mL/minute/1.73m
,consultproduct
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑtoxicityin
animal
seep.310
nausea,vomiting,abdominalpain,dys-
pepsia,constipation,diarrhoea;cough;dizziness,
paraesthesia,asthenia,sleepdisturbances,headache,
weightloss;musclespasms,backpain;tastedistur-
bances;rash,pruritus;
lesscommonly
pancreatitis,
hepaticcirrhosis,rectalbleeding,myocardialinfarc-
tion,myocardialischaemia,bronchospasm,seizures,
hallucinations,lossofconsciousness,polyneuropathy,
pancytopenia,neutropenia,lymphadenopathy,renal
failure,polyuria,andmyositis;seealsoOsteonecrosis,
p.311
Licenseduse
notlicensedforuseinchildren
Indicationanddose
CR5ÐtropicHIVinfectionincombinationwith
otherantiretroviraldrugsinchildrenpreviously
RALTEGRAVIR
riskfactorsformyopathyorrhabdomyolysis;
Appendix1(raltegravir)
Hepaticimpairment
chronichepatitisBorC(greater
riskofhepaticside-effects);usewithcautioninsevere
impairmentÑnoinformationavailable
manufactureradvisesavoidÑtoxicityin
seep.310
diarrhoea,nausea,vomiting,abdominal
pain,ßatulence,hypertriglyceridaemia,dizziness,
headache,insomnia,abnormaldreams,asthenia,rash
(Stevens-Johnsonsyndromereported);
lesscom-
gastritis,hepatitis,pancreatitis,drymouth,
gastro-oesophagealreßux,tastedisturbances,painon
swallowing,pepticulcer,constipation,rectalbleeding,
lipodystrophy(seeLipodystrophySyndrome,p.310),
palpitation,ventricularextrasystoles,bradycardia,
hypertension,ßushing,chestpain,oedema,dyspho-
5.3.2.1
HerpessimplexandvaricellaÐ
zosterinfection
Thetwomostimportantherpesviruspathogensare
herpessimplexvirus(herpesvirushominis)andvari-
cellaÐzostervirus.
Herpessimplexinfections
Herpesinfectionofthe
mouthandlipsandintheeyeisgenerallyassociated
withherpessimplexvirusserotype1(HSV-1);other
areasoftheskinmayalsobeinfected,especiallyin
immunodeÞciency.Genitalinfectionismostoftenasso-
ciatedwithHSV-2andalsoHSV-1.Treatmentofherpes
simplexinfectionshouldstartasearlyaspossibleand
usuallywithin5daysoftheappearanceoftheinfection.
Inindividualswithgoodimmunefunction,mildinfec-
tionoftheeye(ocularherpes,section11.3.3)andofthe
lips(herpeslabialisorcoldsores,section13.10.3)is
Specialistadviceshouldbesoughtforsystemictreat-
mentofherpessimplexinfectioninpregnancy.
VaricellaÐzosterinfections
Regardlessofimmune
functionandtheuseofanyimmunoglobulins,neonates
chickenpox
shouldbetreatedwithaparenteral
antiviraltoreducetheriskofseveredisease.Oral
therapyisnotrecommendedasabsorptionisvariable.
ACICLOVIR
maintainadequatehydration(especiallywith
infusionorhighdoses,orduringrenalimpairment);
Appendix1(aciclovir)
Renalimpairment
seeCautionsabove;alsoriskof
neurologicalreactionsincreased;usenormal
doseevery12hoursifestimatedglomerular
Þltrationrate25Ð50mL/minute/1.73m
(every24
hoursifestimatedglomerularÞltrationrate10Ð
25mL/minute/1.73m
);consultproductliteraturefor
intravenousdoseifestimatedglomerularÞltration
ratelessthan10mL/minute/1.73m
.For
,usenormaloraldoseevery8hoursifesti-
matedglomerularÞltrationrate10Ð25mL/minute/
1.73m
(every12hoursifestimatedglomerularÞl-
trationratelessthan10mL/minute/1.73m
).For
herpessimplex
,usenormaloraldoseevery12hoursif
estimatedglomerularÞltrationratelessthan10mL/
minute/1.73m
notknowntobeharmfulÑmanufacturers
adviseuseonlywhenpotentialbeneÞtoutweighsrisk
signiÞcantamountinmilkaftersys-
temicadministration;notknowntobeharmfulbut
manufacturersadvisecaution
nausea,vomiting,abdominalpain,diarr-
hoea,headache,fatigue,rash,urticaria,pruritus,
photosensitivity;
veryrarely
hepatitis,jaundice,dys-
pnoea,neurologicalreactions(includingdizziness,
confusion,hallucinations,convulsions,ataxia,dysar-
thria,anddrowsiness),acuterenalfailure,anaemia,
thrombocytopenia,andleucopenia;on
intravenous
Infections
Child12Ð18years
5mg/kgevery8hoursusually
for5days,doubledto10mg/kgevery8hoursif
CNSinvolvement(givenforupto21days)orif
immunocompromised
Toavoidexcessivedoseinobesepatientspar-
enteraldoseshouldbecalculatedonthebasisofideal
weightforheight
erpessimplexprophylaxisintheimmuno-
Bymouth
Child1monthÐ2years
100Ð200mg4timesdaily
hild2Ð18years
200Ð400mg4timesdaily
erpessimplexsuppression
Bymouth
Child12Ð18years
400mgtwicedaily
200mg
4timesdaily;increasedto400mg3timesdailyif
recurrencesoccuronstandardsuppressivether-
apyorforsuppressionofgenitalherpesduringlate
pregnancy(from36weeksgestation);therapy
interruptedevery6Ð12monthstoreassessrecur-
rencefrequencyÑconsiderrestartingaftertwoor
morerecurrences
hickenpoxandherpeszosterinfection
Bymouth
Child1monthÐ2years
200mg4timesdailyfor5
hild2Ð6years
400mg4timesdailyfor5days
hild6Ð12years
800mg4timesdailyfor5days
hild12Ð18years
800mg5timesdailyfor7days
Byintravenousinfusion
10Ð20mg/kgevery8hoursforatleast7
Child1Ð3months
10Ð20mg/kgevery8hoursfor
atleast7days
hild3monthsÐ12years
250mg/m
every8
hoursusuallyfor5days,dosedoubledifimmu-
nocompromised
hild12Ð18years
5mg/kgevery8hoursusually
for5days,dosedoubledifimmunocompromised
Toavoidexcessivedoseinobesepatientspar-
enteraldoseshouldbecalculatedonthebasisofideal
weightforheight
rophylaxisofchickenpoxafterdelivery
notesabove)
Byintravenousinfusion
10mg/kgevery8hours;continueduntil
serologicaltestsconÞrmabsenceofvirus
ttenuationofchickenpoxifvaricellaÐzoster
immunoglobulinnotindicated
Bymouth
Child1monthÐ18years
10mg/kg4timesdaily
for7daysstarting1weekafterexposure
erpesvirusskininfections
section13.10.3
erpesviruseyeinfections
section11.3.3
intravenousinfusion
,reconstitute
to25mg/mLwithWaterforInjectionsorSodium
Chloride0.9%thendilutetoconcentrationof5mg/
mLwithSodiumChloride0.9%
SodiumChloride
andGlucoseandgiveover1hour;alternatively,may
beadministeredinaconcentrationof25mg/mL
usingasuitableinfusionpumpandcentralvenous
accessandgivenover1hour
VALACICLOVIR
Valaciclovirisapro-drugofaciclovir
seeunderAciclovir
Hepaticimpairment
manufactureradvisescaution
withhighdosesusedforpreventingcytomegalovirus
diseaseÑnoinformationavailableinchildren
Renalimpairment
maintainadequatehydration;for
herpeszoster
,1gevery12hoursifestimatedglom-
erularÞltrationrate30Ð50mL/minute/1.73m
(1g
every24hoursifestimatedglomerularÞltrationrate
10Ð30mL/minute/1.73m
;500mgevery24hoursif
estimatedglomerularÞltrationratelessthan10mL/
minute/1.73m
);for
treatmentofherpessimplex
500mg(1ginimmunocompromisedorHIV-positive
children)every24hoursifestimatedglomerular
Þltrationratelessthan30mL/minute/1.73m
;for
treatmentofherpeslabialis
,ifestimatedglomerular
Þltrationrate30Ð50mL/minute/1.73m
,initially1g,
then1g12hoursafterinitialdose(ifestimated
glomerularÞltrationrate10Ð30mL/minute/1.73m
initally500mg,then500mg12hoursafterinitial
BNFC2011–
5.3.2Herpesvirusinfections
dose;ifestimatedglomerularÞltrationratelessthan
10mL/minute/1.73m
,500mgasasingledose);for
suppressionofherpessimplex
,250mg(500mgin
immunocompromisedorHIV-positivechildren)every
24hoursifestimatedglomerularÞltrationrateless
than30mL/minute/1.73m
;reducedoseaccording
toestimatedglomerularÞltrationratefor
cyto-
megalovirusprophylaxis
followingsolidorgantrans-
plantation(consultproductliterature)
seeunderAciclovir
seeunderAciclovir
seeunderAciclovirbutneurological
reactionsmorefrequentwithhighdoses
Licenseduse
notlicensedfortreatmentofherpes
zosterinchildren;notlicensedfortreatmentor
suppressionofherpessimplexinfectioninimmu-
nocompromisedorHIV-positivechildren
Indicationanddose
erpeszosterinimmunocompromised
Bymouth
Child12Ð18years
1g3timesdailyforatleast7
days(continuefor2daysaftercrustingoflesions)
reatmentofherpessimplex
Bymouth
Child12Ð18years
firstepisode,500mgtwice
dailyfor5days,longerifnewlesionsappearduring
5.3.2.2
Cytomegalovirusinfection
Recommendationsfortheoptimummaintenancether-
apyofcytomegalovirus(CMV)infectionsandthedura-
tionoftreatmentaresubjecttorapidchange.
Ganciclovir
isrelatedtoaciclovirbutitismoreactive
againstcytomegalovirus;itisalsomuchmoretoxicthan
aciclovirandshouldthereforebeprescribedunder
specialistsupervisionandonlywhenthepotentialben-
eÞtoutweighstherisks.Ganciclovirisadministeredby
intravenousinfusionforthe
initialtreatment
ofCMV
infection.Theuseofganciclovirmayalsobeconsidered
forsymptomaticcongenitalCMVinfection.Ganciclovir
causesprofoundmyelosuppressionwhengivenwith
zidovudine;thetwoshouldnotnormallybegiven
GANCICLOVIR
closemonitoringoffullbloodcount(severe
Infections
hypotension,anaphylacticreactions,psychosis,tre-
mor,maleinfertility,haematuria,disturbancesin
hearingandvision,andalopecia
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ife-threateningorsight-threateningcyto-
megalovirusinfectionsinimmunocompro-
misedpatientsonly;preventionofcyto-
megalovirusdiseaseduring
immunosuppressivetherapyfollowingorgan
Byintravenousinfusion
Child1monthÐ18years
initially(induction)
5mg/kgevery12hoursfor14Ð21daysfortreat-
mentorfor7Ð14daysforprevention;maintenance
leucopenia,granulocytopenia,thrombocytopenia;
thrombophlebitisifgivenundilutedbyperipheralvein;
genitalirritationandulceration(duetohighconcen-
andtheviralload.Acombinationof
ribavirin
5.3.5)witheither
interferonalfa
(section8.2.4)or
peginterferonalfa-2b
islicensedforuseinchildren
over3yearswithchronichepatitisC.Acombinationof
peginterferonalfa(BNFSection8.2.4)andribavirinis
preferred.
Foradviceonimmunisationagainstinßuenza,seesec-
tion14.4.
Oseltamivir
zanamivir
reducereplicationofinßu-
enzaAandBvirusesbyinhibitingviralneuraminidase.
Theyaremosteffectiveforthetreatmentofinßuenzaif
OSELTAMIVIR
Renalimpairment
reducedoseby50%ifestimated
glomerularÞltrationrate10Ð30mL/minute/1.73m
avoidifestimatedglomerularÞltrationratelessthan
10mL/minute/1.73m
useonlyifpotentialbeneÞtoutweighsrisk
(e.g.duringapandemic);seealsoabove
Nationalsurveillanceschemes,includingthoserunbythe
HealthProtectionAgency,shouldbeusedtoindicatewhen
inßuenzaiscirculatinginthecommunity.
TheDepartmentofHealthinEnglandhasadvised
(November2010)thatÔatriskpatientsÕalsoincludes
femaleswhoarepregnant.
5.3.4Inuenza
BNFC2011–
Infections
amountprobablytoosmalltobe
harmful;useonlyifpotentialbeneÞtoutweighsrisk;
(e.g.duringapandemic);seealsop.326
nausea,vomiting,abdominalpain,diarr-
hoea;headache;conjunctivitis;
lesscommonly
ema;alsoreportedhepatitis,gastro-intestinalbleed-
ing,arrhythmias,neuropsychiatricdisorders,
thrombocytopenia,visualdisturbances,Stevens-
Johnsonsyndrome,andtoxicepidermalnecrolysis
Licenseduse
notlicensedforuseinchildrenunder1
yearunlessthereisapandemic
Indicationanddose
reventionofinßuenza
Bymouth
Childunder1month
(seenotesabove)2mg/kg
oncedailyfor10daysforpost-exposureprophy-
hild1Ð3months
(seenotesabove)2.5mg/kg
oncedailyfor10daysforpost-exposureprophy-
hild3monthsÐ1year
(seenotesabove)3mg/
kgoncedailyfor10daysforpost-exposure
prophylaxis
hild1Ð13years
ody-weightunder15kg
30mgoncedailyfor
10daysforpost-exposureprophylaxis;forupto6
weeksduringanepidemic
ody-weight15Ð23kg
45mgoncedailyfor10
daysforpost-exposureprophylaxis;forupto6
weeksduringanepidemic
ody-weight23Ð40kg
60mgoncedailyfor10
daysforpost-exposureprophylaxis;forupto6
weeksduringanepidemic
ody-weightover40kg
75mgoncedailyfor10
daysforpost-exposureprophylaxis;forupto6
weeksduringanepidemic
hild13Ð18years
75mgoncedailyfor10days
forpost-exposureprophylaxis;forupto6weeks
duringanepidemic
reatmentofinßuenza
Bymouth
Childunder1month
(seenotesabove)2mg/kg
twicedailyfor5days
hild1Ð3months
(seenotesabove)2.5mg/kg
twicedailyfor5days
hild3monthsÐ1year
(seenotesabove)3mg/
kgtwicedailyfor5days
hild1Ð13years
ody-weightunder15kg
30mgtwicedailyfor5
ody-weight15Ð23kg
45mgtwicedailyfor5
ody-weight23Ð40kg
60mgtwicedailyfor5
ody-weightover40kg
75mgtwicedailyfor5
hild13Ð18years
75mgtwicedailyfor5days
ifsuspensionnotavailable,capsules
canbeopenedandthecontentsmixedwithasmall
asthmaandchronicpulmonarydisease(risk
ofbronchospasmÑshort-actingbronchodilator
shouldbeavailable;avoidinsevereasthmaunless
closemonitoringpossibleandappropriatefacilities
availabletotreatbronchospasm);uncontrolled
chronicillness;otherinhaleddrugsshouldbeadmi-
nisteredbeforezanamivir
useonlyifpotentialbeneÞtoutweighsrisk
(e.g.duringapandemic);seealsop.326
amountprobablytoosmalltobe
harmful;useonlyifpotentialbeneÞtoutweighsrisk
(e.g.duringapandemic);seealsop.326
veryrarely
bronchospasm,respiratory
impairment,angioedema,urticaria,andrash;also
reportedneuropsychiatricdisorders,Stevens-Johnson
syndrome,toxicepidermalnecrolysis
Indicationanddose
ost-exposureprophylaxisofinßuenza
Byinhalationofpowder
Child5Ð18years
10mgoncedailyfor10days
reventionofinßuenzaduringanepidemic
Byinhalationofpowder
Child5Ð18years
10mgoncedailyforupto28
reatmentofinßuenza
Byinhalationofpowder
Child5Ð18years
10mgtwicedailyfor5days(for
upto10daysifresistancetooseltamivirsus-
Drypowderforinhalation
diskscontaining4blisters
respiratorysyncytialvirus(RSV)ininfants,especially
whentheyhaveotherseriousdiseases.However,there
isnoevidencethatribavirinproducesclinicallyrelevant
beneÞtinRSVbronchiolitis.Ribavirinisgivenbymouth
withpeginterferonalfaorinterferonalfaforthetreat-
mentofchronichepatitisCinfection(seeViralHepat-
itis,section5.3.3).RibavirinisalsoeffectiveinLassa
feverandhasalsobeenusedparenterallyinthetreat-
mentoflife-threateningRSV,parainßuenzavirus,and
adenovirusinfectionsinimmunocompromisedchildren
[unlicensedindications].
Palivizumab
isamonoclonalantibodylicensedfor
preventingseriouslowerrespiratory-tractdisease
causedbyrespiratorysyncytialvirusinchildrenat
highriskofthedisease;itshouldbeprescribedunder
specialistsupervisionandonthebasisofthelikelihood
ofhospitalisation.
Palivizumabisrecommendedfor:
childrenunder9monthsofagewithchroniclung
disease(deÞnedasrequiringoxygenforatleast28
PALIVIZUMAB
moderatetosevereacuteinfectionorfebrile
illness;thrombocytopenia;serum-palivizumabcon-
centrationmaybereducedaftercardiacsurgery;
hypersensitivitytohumanisedmonoclonalantibodies
fever,injection-sitereactions,nervous-
lesscommonly
diarrhoea,vomiting,constipa-
tion,haemorrhage,rhinitis,cough,wheeze,pain,
drowsiness,asthenia,hyperkinesia,leucopenia,and
rash;alsoreported,apnoea,hypersensitivityreactions
(includinganaphylaxis),convulsionsandthrombocy-
Licenseduse
notlicensedinchildrenwithcongeni-
talimmunodeÞciencyorinchildrenbornat35
weeksgestationorlessandolderthan6months
(licensedinchildrenunder6months)
Indicationanddose
reventionofseriousdiseasecausedbyresp-
iratorysyncytialvirusinfection(seenotes
Byintramuscularinjection(preferablyinante-
rolateralthigh)
15mg/kgonceamonthduringseasonof
RSVrisk
Child1monthÐ2years
15mg/kgonceamonth
duringseasonofRSVrisk(childundergoingcar-
diacbypasssurgery,15mg/kgassoonasstable
aftersurgery,thenonceamonthduringseasonof
risk);injectionvolumeover1mLshouldbedivided
RIBAVIRIN
(Tribavirin)
SpeciÞccautionsforinhaledtreatment
Maintainstandard
supportiverespiratoryandßuidmanagementtherapy;
monitorelectrolytesclosely;monitorequipmentforpreci-
pitation;pregnantwomen(andthoseplanningpregnancy)
shouldavoidexposuretoaerosol
SpeciÞccautionsforsystemictreatment
Exclude
pregnancybeforetreatmentinfemalesofchildbearingage;
effectivecontraceptionessentialduringtreatmentandfor4
monthsaftertreatmentinfemalesandfor7monthsafter
treatmentinmalesofchildbearingage;routinemonthly
pregnancytestsrecommended;condomsmustbeusedif
Infections
ingdecreaseinheightandweight),thyroiddisorders,
hyperglycaemia,menstrualdisturbances,virilism,breast
pain,testicularpain,sexualdysfunction,micturitiondisor-
ders,leucopenia,thrombocytopenia,lymphadenopathy,
dehydration,hypocalcaemia,myalgia,arthralgia,hyperuric-
aemia,visualdisturbances,eyepain,dryeyes,hearing
impairment,tinnitus,earache,drymouth,tastedisturbances,
mouthulcers,stomatitis,glossitis,toothdisorder,gingivitis,
alopecia,pruritus,dryskin,skindiscoloration,rash(includ-
ingveryrarelyStevens-Johnsonsyndromeandtoxicepi-
dermalnecrolysis),increasedsweating,psoriasis,photo-
sensitivity,andacne;
lesscommonly
pancreatitis,gastro-
intestinalbleeding,andhypertriglyceridaemia;
ulcer,arrhythmias,cardiomyopathy,myocardialinfarction,
pericarditis,stroke,interstitialpneumonitis,pulmonary
embolism,seizures,renalfailure,vasculitis,rheumatoid
arthritis,systemiclupuserythematosus,sarcoidosis,optic
withquinine,
Malarone
(proguanilwith
atovaquone),or
Validforquininehydrochloride,dihydrochloride,and
sulphate;notvalidforquininebisulphatewhichcontains
acorrespondinglysmalleramountofquinine.
Inintensivecareunitstheloadingdosecanalternativelybe
givenasquininesalt
7mg/kginfusedover30minutes
followedimmediatelyby10mg/kgover4hoursthen(after
8hours)maintenancedoseasdescribed.
Important:
theloadingdoseof20mg/kgshould
usedifthepatienthasreceivedquinineormeßoquine
duringtheprevious12hours
Maintenancedoseshouldbereducedto5Ð7mg/kgof
quininesalt
inchildrenwithsevererenalimpairment,
severehepaticimpairment,orifparenteraltreatmentis
requiredformorethan48hours.
5.4.1Antimalarials
BNFC2011–
Infections
Benignmalarias(treatment)
Benignmalariaisusuallycausedby
Plasmodiumvivax
andlesscommonlyby
P.ovale
P.malariae
isthedrugofchoiceforthetreatment
ofbenignmalarias(butchloroquine-resistant
P.vivax
infectionhasbeenreportedfromIndonesia,New
Guineaandsomeadjacentislands).
Chloroquinealoneisadequatefor
P.malariae
tionsbutinthecaseof
P.vivax
P.ovale
,a
(todestroyparasitesintheliverandthusprevent
relapses)isrequired.Thisisachievedwith
primaquine
givenafterthechloroquine.
Thedosageregimenofchloroquine
bymouth
forbenign
malariainchildrenis:
initialdoseof10mg/kgofbase(max.620mg)
asingledoseof5mg/kgofbase(max.310mg)after6Ð8
hours
asingledoseof5mg/kgofbase(max.310mg)dailyfor
2days
Fora
radicalcure
primaquine
[unlicensed]isthen
giventochildrenover6monthsofage;specialistadvice
shouldbesoughtforchildrenunder6monthsofage.
Primaquineisgiveninadoseof250micrograms/kg
(max.15mg)dailyfor14daysin
P.ovale
infectionor
500micrograms/kg(max.30mg)dailyfor14daysin
Parenteral
Ifthechildisunabletotakeoraltherapy,
quininecanbegivenby
intravenousinfusion
.Thedose
is10mg/kg
(max.700mg)ofquininesalt
infusedover
4hoursevery8hours,changedtooralchloroquineas
soonasthechildÕsconditionpermits.
Treatmentdosesofchloroquinecanbe
givenforbenignmalaria.Inthecaseof
P.vivax
,however,theradicalcurewithprimaquineshould
untilthepregnancyisover;instead
chloroquineshouldbecontinuedatadoseof10mg/
kg(max.310mg)eachweekduringthepregnancy.
Prophylaxisagainstmalaria
Therecommendationsonprophylaxisreßectguidelines
agreedbyUKmalariaspecialists;theadviceisaimedat
residentsoftheUKwhotraveltoendemicareas.The
choiceofdrugforaparticularchildshouldtakeinto
riskofexposuretomalaria;
extentofdrugresistance;
efÞcacyoftherecommendeddrugs;
side-effectsofthedrugs;
patient-relatedfactors(e.g.age,pregnancy,renalor
hepaticimpairment,compliancewithprophylactic
Prophylacticdosesarebasedonguidelinesagreedby
UKmalariaexpertsandmaydifferfromadvicein
productliterature.
p.329.
Protectionagainstbites
Prophylaxisisnotabso-
,andbreakthroughinfectioncanoccurwithanyof
thedrugsrecommended.Personalprotectionagainst
Forthetreatmentofchloroquine-resistantbenignmalaria
[unlicensedindication],quinine,or
mildG6PDdeÞciency,primaquineinadoseof750micr-
ograms/kg(max.45mg)onceaweekfor8weeks,has
beenfoundusefulandwithoutundueharmfuleffects.
Maintenancedoseshouldbereducedto5Ð7mg/kgof
quininesalt
inchildrenwithsevererenalimpairment,
severehepaticimpairment,orifparenteraltreatmentis
requiredformorethan48hours.
Validforquininehydrochloride,dihydrochloride,and
sulphate;notvalidforquininebisulphatewhichcontains
acorrespondinglysmalleramountofquinine.
BNFC2011–
5.4.1Antimalarials
Asplenicchildren(orthosewithsevere
splenicdysfunction)areatparticularriskofsevere
malaria.Iftraveltomalariousareasisunavoidable,
rigorousprecautionsarerequiredagainstcontracting
thedisease.
Renalimpairment
Avoidance(ordosagereduction)
Infections
NovemberÐJuneinotherareasbelow1200m;riskneg-
ligibleinHarareandBulawayo):
meßoquine
doxycycline(ifchildover12)
Malarone
CentralandSouthAmericaandthe
Caribbean
Verylowrisk
verylow
inJamaica:
chemoprophylaxisnotrecommendedbutavoid
mosquitobitesandconsidermalariaiffeverpre-
Variabletolowrisk
variabletolow
inArgentina
(ruralareasalongnorthernbordersonly),ruralBelize
(exceptBelizedistrict),CostaRica(LimonProvince
exceptPuertoLimonandnortherncantonofPococci),
DominicanRepublic,ElSalvador(SantaAnaprovincein
west),Guatemala(below1500m),Haiti,Honduras,
Mexico(statesofOaxacaandChiapas),Nicaragua,
Panama(westofPanamaCanalbut
variabletohigh
eastofPanamaCanal,seebelow),ruralParaguay:
(ifchloroquinenotappropriate)pro-
guanilhydrochloride
Variabletohighrisk
variabletohighand
chloroquineresistancepresent
inruralareasofBolivia
(below2500m;seebelowforAmazonbasinarea),
Ecuador(below1500m;nomalariainGalapagos
IslandsandGuayaquil;seebelowforEsmeraldasPro-
vince),Panama(eastofPanamaCanal),Peru(rural
areaseastoftheAndesandwestoftheAmazonbasin
areabelow1500m;seebelowforAmazonbasinarea),
Venezuela(northofOrinocoriver;
highrisk
southofand
includingOrinocoriverandAmazonbasinarea,see
below;Caracasfreeofmalaria):
chloroquine+proguanilhydrochloride
chloroquine+proguanilnotappropriate)meßo-
doxycycline(ifchildover12)
orMalarone
Highrisk
markedchloroquineresis-
inBolivia(Amazonbasinarea;seealso
variableto
highrisk
above),Brazil(throughoutÔLegalAmazonÕarea
whichincludestheAmazonbasinarea,MatoGrosso
andMaranhaoonly;elsewhere
verylowrisk
Ñnoche-
moprophylaxis),Colombia(mostareasbelow800m),
Ecuador(EsmeraldasProvince;
variabletohighrisk
otherareas,seeabove),FrenchGuiana,allinterior
regionsofGuyana,Peru(Amazonbasinarea;seealso
variabletohighrisk
above),Suriname(exceptParamar-
iboandcoast),Venezuela(Amazonbasinarea,areas
southofandincludingOrinocoriver;seealso
variable
tohighrisk
above):
meßoquine
doxycycline(ifchildover12)
Malarone
Standbytreatment[unlicensed]
Childrenandtheircarersvisitingremote,malarious
areasforprolongedperiodsshouldcarrystandby
treatmentiftheyarelikelytobemorethan24hours
awayfrommedicalcare.Self-medicationshouldbe
avoided
ifmedicalhelpisaccessible.
Inordertoavoidexcessiveself-medication,the
travellershouldbeprovidedwith
writteninstruc-
thaturgentmedicalattentionshouldbesought
iffever(38
Cormore)develops7days(ormore)
afterarrivinginamalariousareaandthatself-treat-
mentisindicatedifmedicalhelpisnotavailable
Infections
CHLOROQUINE
mayexacerbatepsoriasis,neurologicaldis-
orders(avoidforprophylaxisifhistoryofepilepsy,see
notesabove),mayaggravatemyastheniagravis,
severegastro-intestinaldisorders,G6PDdeÞciency
(seesection9.1.5);ophthalmicexaminationwithlong-
termtherapy;avoidconcurrenttherapywithhepato-
toxicdrugsÑother
Appendix1
(chloroquineandhydroxychloroquine)
Hepaticimpairment
usewithcautioninmoderateto
severeimpairment
Renalimpairment
manufacturersadvisecaution;see
alsoProphylaxisAgainstMalaria,p.332
beneÞtofprophylaxisandtreatmentin
malariaoutweighsrisk;seealsoBenignMalarias
(treatment),p.331andProphylaxisAgainstMalaria,
p.332
amountinmilkprobablytoosmallto
beharmful;seealsoProphylaxisAgainstMalaria,
p.332
gastro-intestinaldisturbances,headache;
alsohypotension,convulsions,visualdisturbances,
depigmentationorlossofhair,skinreactions(rashes,
pruritus);rarely,bone-marrowsuppression,hyper-
sensitivityreactionssuchasurticariaandangio-
edema;otherside-effects(notusuallyassociatedwith
malariaprophylaxisortreatment),seeunderAnti-
malarials,section10.1.3;verytoxicin
overdosage
immediateadvicefrompoisonscentresessential(see
alsop.29)
Indicationanddose
rophylaxisofmalaria
Bymouth
Dose(expressedaschloroquinebase)preferably
started1weekbeforeenteringendemicareaand
continuedfor4weeksafterleaving(seenotes
hildupto12weeks,body-weightunder6kg
37.5mgonceweekly
hild12weeksÐ1year,body-weight6Ð10kg
75mgonceweekly
hild1Ð4years,body-weight10Ð16kg
112.5mgonceweekly
hild4Ð8years,body-weight16Ð25kg
150mg
Withproguanil
Forcautionsandside-effectsofproguanilseePro-
guanil;fordoseseeChloroquineandProguanil
(AstraZeneca)
Canbesoldtothepublicprovideditislicensedand
labelledfortheprophylaxisofmalaria.Drugsformalaria
prophylaxisnotprescribableontheNHS;healthauthorities
mayinvestigatecircumstancesunderwhichantimalarials
areprescribed
BNFC2011–
5.4.1Antimalarials
MEFLOQUINE
cardiacconductiondisorders;epilepsy
(avoidforprophylaxis);notrecommendedininfants
under3months(5kg);
Appendix1
(meßoquine)
Skilledtasks
Dizzinessoradisturbedsenseofbalancemay
affectperformanceofskilledtasks;effectsmaypersistforup
to3weeks
Contra-indications
hypersensitivitytoquinine;avoid
forprophylaxisifhistoryofpsychiatricdisorders
(includingdepression)orconvulsions
Hepaticimpairment
avoidforchemoprophylaxisin
severeliverdisease
manufactureradvisesadequatecontra-
ceptionduringprophylaxisandfor3monthsafter
stopping(teratogenicityin
studies),butsee
alsop.332
presentinmilkbutrisktoinfant
minimal;seealso,p.332
nausea,vomiting,dyspepsia,abdominal
pain,diarrhoea;headache,dizziness,sleepdistur-
lessfrequently
anorexia,bradycardia,fatigue,
abnormaldreams,fever,tinnitus,andneuropsych-
iatricreactions(includingsensoryandmotorneuro-
G6PDdeÞciency(testblood,seeunder
BenignMalarias(treatment),p.331);systemicdis-
easesassociatedwithgranulocytopenia(e.g.juvenile
idiopathicarthritis,lupuserythematosus);
Appendix1(primaquine)
riskofneonatalhaemolysisand
PROGUANILHYDROCHLORIDE
Appendix1(proguanil)
Renalimpairment
(seenotesunderProphylaxis
againstmalaria).Usehalfnormaldoseifestimated
glomerularÞltrationrate20Ð60mL/minute/1.73m
Useone-quarternormaldoseonalternatedaysif
Drugsformalariaprophylaxisnotprescribableonthe
NHS;healthauthoritiesmayinvestigatecircumstances
underwhichantimalarialsprescribed
5.4.1Antimalarials
BNFC2011–
Infections
estimatedglomerularÞltrationrate10Ð20mL/min-
ute/1.73m
.Useone-quarternormaldoseonce
weeklyifestimatedglomerularÞltrationratelessthan
10mL/minute/1.73m
;increasedriskofhaematolo-
gicaltoxicity.
beneÞtofprophylaxisinmalariaoutweighs
risk;adequatefolatesupplementsshouldbegivento
mother;seealsop.332
amountinmilkprobablytoosmallto
beharmfulwhenusedformalariaprophylaxis;see
alsop.332
mildgastricintolerance,diarrhoea,and
constipation;occasionallymouthulcersandstomat-
veryrarely
cholestasis,vasculitis,skinreactions
andhairloss
Indicationanddose
rophylaxisofmalaria
preferablystarted1week
beforeenteringendemicareaandcontinuedfor4
weeksafterleaving(seenotesabove)
Bymouth
Childupto12weeks,body-weightunder6kg
25mgoncedaily
hild12weeksÐ1year,body-weight6Ð10kg
50mgoncedaily
hild1Ð4years,body-weight10Ð16kg
75mg
oncedaily
hild4Ð8years,body-weight16Ð25kg
100mg
oncedaily
hild8Ð13years,body-weight25Ð45kg
150mgoncedaily
hildover13years,body-weightover45kg
200mgoncedaily
Counselling
Warntravellersandcarersofchildrentra-
vellingabout
importance
ofavoidingmosquitobites,
importance
oftakingprophylaxisregularly,and
ofimmediatevisittodoctorifillwithin1yearand
Withchloroquine
SeeunderChloroquine
PROGUANILHYDROCHLORIDEWITH
ATOVAQUONE
diarrhoeaorvomiting(reducedabsorption
ofatovaquone);efÞcacynotevaluatedincerebralor
complicatedmalaria(includinghyperparasitaemia,
pulmonaryoedemaorrenalfailure);
Appendix1(proguanil,atovaquone)
Renalimpairment
avoidformalariaprophylaxisand,
ifpossible,fortreatmentifestimatedglomerularÞl-
trationratelessthan30mL/minute/1.73m
manufactureradvisesavoidunlessessen-
useonlyifnosuitablealternative
available;seealsoBreast-feeding,p.332
abdominalpain,nausea,vomiting,diarr-
hoea;cough;headache,dizziness,insomnia,abnormal
dreams,depression,anorexia,fever;rash,pruritus;
lessfrequently
Canbesoldtothepublicprovideditislicensedand
labelledfortheprophylaxisofmalaria.Drugsformalaria
prophylaxisnotprescribableontheNHS;healthauthorities
mayinvestigatecircumstancesunderwhichantimalarials
areprescribed
Drugsformalariaprophylaxisnotprescribableonthe
NHS;healthauthoritiesmayinvestigatecircumstances
underwhichantimalarialsprescribed
BNFC2011–
5.4.1Antimalarials
cardiacdisease(includingatrialÞbrillation,
conductiondefects,heartblock)ÑmonitorECGdur-
ingparenteraltreatment;monitorbloodglucoseand
electrolyteconcentrationduringparenteraltreatment;
G6PDdeÞciency(seesection9.1.5);
Appendix1(quinine)
Contra-indications
haemoglobinuria,myasthenia
gravis,opticneuritis,tinnitus
Hepaticimpairment
fortreatmentofmalariain
severeimpairment,reduceparenteralmaintenance
doseto5Ð7mg/kgofquininesalt
Renalimpairment
fortreatmentofmalariainsevere
impairment,reduceparenteralmaintenancedoseto
5Ð7mg/kgofquininesalt
riskofteratogenesiswithhighdosesin
rst
trimester
;butinmalariabeneÞtoftreatmentout-
weighsrisk,seealsop.330
presentinmilkbutnotknowntobe
harmful
cinchonism,includingtinnitus,hearing
impairment,vertigo,headache,nausea,vomiting,
abdominalpain,diarrhoea,visualdisturbances
(includingtemporaryblindness),confusion;cardio-
vasculareffects(seeCautions);dyspnoea;hyper-
sensitivityreactionsincludingangioedema,rashes,
hotandßushedskin;hypoglycaemia(especiallyafter
parenteraladministration);blooddisorders(including
thrombocytopeniaandintravascularcoagulation);
acuterenalfailure;muscleweakness;photosensitivity;
verytoxicin
overdosage
Ñimmediateadvicefrom
poisonscentresessential(seealsop.29)
Licenseduse
injectionnotlicensed
Indicationanddose
reatmentofmalaria
seep.330
Quinine(anhydrousbase)100mg
quininebisulphate
169mg
quininedihydrochloride122mg
quininehydro-
chloride122mg
quininesulphate121mg.Quininebisul-
DOXYCYCLINE
section5.1.3
Contra-indications
section5.1.3
5.4.1Antimalarials
BNFC2011–
Infections
Hepaticimpairment
section5.1.3
Renalimpairment
section5.1.3
section5.1.3
section5.1.3
section5.1.3
Licenseduse
notlicensedforuseinchildrenunder
12years
Indicationanddose
rophylaxisofmalaria
preferablystarted1Ð2days
beforeenteringendemicareaandcontinuedfor4
weeksafterleaving(seenotesabove)
Bymouth
Childover12years
100mgoncedaily
reatmentoffalciparummalaria
seep.330
Section5.1.3
Amoebicides
DILOXANIDEFUROATE
manufactureradvisesavoidÑnoinforma-
tionavailable
manufactureradvisesavoid
ßatulence,vomiting,urticaria,pruritus
Licenseduse
notlicensedforuseinchildrenunder
25kgbody-weight
Indicationanddose
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Section5.1.11
BNFC2011–
5.4.2Amoebicides
(kala-azar).Leishmaniasisshouldbetreatedunderspe-
cialistsupervision.
Sodiumstibogluconate
,anorganicpentavalentanti-
monycompound,isthetreatmentofchoiceforvisceral
leishmaniasis.Thedoseis20mg/kgdaily(max.850mg)
foratleast20daysbyintramuscularorintravenous
injection;thedosagevarieswithdifferentgeographical
regionsandexpertadviceshouldbeobtained.Skin
lesionscanalsobetreatedwithsodiumstibogluconate.
Amphotericin
isusedwithorafteranantimonycom-
poundforvisceralleishmaniasisunresponsivetothe
antimonialalone;side-effectsmaybereducedby
usingliposomalamphotericin(
AmBisome
5.2)atadoseof1Ð3mg/kgdailyfor10Ð21daystoa
cumulativedoseof21Ð30mg/kg
atadoseof3mg/
kgfor5consecutivedaysfollowedbyasingledoseof
3mg/kg6dayslater.
SODIUMSTIBOGLUCONATE
intravenousinjectionsmustbegivenslowly
over5minutes(toreduceriskoflocalthrombosis)
andstoppedifcoughingorsubsternalpain;mucocu-
taneousdisease(seebelow);monitorECGbeforeand
duringtreatment;heartdisease(withdrawifconduc-
tiondisturbancesoccur);treatintercurrentinfection
(e.g.pneumonia)
Mucocutaneousdisease
Successfultreatmentofmucocu-
taneousleishmaniasismayinducesevereinßammation
aroundthelesions(maybelife-threateningifpharyngealor
trachealinvolvement)Ñmayrequirecorticosteroid
Hepaticimpairment
usewithcaution
Renalimpairment
avoidinsigniÞcantimpairment
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
amountprobablytoosmalltobe
harmful
anorexia,nausea,vomiting,abdominal
pain;ECGchanges;coughing(seeCautions);head-
Infections
Trypanocides
Theprophylaxisandtreatmentoftrypanosomiasisis
difÞcultanddiffersaccordingtothestrainoforganism.
Expertadviceshouldthereforebeobtained.
Drugsfortoxoplasmosis
Mostinfectionscausedby
Toxoplasmagondii
areself-
limiting,andtreatmentisnotnecessary.Exceptionsare
childrenwitheyeinvolvement(toxoplasmachoroido-
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
cardiacdisease,arrhythmias(includingpre-
dispositiontoQTintervalprolongation)
Contra-indications
sensitivitytoothermacrolides
Hepaticimpairment
usewithcaution
presentinbreastmilk
gastro-intestinaldisturbancesincluding
nausea,vomiting,diarrhoea;dizziness,headache;
rash;hepatotoxicity;
,prolongationofQT
interval,thrombocytopeniaandvasculitis
Licenseduse
notlicensed
Indicationanddose
oxoplasmosisinpregnancy
seenotesabove
Bymouth
Child12Ð18years
1.5gtwicedailyuntildelivery
hemoprophylaxisofcongenitaltoxoplasmosis
Bymouth
50mg/kgtwicedaily
Spiramycin
(Sulphadiazine)
seeunderCo-trimoxazole,section5.1.8;
Appendix1(sulfonamides)
Contra-indications
seeunderCo-trimoxazole,section
Hepaticimpairment
usewithcautioninmildto
moderateimpairment;avoidinsevereimpairment
Renalimpairment
usewithcautioninmildtomod-
erateimpairment;avoidinsevereimpairment;high
riskofcrystalluria
riskofneonatalhaemolysisand
seeunderCo-trimoxazole,section5.1.8;
alsohypothyroidism,benignintracranialhyper-
tension,opticneuropathy
Licenseduse
notlicensedforuseintoxoplasmosis
Indicationanddose
oxoplasmosisinpregnancy(incombination
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Drugsforpneumocystis
pneumonia
Pneumoniacausedby
Pneumocystisjirovecii
cystiscarinii
)occursinimmunosuppressedchildren;it
isacommoncauseofpneumoniainAIDS.Pneumo-
cystispneumoniashouldgenerallybetreatedbythose
experiencedinitsmanagement.Bloodgasmeasure-
mentisusedtoassessdiseaseseverity.
Treatment
Therecommendeddurationoftreatmentisgenerally
14Ð21days.
Mildtomoderatedisease
Co-trimoxazole
5.1.8)inhighdosageisthedrugofchoiceforthe
treatmentofmildtomoderatepneumocystispneu-
Atovaquone
oracombinationof
tri-
ATOVAQUONE
initialdiarrhoeaanddifÞcultyintakingwith
foodmayreduceabsorption(andrequirealternative
therapy);othercausesofpulmonarydiseaseshouldbe
soughtandtreated;
Appendix1(ato-
Hepaticimpairment
manufactureradvisescautionÑ
monitormoreclosely
Renalimpairment
manufactureradvisescautionÑ
monitormoreclosely
manufactureradvisesavoidunlesspoten-
tialbeneÞtoutweighsriskÑnoinformationavailable
manufactureradvisesavoid
nausea,diarrhoea,vomiting,headache,
insomnia,fever,anaemia,neutropenia,hyponatr-
aemia,rash,pruritus;alsoreported,Stevens-Johnson
Licenseduse
notlicensedforuseinchildren
5.4.8Drugsforpneumocystispneumonia
BNFC2011–
Infections
Indicationanddose
reatmentof
Pneumocystisjirovecii(P.carinii)
pneumoniainchildrenintolerantofco-trim-
Bymouth
Child1Ð3months
15Ð20mg/kgtwicedailywith
food(particularlyhighfat)for14Ð21days
hild3monthsÐ2years
22.5mg/kgtwicedaily
withfood(particularlyhighfat)for14Ð21days
hild2Ð18years
15Ð20mg/kg(max.750mg)
twicedailywithfood(particularlyhighfat)for14Ð
21days
Wellvone
,sugar-free,atovaquone750mg/5mL,
Withproguanilhydrochloride
Seesection5.4.1
cardiacorpulmonarydisease;anaemia
(treatsevereanaemiabeforestarting);susceptibility
tohaemolysisincludingG6PDdeÞciency(section
9.1.5);avoidinacuteporphyria(section9.8.2);
inter-
Appendix1(dapsone)
Blooddisorders
Onlong-termtreatment,childrenandtheir
carersshouldbetoldhowtorecognisesignsofblood
disordersandadvisedtoseekimmediatemedicalattentionif
symptomssuchasfever,sorethroat,rash,mouthulcers,
purpura,bruisingorbleedingdevelop
utaneousleishmaniasis
Bydeepintramuscularinjection
Child1Ð18years
3Ð4mg/kgonceortwice
weeklyuntilconditionresolves(butseealsosec-
tion5.4.5)
rypanosomiasis
Bydeepintramuscularinjectionorintravenous
Child1Ð18years
4mg/kgdailyoronalternate
daystototalof7Ð10injections
Directintravenousinjectionshouldbe
avoidedwheneverpossibleand
never
givenrapidly;
intramuscularinjectionsshouldbedeepandprefer-
ablygivenintothebuttock.
For
intravenousinfusion
,reconstitute300mgwith3Ð
5mLWaterforInjections(displacementvaluemaybe
signiÞcant),thendiluterequireddosewith50Ð250mL
Glucose5%
SodiumChloride0.9%;giveoverat
least60minutes
Pentacarinat
,powderforreconstitution,pentamidine
Appendix1(mebendazole)
Infections
Packsonsaletothegeneralpubliccarryawarningto
avoidinepilepsy,liverorkidneydisease,andtoseekmedical
adviceinpregnancy
Hepaticimpairment
manufactureradvisesavoid
Renalimpairment
usewithcaution;avoidinsevere
renalimpairment;riskofneurotoxicity
notknowntobeharmfulbutmanufacturer
advisesavoidinÞrsttrimester
presentinmilkÑmanufacturer
advisesavoidbreast-feedingfor8hoursafterdose
(expressanddiscardmilkduringthistime)
nausea,vomiting,colic,diarrhoea,aller-
gicreactionsincludingurticaria,bronchospasm,and
rarereportsofarthralgia,fever,Stevens-Johnson
syndromeandangioedema;rarelydizziness,muscular
inco-ordination(ÔwormwobbleÕ);drowsiness,nystag-
mus,vertigo,blurredvision,confusionandclonic
contractionsinchildrenwithneurologicalorrenal
abnormalities
Indicationanddose
Seeunderpreparation,below
Withsennosides
Forcautions,contra-indications,side-effectsofsenna
seesection1.6.2
(Thornton&Ross)
Oralpowder
,piperazinephosphate4g,totalsenno-
LEVAMISOLE
epilepsy;juvenileidiopathicarthritis;Sjo
renÕssyndrome
Contra-indications
blooddisorders
Hepaticimpairment
usewithcautionÑdoseadjust-
mentmaybenecessary
embryotoxicin
animal
studies,avoidif
noinformationavailable
nausea,vomiting,diarrhoea;dizziness,
headache;on
prolongedtreatment
tastedisturbances,
insomnia,convulsions,inßuenza-likesyndrome,
blooddisorders,vasculitis,arthralgia,myalgia,rash
Licenseduse
notlicensed
Indicationanddose
oundworm(
Ascarislumbricoides
Bymouth
Child1monthÐ18years
2.5Ð3mg/kg(max.
150mg)asasingledose
Bymouth
Child1monthÐ18years
2.5mg/kg(max.
150mg)asasingledoserepeatedafter7daysif
ephroticsyndrome(specialistsupervision
section6.3.2)
Bymouth
Child1monthÐ18years
2.5mg/kg(max.150mg)
onalternatedays
Infections
Drugsforstrongyloidiasis
Adultformsof
Strongyloidesstercoralis
liveinthegut
Endocrinesystem
Endocrinesystem
Endocrinesystem
Thedurationofactionofaparticulartypeofinsulincan
varyfromonechildtoanother,andneedstobeassessed
individually.
Mixturesofinsulinpreparationsmayberequiredand
Endocrinesystem
Solubleinsulinbythe
intravenousroute
isreservedfor
Endocrinesystem
lifeandifpremature.Ifintravenousglucoseisnecessary
e.g.fortotalparenteralnutrition,infuseatalowerrate
for6Ð12hoursandtheglucoseintoleranceshould
resolve.Insulinisnotneededforsuchtransientglucose
intolerance,butmaybeneededifblood-glucosecon-
centrationispersistentlyhigh.
6.1.1.1
Short-actinginsulins
Solubleinsulin
isashort-actingformofinsulin.For
maintenanceregimensitisusualtoinjectit15to30
minutesbeforemeals.
Solubleinsulinisthemostappropriateformofinsulin
(InsulinInjection;NeutralInsulin;Soluble
Asterilesolutionofinsulin(i.e.bovineorporcine)or
ofhumaninsulin;pH6.6Ð8.0
section6.1.1;
Appendix1
Indicationanddose
yperglycaemiaduringillness,neonataldia-
HighlypuriÞedanimal
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed
BovineNeutral
(Wockhardt)
,solubleinsulin(bovine,highlypuriÞed)
Humansequence
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed
(NovoNordisk)
,solubleinsulin(human,pyr)100units/mL.
Mixedpreparations
SeeBiphasicIsophaneInsulin(section6.1.1.2)
6.1.1Insulins
BNFC2011–
Endocrinesystem
INSULINASPART
(Recombinanthumaninsulinanalogue)
section6.1.1;
Appendix1
INSULINGLULISINE
(Recombinanthumaninsulinanalogue)
section6.1.1;
Appendix1
INSULINLISPRO
(Recombinanthumaninsulinanalogue)
section6.1.1;childrenunder12years(use
onlyifbeneÞtlikelycomparedtosolubleinsulin);
6.1.1.2
Intermediate-andlong-acting
Whengivenbysubcutaneousinjection,intermediate-
Endocrinesystem
Isophaneinsulin
isasuspensionofinsulinwithprot-
amine;itisofparticularvalueforinitiationoftwice-daily
insulinregimens.Isophanecanbemixedwithsoluble
insulinbeforeinjectionbutready-mixedpreparations
maybemoreappropriate(
biphasicisophaneinsulin
biphasicinsulinaspart
,or
biphasicinsulinlispro
Insulinzincsuspension
(30%amorphous,70%cryst-
alline)hasamoreprolongeddurationofaction.
Protaminezincinsulin
isusuallygivenoncedailywith
short-acting(soluble)insulin.Ithasthedrawbackof
bindingwiththesolubleinsulinwhenmixedinthe
samesyringeandisnowrarelyused.
INSULINGLARGINE
(RecombinanthumaninsulinanalogueÑlong
section6.1.1;
Appendix1
INSULINZINCSUSPENSION
(InsulinZincSuspension(Mixed)Ñlongacting)
Asterileneutralsuspensionofbovineinsulinorofhuman
insulinintheformofacomplexobtainedbytheadditionofa
suitablezincsalt;consistsofrhombohedralcrystals(10Ð
40microns)andofparticlesofnouniformshape(notexceed-
ing2microns)
section6.1.1;
Appendix1
Endocrinesystem
HighlypuriÞedanimal
BovineLente
(Wockhardt)
,insulinzincsuspension(bovine,highly
ISOPHANEINSULIN
(IsophaneInsulinInjection;IsophaneProt-
amineInsulinInjection;IsophaneInsulin
(NPH)Ñintermediateacting)
Asterilesuspensionofbovineorporcineinsulinorofhuman
insulinintheformofacomplexobtainedbytheadditionof
protaminesulphateoranothersuitableprotamine
section6.1.1;
Appendix1
HighlypuriÞedanimal
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed
BovineIsophane
(Wockhardt)
,isophaneinsulin(bovine,highlypuriÞed)
Humansequence
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed
Insulatard
(NovoNordisk)
,isophaneinsulin(human,pyr)100units/
Mixedpreparations
SeeBiphasicIsophaneInsulin(p.356)
PROTAMINEZINCINSULIN
(ProtamineZincInsulinInjectionÑlongacting)
Asterilesuspensionofinsulinintheformofacomplex
obtainedbytheadditionofasuitableprotamineandzinc
chloride;thispreparationwasincludedinBP1980butisnot
includedinBP1988
section6.1.1;seealsonotesabove;
BIPHASICINSULINASPART
(Intermediate-actinginsulin)
section6.1.1;
Appendix1
Endocrinesystem
BIPHASICINSULINLISPRO
(Intermediate-actinginsulin)
seesection6.1.1andInsulinLispro;
BIPHASICISOPHANEINSULIN
(BiphasicIsophaneInsulinInjectionÑinter-
mediateacting)
Asterilebufferedsuspensionofeitherporcineorhumaninsulin
complexedwithprotaminesulphate(oranothersuitableprot-
amine)inasolutionofinsulinofthesamespecies
section6.1.1;
Appendix1
HighlypuriÞedanimal
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed;theproportionsofthetwo
componentsshouldbechecked
(theorderinwhich
theproportionsarestatedmaynotbethesameinother
Porcine30/70Mix
(Wockhardt)
,biphasicisophaneinsulin(porcine,highly
puriÞed),30%soluble,70%isophane,100units/mL,
Humansequence
Counselling
ShowcontainertochildorcarerandconÞrm
theexpectedversionisdispensed;theproportionsofthetwo
componentsshouldbechecked
(theorderinwhich
theproportionsarestatedmaynotbethesameinother
HumulinM3
,biphasicisophaneinsulin(human,prb),
6.1.1.3
Hypodermicequipment
Carersandchildrenshouldbeadvisedonthesafe
Endocrinesystem
Injectiondevices
(OwenMumford)
Injectiondevice
(forusewithSanoÞ-Aventis
3-mLinsulincartridges),allowing1-unitdosageadjustment,
max.21units(single-unitversion)
2unitdosageadjust-
HypodermicNeedle,Sterilesingleuse
(DrugTariff)
Forusewithreusableglasssyringe,sizes0.5mm(25G),
HypodermicSyringe
(DrugTariff)
CalibratedglasswithLuertaperconicalÞtting,forusewith
Accessories
NeedleClipping(Chopping)Device
(DrugTariff)
Consistingofaclippertoremoveneedlefromitshuband
Endocrinesystem
endoftheadultdoserangeandthenadjustedaccording
toresponse.
6.1.2.1
Sulfonylureas
ThesulfonylureasarenottheÞrstchoiceoralanti-
seenotesabove;
Appendix1
Endocrinesystem
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
seenotesabove;
Appendix1
TOLBUTAMIDE
seenotesabove;
Appendix1
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
6.1.2.2
Endocrinesystem
6.1.2.3
Otherantidiabeticdrugs
Thereislittleexperienceoftheuseof
children.Ithasbeenusedinolderchildren;therapy
shouldbeinitiatedbyanappropriateexpert.
Theuseofnateglinideincombinationwithasulfonylur-
eaisgenerallyreservedforthemanagementofsome
Availableat
www.bsped.org.uk
Endocrinesystem
Treatmentof
hypoglycaemia
Prompttreatmentofhypoglycaemiainchildrenfrom
anycauseisessentialasseverehypoglycaemiamay
causesubsequentneurologicaldamage.Hyperinsulin-
ism,fattyacidoxidationdisordersandglycogenstorage
diseasearelesscommoncausesofacutehypoglyc-
aemiainchildren.
Initiallyglucose10Ð20gisgivenbymoutheitherin
liquidformorasgranulatedsugarorsugarlumps.
Approximately10gofglucoseisavailablefromnon-
seenotesabove,insulinoma,glucagonoma;
ineffectiveinchronichypoglycaemia,starvation,and
adrenalinsufÞciency;delayedhypoglycaemiawhen
usedasadiagnostictestÑdeathsreported(ensurea
mealiseatenbeforedischarge)
Contra-indications
phaeochromocytoma
nausea,vomiting,diarrhoea,hypokal-
aemia,rarelyhypersensitivityreactions
Licenseduse
unlicensedforgrowthhormonetest
andhyperinsulinism
Indicationanddose
Endocrinesystem
2.2.1)reducesdiazoxide-inducedsodiumandwater
ischaemicheartdisease;monitorblood
pressure,duringprolongedusemonitorwhitecelland
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
OCTREOTIDE
avoidabruptwithdrawalofshort-acting
octreotideÑseeSide-effectsbelow;ininsulinoma
(riskofincreaseddepthanddurationofhypoglyc-
aemiaÑmonitorcloselywheninitiatingtreatmentand
functiononlong-termtherapy;
Appen-
dix1(octreotide)
Endocrinesystem
andprovepositive,theresultshouldbeconÞrmedby
laboratoryanalysisofaurinesample.Microalbuminuria
canoccurtransientlyduringpuberty;ifitpersists(at
least3positivetests)treatmentwithanACEinhibitor
(section2.5.5.1)oranangiotensin-IIreceptorantagonist
(section2.5.5.2)underspecialistguidanceshouldbe
Inadequateunderstandingofthenormalßuctuations
inbloodglucosecanleadtoconfusionandinappropri-
ateaction.
Childrenusingmultipleinjectionregimensshould
understandhowtoadjusttheirinsulindoseaccording
totheircarbohydrateintake.WithÞxed-doseinsulin
regimens,thecarbohydrateintakeneedstoberegu-
lated,andshouldbedistributedthroughoutthedayto
matchtheinsulinregimen.
IntheUKblood-glucoseconcentrationisexpressedin
whentoseekmedicalattention.
TestsforglucoserangefromreagentstripsspeciÞcto
Clinistix
Reagentstrips
Otherreagentstripsavailableforurinalysis
Combur-3Test
(glucoseandproteinÑRoche
ClinitekMicroalbumin
(albuminand
creatinineÑSiemens),
Endocrinesystem
Endocrinesystem
Oralglucosetolerancetest
Theoralglucosetolerancetestisusedmainlyfor
diagnosisofimpairedglucosetolerance;itisnotrecom-
mendedornecessaryforroutinediagnosticusewhen
severesymptomsofhyperglycaemiaarepresent.How-
ever,itisusedfortheinvestigationofinsulinresistance,
glycogenstoragedisease,andexcessivegrowthhorm-
Endocrinesystem
thyroiditis(lymphadenoidgoitre).Neonatalhypo-
thyroidismrequiresprompttreatmenttofacilitatenor-
maldevelopment.
Levothyroxinesodium
(thyroxinesodium)isthetreat-
mentofchoicefor
maintenance
therapy.
Dosesforcongenitalhypothyroidismandjuvenilemyx-
oedemashouldbetitratedaccordingtoclinical
response,growthassessment,andmeasurementof
plasmathyroxineandthyroid-stimulatinghormonecon-
centrations.Incongenitalhypothyroidismhigherinitial
LEVOTHYROXINESODIUM
(Thyroxinesodium)
panhypopituitarismorpredispositionto
adrenalinsufÞciency(initiatecorticosteroidtherapy
beforestartinglevothyroxine);cardiacdisorders
(monitorECG;startatlowdoseandcarefullytitrate);
LIOTHYRONINESODIUM
-Tri-iodothyroninesodium)
severeandprolongedhypothyroidism(initi-
atecorticosteroidtherapyinadrenalinsufÞciency);
cardiacdisorders(monitorECG;startatlowdoseand
Endocrinesystem
ypothyroidcoma
Byslowintravenousinjection
Child12–18years
5Ð20microgramsrepeated
every12hoursoruptoevery4hoursifnecessary;
alternatively
initially50microgramsthen25micr-
ogramsevery8hoursreducingto25micrograms
twicedaily
Liothyroninesodium
Rashesandpruritusarecommonwithcarbimazolebut
theycanbetreatedwithantihistamineswithoutdiscon-
tinuingtherapy;alternativelypropylthiouracilcanbe
substituted.Ifachildoncarbimazoledevelopsasore
throatitshouldbereportedimmediatelybecauseofthe
rarecomplicationofagranulocytosis(seeNeutropenia
andAgranulocytosis,above).
hasbeenusedasanadjuncttoantithyroiddrugs
for10to14daysbeforepartialthyroidectomy;however,
thereislittleevidenceofabeneÞcialeffect.Iodine
shouldnotbeusedforlong-termtreatmentbecause
itsantithyroidactiontendstodiminish.
Radioactivesodiumiodide(
I)solutionisusedincreas-
inglyforthetreatmentofthyrotoxicosisatallages,
particularlywheremedicaltherapyorcomplianceisa
problem,inpatientswithcardiacdisease,andinpatients
whorelapseafterthyroidectomy.
Propranolol
(section2.4)isusefulforrapidreliefof
thyrotoxicsymptomsandcanbeusedinconjunction
withantithyroiddrugsorasanadjuncttoradioactive
CARBIMAZOLE
Hepaticimpairment
usewithcautioninmildto
moderateimpairment;avoidinseverehepatic
impairment
seenotesabove
BNFC2011–
6.2.2Antithyroiddrugs
Endocrinesystem
amountinmilkmaybesufÞcientto
affectneonatalthyroidfunction,thereforelowest
effectivedoseshouldbeused;seenotesabove
nausea,mildgastro-intestinaldistur-
bances,tastedisturbance,hepaticdisorders(including
hepatitisandjaundice),headache,fever,malaise,rash,
pruritus,arthralgia;
rarely
myopathy,alopecia,bone
marrowsuppression(includingpancytopeniaand
agranulocytosis,seeNeutropeniaandAgranulocyto-
sisabove),hypersensitivityreactions
Indicationanddose
yperthyroidism(includingGravesÕdisease)
Bymouth
initially750micrograms/kgdailyinsin-
gleordivideddosesuntileuthyroidthenadjustas
necessary(seenotesabove);higherinitialdoses
(upto1mg/kgdaily)areoccasionallyrequired,
particularlyinthyrotoxiccrisis
Child1month–12years
initially750micr-
ograms/kg(max.30mg)dailyinsingleordivided
dosesuntileuthyroidthenadjustedasnecessary
(seenotesabove);higherinitialdosesoccasionally
required,particularlyinthyrotoxiccrisis
hild12–18years
initially30mgdailyinsingle
ordivideddosesuntileuthyroidthenadjustedas
necessary(seenotesabove);higherinitialdoses
occasionallyrequired,particularlyinthyrotoxic
Counselling
Warnchildandcarerstotelldoctor
ifsorethroat,mouthulcers,bruising,fever,
malaise,ornon-speciÞcillnessdevelops
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
IODINEANDIODIDE
notforlong-termtreatment
neonatalgoitreandhypothyroidism;see
alsonotesabove
stopbreast-feeding;dangerofneo-
natalhypothyroidismorgoitre;appearstobecon-
centratedinmilk;seealsonotesabove
hypersensitivityreactionsincludingcor-
yza-likesymptoms,headache,lacrimation,con-
junctivitis,paininsalivaryglands,laryngitis,bronch-
itis,rashes;onprolongedtreatmentdepression,
insomnia,impotence;goitreininfantsofmothers
takingiodides
Indicationanddose
Seeunderpreparation
AqueousIodineOralSolution
Oralsolution
,iodine5%,potassiumiodide10%in
puriÞedwater,freshlyboiledandcooled,totaliodine
PROPYLTHIOURACIL
monitorforhepatotoxicity
Hepatotoxicity
Severehepaticreactionshavebeen
reported,includingfatalcasesandcasesrequiringliver
transplantÑdiscontinueifsigniÞcantliver-enzymeabnorm-
alitiesdevelop
Counselling
Patientsshouldbetoldhowtorecognisesigns
ofliverdisorderandadvisedtoseekpromptmedicalatten-
tionifsymptomssuchasanorexia,nausea,vomiting,fatigue,
abdominalpain,jaundice,darkurine,orpruritusdevelop
Hepaticimpairment
reducedose(seealsoHepato-
toxicityabove)
Renalimpairment
estimatedglomerularÞltration
rate10Ð50mL/minute/1.73m
,use75%ofnormal
dose;estimatedglomerularÞltrationratelessthan
10mL/minute/1.73m
,use50%ofnormaldose
seenotesabove
monitorinfantÕsthyroidstatusbut
amountinmilkprobablytoosmalltoaffectinfant;
highdosesmayaffectneonatalthyroidfunction;see
alsonotesabove
seeunderCarbimazole;leucopenia;
cutaneousvasculitis,thrombocytopenia,
aplasticanaemia,hypoprothrombinaemia,hepatic
disorders(includinghepatitis,hepaticfailure,
encephalopathy,hepaticnecrosis;seealsoHepato-
toxicityabove),nephritis,lupuserythematous-like
Licenseduse
notlicensedforuseinchildrenunder6
yearsofage
Indicationanddose
yperthyroidism(includingGravesÕdisease)
Bymouth
initially2.5Ð5mg/kgtwicedailyuntil
euthyroidthenadjustedasnecessary(seenotes
above);higherdosesoccasionallyrequired,parti-
cularlyinthyrotoxiccrisis
Child1month–1year
initially2.5mg/kg3times
dailyuntileuthyroidthenadjustedasnecessary
(seenotesabove);higherdosesoccasionally
required,particularlyinthyrotoxiccrisis
hild1–5years
initially25mg3timesdailyuntil
euthyroidthenadjustedasnecessary(seenotes
above);higherdosesoccasionallyrequired,parti-
cularlyinthyrotoxiccrisis
6.2.2Antithyroiddrugs
BNFC2011–
Endocrinesystem
Child5–12years
initially50mg3timesdailyuntil
euthyroidthenadjustedasnecessary(seenotes
above);higherdosesoccasionallyrequired,parti-
cularlyinthyrotoxiccrisis
hild12–18years
initially100mg3timesdaily
administereduntileuthyroidthenadjustedas
necessary(seenotesabove);higherdosesocca-
sionallyrequired,particularlyinthyrotoxiccrisis
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
PROPRANOLOLHYDROCHLORIDE
seesection2.4
Contra-indications
seesection2.4
Hepaticimpairment
section2.4
Renalimpairment
section2.4
section2.4
section2.4
seesection2.4
Indicationanddose
Hyperthyroidismwithautonomicsymptoms,
thyrotoxicosis,thyrotoxiccrisis
Bymouth
initially250Ð500micrograms/kgevery
6Ð8hours,adjustedaccordingtoresponse
Child1month–18years
initially250Ð500micr-
ograms/kgevery8hours,thenadjustedaccording
toresponse;dosesupto1mg/kgevery8hours
occasionallyrequired,max.40mgevery8hours
Byintravenousinjectionover10minutes
initially20Ð50micrograms/kgevery6Ð8
hours,adjustedaccordingtoresponse
Child1month–18years
initially25Ð50micr-
ograms/kg(max.5mg)every6Ð8hours,adjusted
accordingtoresponse
Seesection2.4
Corticosteroids
Replacementtherapy
Glucocorticoidtherapy
Replacementtherapy
Endocrinesystem
A
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
ingsystemicside-effects(e.g.forskinapplicationsand
asthmainhalations).
Deßazacort
hasahighglucocorticoidactivity;itis
derivedfromprednisolone.
Useofcorticosteroids
Dosagesofcorticosteroidsvarywidelyindifferentdis-
easesandindifferentchildren.Iftheuseofacortico-
steroidcansaveorprolonglife,asinexfoliative
dermatitis,pemphigus,acuteleukaemiaoracutetrans-
plantrejection,highdosesmayneedtobegiven,
becausethecomplicationsoftherapyarelikelytobe
lessseriousthantheeffectsofthediseaseitself.
Whenlong-termcorticosteroidtherapyisusedinsome
chronicdiseases,theadverseeffectsoftreatmentmay
becomegreaterthanthedisabilitiescausedbythe
disease.Tominimiseside-effectsthemaintenance
doseshouldbekeptaslowaspossible.
Whenpotentiallylessharmfulmeasuresareineffective
corticosteroidsareusedtopicallyforthetreatmentof
inßammatoryconditionsoftheskin(section13.4).Cor-
ticosteroidsshouldbeavoidedorusedonlyunder
specialistsupervisioninpsoriasis(section13.5).
Corticosteroidsareusedbothtopically(byrectum)and
systemically(bymouthorintravenously)inthemanage-
mentofulcerativecolitisandCrohnÕsdisease(section
1.5andsection1.7.2).
Usecanbemadeofthemineralocorticoidactivityof
ßudrocortisonetotreatposturalhypotensioninauto-
nomicneuropathy.
High-dosecorticosteroidsshouldbeavoidedforthe
managementofsepticshock.However,low-dosehydro-
cortisonecanbeusedinsepticshock(section2.7.1)that
isresistanttovolumeexpansionandcatecholamines,
andisaccompaniedbysuspectedorprovenadrenal
insufÞciency.
Thesuppressiveactionofglucocorticoidsonthehypo-
thalamic-pituitary-adrenalaxisisgreatestandmost
prolongedwhentheyaregivenatnight.Inmostadults
Endocrinesystem
Inacutehypersensitivityreactions,suchasangioedema
oftheupperrespiratorytractandanaphylaxis,corticos-
teroidsareindicatedasanadjuncttoemergencytreat-
mentwithadrenaline(epinephrine)(section3.4.3).In
suchcaseshydrocortisone(assodiumsuccinate)by
intravenousinjectionmayberequired.
Inthemanagementofasthma,corticosteroidsarepre-
ferablyusedbyinhalation(section3.2)butsystemic
therapyalongwithbronchodilatorsisrequiredforthe
emergencytreatmentofsevereacuteasthma(section
successfulinthemanagementofasthma(section3.2).
Pituitary-adrenalsuppressioncanalsobereducedby
meansofintermittenttherapywithshortcourses.In
someconditionsitmaybepossibletoreducethedoseof
corticosteroidbyaddingasmalldoseofanimmuno-
suppressivedrug(section8.2.1).
Cautionsandcontra-indicationsof
corticosteroids
Adrenalsuppression
Duringprolongedtherapywithcorticosteroids,adrenal
atrophydevelopsandcanpersistforyearsafterstop-
ping.Abruptwithdrawalafteraprolongedperiodcan
leadtoacuteadrenalinsufÞciency,hypotension,or
death(seeWithdrawalofCorticosteroids,below).With-
drawalcanalsobeassociatedwithfever,myalgia,arthr-
algia,rhinitis,conjunctivitis,painfulitchyskinnodules,
andweightloss.
Tocompensateforadiminishedadrenocortical
responsecausedbyprolongedcorticosteroidtreatment,
anysigniÞcantintercurrentillness,trauma,orsurgical
procedurerequiresatemporaryincreaseincortico-
steroiddose,orifalreadystopped,atemporaryre-
introductionofcorticosteroidtreatment.Toavoida
precipitousfallinbloodpressureduringanaesthesiaor
Endocrinesystem
Topical,inhaledorrectalcorticosteroidsarelesslikely
tobeassociatedwithanincreasedriskofsevere
chickenpox.
Childrentakingcorticosteroids,andtheir
carers,shouldbeadvisedtotakeparticularcareto
avoidexposuretomeaslesandtoseekurgentmedical
adviceifexposureoccurs.Prophylaxiswithintramus-
cularnormalimmunoglobulin(section14.5.1)maybe
Withdrawalofcorticosteroids
Themagnitudeandspeedofdosereductionincortico-
Advicetochildrenandcarers
EnglandandWales
3MSecurityPrintingandSystemsLimited
Tel:(028)90535652
Othercautionsandcontra-indications
Othercautionsinclude
:growthrestrictionÑpossibly
irreversible,frequentmonitoringrequiredifhistoryof
6.3.2Glucocorticoidtherapy
BNFC2011–
Endocrinesystem
tuberculosis(orX-raychanges),hypertension,conges-
Hepaticimpairment
Whencorticosteroidsareadministeredorallyorparent-
erally,theplasma-drugconcentrationmaybeincreased
inchildrenwithhepaticimpairment.Corticosteroids
shouldbeusedwithcautioninhepaticimpairment
andthechildshouldbemonitoredclosely.
Renalimpairment
Oralandparenteralpreparationsofcorticosteroids
shouldbeusedwithcautioninchildrenwithrenal
impairment.
Pregnancyandbreast-feeding
ThebeneÞtoftreatmentwithcorticosteroidsduring
pregnancyandbreast-feedingoutweighstherisk;preg-
BNFC2011–
6.3.2Glucocorticoidtherapy
Endocrinesystem
Glucocorticoid
DEFLAZACORT
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
nßammatoryandallergicdisorders
Bymouth
Child1month–12years
0.25Ð1.5mg/kgonce
dailyoronalternatedays;upto2.4mg/kg(max.
120mg)dailyhasbeenusedinemergencysitua-
hild12–18years
3Ð18mgoncedailyoron
alternatedays;upto2.4mg/kg(max.120mg)
dailyhasbeenusedinemergencysituations
ephroticsyndrome
Bymouth
Child1month–18years
initially1.5mg/kgonce
daily(max.120mg)reducedtolowesteffective
doseformaintenance
Calcort
Endocrinesystem
Indicationanddose
Inßammatoryandallergicdisorders
Bymouth
Child1month–18years
10Ð100micrograms/kg
dailyin1Ð2divideddoses,adjustedaccordingto
response;upto300micrograms/kgdailymaybe
requiredinemergencysituations
Byintramuscularinjectionorslowintravenous
injectionorinfusion
Child1month–12years
83Ð333micrograms/kg
dailyin1Ð2divideddoses;max.20mgdaily
hild12–18years
initially0.4Ð20mgdaily
Life-threateningcerebraloedema
Byintravenousinjection
Childunder35kgbody-weight
initially16.7mg,
then3.3mgevery3hoursfor3days,then3.3mg
every6hoursfor1day,then1.7mgevery6hours
for4days,thendecreaseby0.8mgdaily
hildover35kgbody-weight
initially20.8mg,
then3.3mgevery2hoursfor3days,then3.3mg
every4hoursfor1day,then3.3mgevery6hours
for4days,thendecreaseby1.7mgdaily
Bacterialmeningitis
(seesection5.1)
Byslowintravenousinjection
Child3months–18years
150micrograms/kg
(max.10mg)every6hoursfor4daysstarting
beforeorwithÞrstdoseofantibacterial
Physiologicalreplacement
Bymouthorbyslowintravenousinjection
Child1month–18years
250Ð500micrograms/
every12hours,adjustedaccordingtoresponse
section3.1
auseaandvomitingwithchemotherapy
tion8.1
heumaticdisease
section10.1.2
section11.4.1
foradministration
bymouth
HYDROCORTISONE
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsophosphateester
associatedwithparaesthesiaandpain(particularlyin
theperinealregion)
Indicationanddose
ongenitaladrenalhyperplasia
seealsosection
Bymouth
9Ð15mg/m
in3divideddoses,adjusted
accordingtoresponse
Child1month–18years
9Ð15mg/m
in3
divideddoses,adjustedaccordingtoresponse
cuteadrenocorticalinsufÞciency(
Addisonian
seealsonotesaboveandsection6.3.1
Byslowintravenousadministration
initially10mg
byslowintravenous
injection
then100mg/m
bycontinuous
intravenousinfusion
orindivideddosesevery6Ð8
hours;adjustedaccordingtoresponse;whenstable
reduceover4Ð5daystooralmaintenancedose
Child1month–12years
initially2Ð4mg/kg
slowintravenousinjection
infusion
then2Ð
4mg/kgevery6hours;adjustedaccordingto
response;whenstablereduceover4Ð5daystooral
maintenancedose
hild12–18years
100mgevery6to8hoursby
slowintravenousinjection
infusion
drenalhypoplasia,AddisonÕsdisease,chronic
maintenanceorreplacementtherapy
Bymouth
8Ð10mg/m
dailyin3divideddoses;
higherdosesmaybeneeded
Child1month–18years
8Ð10mg/m
dailyin3
divideddoses;higherdosesmaybeneeded
Givelargerdosesinthemorningandsmallerdoses
intheevening
nßammatoryboweldiseaseÑinductionof
remission
seealsosection1.5.2
Byintravenousinjection
Child2–18years
2.5mg/kg(max.100mg)every
6hours
Bycontinuousintravenousinfusion
Child2–18years
10mg/kgdaily(max.400mg
cutehypersensitivityreactions,angioedema
seealsosection3.4.3
Byintramuscularorintravenousinjection
Childunder6months
initially25mg3times
daily,adjustedaccordingtoresponse
hild6months–6years
initially50mg3times
daily,adjustedaccordingtoresponse
BNFC2011–
6.3.2Glucocorticoidtherapy
Endocrinesystem
Child6–12years
initially100mg3timesdaily,
adjustedaccordingtoresponse
hild12–18years
initially200mg3timesdaily,
adjustedaccordingtoresponse
ypotensionresistanttoinotropictreatment
andvolumereplacement(limitedevidence)
Byintravenousinjection
initially2.5mg/kgrepeatedifnecessary
after4hours,then2.5mg/kgevery6hoursfor48
hoursoruntilbloodpressurerecovers,thendose
reducedgraduallyoveratleast48hours
Child1month–18years
1mg/kg(max.100mg)
every6hours
evereacuteasthma
p.134
section11.4.1
section1.7.2
heumaticdisease
section10.1.2
hock
section2.7.1
section13.4
intravenousadministration
,dilute
withGlucose5%orSodiumChloride0.9%;for
inter-
mittentinfusion
giveover20Ð30minutes.
Foradministration
bymouth
,injectionsolutionmay
beswallowed[unlicenseduse]butconsiderphos-
phatecontent;alternatively
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Intramusculardepot
PREDNISOLONE
seenotesabove;alsoDuchenneÕsmuscular
dystrophy(possibletransientrhabdomyolysisand
myoglobinuriafollowingstrenuousphysicalactivity)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
6.3.2Glucocorticoidtherapy
BNFC2011–
Endocrinesystem
seenotesabove
seenotesabove
Indicationanddose
Autoimmuneinßammatorydisorders(including
juvenileidiopathicarthritis,connectivetissue
disordersandsystemiclupuserythematosus)
Bymouth
Child1month–18years
initially1Ð2mg/kgonce
daily(usualmax.60mgdaily),thenreducedaftera
fewdaysifappropriate
Autoimmunehepatitis
Bymouth
Child1month–18years
initially2mg/kgonce
daily(max.40mgdaily)thenreducedtominimum
effectivedose
orticosteroidreplacementtherapy
Bymouth
Child12–18years
2Ð2.5mg/m
dailyin1Ð2
divideddosesadjustedaccordingtoresponse
Infantilespasms
Bymouth
Child1month–2years
initially10mg4times
dailyfor14days(ifseizuresnotcontrolledafter7
daysincreaseto20mg3timesdailyfor7days);
reducedosegraduallyover15daysuntilstopped
(patientstaking40mgdaily,reducedoseinsteps
of10mgevery5days,thenstop;patientstaking
60mgdaily,reducedoseto40mgdailyfor5days,
then20mgdailyfor5days,then10mgdailyfor5
days,thenstop)
diopathicthrombocytopenicpurpura
Bymouth
Child1–10years
1Ð2mg/kgdailyformax.14
4mg/kgdailyformax.4days
Nephroticsyndrome
Bymouth
Child1month–18years
initially60mg/m
daily(max.80mgdaily)for4Ð6weeksuntilpro-
teinuriaceasesthen40mg/m
onalternatedays
for4Ð6weeks,thenwithdrawbyreducingdose
gradually;preventionofrelapse0.5Ð1mg/kgonce
dailyoronalternatedaysfor3Ð6months
seep.146
section12.1.1
section11.4.1
mmunosuppression
section8.2.2
nßammatoryboweldisease
section1.5.2
neumocystispneumonia
section5.4.8
heumaticdisease
section10.1.2
6.4.1.1
Oestrogens
Oestrogensarenecessaryforthedevelopmentof
Endocrinesystem
[unlicensedindication](seesection7.3.1)orasacom-
binedoestrogenandprogestogenhormonereplacement
therapypreparation[unlicensedindication](seeBNF
section6.4.1.1).Thereislimitedexperienceintheuse
oftransdermalpatchesorgelsinchildren;compliance
6.4.1.2
Progestogens
Therearetwomaingroupsofprogestogen,
oneanditsanalogues
(dydrogesteroneandmedroxy-
progesterone)and
testosteroneanalogues
Endocrinesystem
ostponementofmenstruation
Bymouth
5mg3timesdaily,starting3daysbeforeexpected
TESTOSTERONEANDESTERS
cardiacimpairment,hypertension,epilepsy,
Testocaps
Capsules
,orange,testosteroneundecanoate40mgin
Intramuscular
TestosteroneEnantate
Endocrinesystem
L
Testosterone
Testosterone
,testosterone5%(otherstrengthsavailable)
AvailablefromÔspecial-orderÕmanufacturersorspecialist
importingcompanies,seep.809
Anti-androgensandprecocious
puberty
Thegonadorelinstimulationtest(section6.5.1)isused
TESTOLACTONE
Appendix1(testolactone)
avoid
noinformationavailable
nausea,vomiting,anorexia,diarrhoea;
hypertension;peripheralneuropathy;weightchanges;
changesinhairpattern;rarelyhypersensitivityreac-
tions,rash
Indicationanddose
onadotrophin-independentprecocious
puberty
(specialistuseonly;seealsonotesabove)
Bymouth
5mg/kg3Ð4timesdaily;upto10mg/kg4times
dailymayberequired
Testolactone
monitorbonemineraldensity
Contra-indications
undiagnosedvaginalbleeding
avoid
avoid
changesinbloodpressure,headache,
moodchangesincludingdepression,hypersensitivity
reactionsincludingurticaria,pruritus,rash,asthma
6.4.2Malesexhormonesandantagonists
BNFC2011–
Endocrinesystem
andanaphylaxis;changesinscalpandbodyhair,
weightchanges,withdrawalbleeding,ovariancysts
(mayrequirewithdrawal),breastswellingandten-
derness(malesandfemales),visualdisturbances,
paraesthesia,localreactionsatinjectionsite
Licenseduse
notlicensedforuseinchildren
Indicationanddose
onadotrophin-dependentprecociouspuberty
Seenotesabove;fordoses,seeunderpreparations
Injectionsmayberequiredmorefrequentlyinsome
Rotateinjectionsitetopreventatro-
phyandnoduleformation
TRIPTORELIN
seeGoserelin
Contra-indications
seeGoserelin
avoid
avoid
seeGoserelin;alsogastro-intestinaldis-
turbances;asthenia;arthralgia
Indicationanddose
Gonadotrophin-dependentprecociouspuberty
Seenotesabove;fordoses,seeunderpreparations
rotateinjectionsitetopreventatro-
phyandnoduleformation
(Ipsen)
,(powderforsuspension),m/r,triptorelin(as
OXANDROLONE
seeTestosterone(section6.4.2);
Appendix1(oxandrolone)
Contra-indications
seeTestosterone(section6.4.2)
Hepaticimpairment
seeTestosterone(section6.4.2)
BNFC2011–
6.4.3Anabolicsteroids
Endocrinesystem
Renalimpairment
seeTestosterone(section6.4.2)
seeTestosterone(section6.4.2)
seeTestosterone(section6.4.2)
seeTestosterone(section6.4.2)
Indicationanddose
timulationoflatepre-pubertalgrowthinboys
withshortstature
Bymouth
Boys10–18years(orappropriateage)
2.5mgdailyfor3Ð6months
timulationoflatepre-pubertalgrowthingirls
withTurnerÕssyndrome
Bymouth
incombinationwithgrowthhormone0.625Ð
2.5mgdaily
CORTICORELIN
(Corticotrophin-releasinghormone,CRH)
avoid
avoid
ßushingofface,neckandupperbody,
hypotension,mildsensationoftasteorsmell
Licenseduse
notlicensed
6.5Hypothalamicandpituitaryhormones
BNFC2011–
Endocrinesystem
Indicationanddose
estofanteriorpituitaryfunction
Byintravenousinjectionover30seconds
Child1month–18years
1microgram/kg(max.
100micrograms)asasingledose
CRHFerring
,corticorelin100micrograms
Gonadotrophins
Gonadotrophinsareoccasionallyusedinthetreatment
ofhypogonadotrophichypogonadismandassociated
oligospermia.ThereisnojustiÞcationfortheirusein
primarygonadalfailure.
Chorionicgonadotrophinisusedintheinvestigationof
testicularfunctioninsuspectedprimaryhypogonadism
CHORIONICGONADOTROPHIN
(HumanChorionicGonadotrophin;HCG)
theactionofthepituitaryluteinisinghormone
cardiacimpairment,asthma,epilepsy,
migraine;prepubertalboys(riskofprematureepi-
physealclosureorprecociouspuberty)
Contra-indications
androgen-dependenttumours
Renalimpairment
usewithcaution
oedema(reducedose),headache,tired-
ness,moodchanges,gynaecomastia,localreactions
Licenseduse
unlicensedinchildrenfortestoftes-
ticularfunction
Indicationanddose
estoftesticularfunction
Byintramuscularinjection
Shortstimulationtest:
Child1month–18years
1500Ð2000unitsonce
dailyfor3days
Prolongedstimulationtest:
Child1month–18years
1500Ð2000unitstwice
weeklyfor3weeks
ypogonadotrophichypogonadism
Byintramuscularinjection
Child1month–18years
1000Ð2000unitstwice
weekly,adjustedtoresponse
ndescendedtestes
Byintramuscularinjection
Child7–18years
initially500units3times
weekly(1000unitstwiceweeklyifover17years);
adjustedtoresponse;upto4000units3times
weeklymayberequired;continuefor1Ð2months
aftertesticulardescent
,powderforreconstitution,chorionic
SOMATROPIN
(RecombinantHumanGrowthHormone)
Endocrinesystem
Prader-Willisyndrome);severeobesityorsevere
respiratorysyndromeinPrader-Willisyndrome
interrupttreatmentifpregnancyoccurs
absorptionfrommilkunlikely
headache,funduscopyforpapilloedema
recommendedifsevereorrecurrentheadache,visual
problems,nauseaandvomitingoccurÑifpapilloede-
maconÞrmedconsiderbenignintracranialhyper-
Endocrinesystem
Zomacton
,powderforreconstitution,somatropin
(Gonadotrophin-releasinghormone;GnRH;
pituitaryadenoma
avoid
avoid
rarelynausea,headache,abdominal
pain,increasedmenstrualbleeding;rarely,hyper-
sensitivityreactiononrepeatedadministrationof
largedoses;irritationatinjectionsite
Licenseduse
notlicensedforuseinchildrenunder1
year
Indicationanddose
ssessmentofanteriorpituitaryfunction;
assessmentofdelayedpuberty
Bysubcutaneousorintravenousinjection
Child1–18years
2.5micrograms/kg(max.
100micrograms)asasingledose
DESMOPRESSIN
seeunderVasopressin;lesspressoractivity,
butstillconsiderablecautionincardiovasculardis-
easeandinhypertension(notindicatedfornocturnal
enuresisornocturiainthesecircumstances);also
considerablecautionincysticÞbrosis;innocturiaand
nocturnalenuresislimitßuidintakefrom1hour
beforedoseuntil8hoursafterwards;innocturia
periodicbloodpressureandweightchecksneededto
monitorforßuidoverload;
Appendix1
ForcautionsspeciÞcallyrelatingtotheuseof
desmopressininnocturnalenuresisseesection7.4.2
Hyponatraemicconvulsions
Patientsbeingtreatedforpri-
marynocturnalenuresisshouldbewarnedtoavoidßuid
overload(includingduringswimming)andtostoptaking
desmopressinduringanepisodeofvomitingordiarrhoea
(untilßuidbalancenormal).Theriskofhyponatraemic
convulsionscanalsobeminimisedbykeepingtothe
recommendedstartingdosesandbyavoidingconcomitant
Endocrinesystem
smalloxytociceffectinthirdtrimester;
increasedriskofpre-eclampsia
amounttoosmalltobeharmful
Endocrinesystem
Child1–18years
4micrograms/kgasasingle
dose,forpre-operativeusegive2hoursbefore
procedure
enalfunctiontesting
Child1month–1year
10micrograms(empty
bladderattimeofadministrationandrestrictßuid
intaketo50%atnext2feedstoavoidßuidover-
hild1–15years
20micrograms(emptybladder
attimeofadministrationandrestrictßuidintaketo
500mLfrom1hourbeforeuntil8hoursafter
administrationtoavoidßuidoverload)
hild15–18years
40micrograms(empty
bladderattimeofadministrationandrestrictßuid
intaketo500mLfrom1hourbeforeuntil8hours
afteradministrationtoavoidßuidoverload)
Bysubcutaneousorintramuscularinjection
Child1month–1year
400nanograms(empty
bladderattimeofadministrationandrestrictßuid
intaketo50%atnext2feedstoavoidßuidover-
hild1–18years
2micrograms(emptybladderat
timeofadministrationandrestrictßuidintaketo
500mLfrom1hourbeforeuntil8hoursafter
administrationtoavoidßuidoverload)
A
VASOPRESSIN
heartfailure,hypertension,asthma,epilepsy,
migraineorotherconditionswhichmightbeaggra-
Endocrinesystem
chronicnephritis(untilreasonablebloodnitrogen
concentrationsattained)
Renalimpairment
seeContra-indications
oxytociceffectinthirdtrimester
notknowntobeharmful
CALCITONIN(SALMON)/
SALCATONIN
historyofallergy(skintestadvised);heart
failure;childrenÑuseforshortperiodsonlyand
monitorbonegrowth
Contra-indications
Renalimpairment
usewithcaution
avoidunlessessential,toxicityin
avoidunlessessential,mayinhibit
nausea,vomiting,diarrhoea,abdominal
pain,ßushing,dizziness,headache,tastedisturbances;
Endocrinesystem
dissolution,andthereforereducingtherateofbone
turnover.
Abisphosphonatesuchas
disodiumpamidronate
usedinthemanagementofsevereformsof
osteogenesis
imperfecta
andothercausesofosteoporosisinchildren
toreducethenumberoffractures;thelong-termeffects
ofbisphosphonatesinchildrenhavenotbeenestab-
lished.Singledosesofbiphosphonatesarealsousedto
managehypercalaemia(section9.5.1.2).Treatment
shouldbeinitiatedunderspecialistadvice
MHRA/CHMadvice(October2007andNovem-
ber2009)
Theriskofosteonecrosisofthejawissubstantially
greaterforpatientsreceivingintravenousbisphos-
phonatesinthetreatmentofcancerthanforpatients
receivingoralbisphosphonatesforosteoporosisor
ALENDRONICACID
uppergastro-intestinaldisorders(dysphagia,
symptomaticoesophagealdisease,gastritis,duodeni-
tis,orulcersÑseealsounderContra-indicationsand
Side-effects);history(within1year)ofulcers,active
gastro-intestinalbleeding,orsurgeryoftheupper
gastro-intestinaltract;correctdisturbancesofcalcium
DISODIUMPAMIDRONATE
Disodiumpamidronatewasformerlycalledaminohydroxypro-
pylidenediphosphonatedisodium(APD)
cardiacdisease;previousthyroidsurgery
(riskofhypocalcaemia);monitorserumelectrolytes,
calcium,andphosphateÑpossibilityofconvulsions
duetoelectrolytechanges;ensureadequatehydra-
tion;avoidconcurrentusewithotherbisphosphon-
ates;considerdentalcheck-upbeforeinitiating
bisphosphonate(riskofosteonecrosisofthejaw,see
MHRA/CHMadvice,above);
Appendix
1(bisphosphonates)
Skilledtasks
Patientsshouldbewarnedagainstdriving,
cycling,orperformingskilledtasksimmediatelyaftertreat-
ment(somnolenceordizzinesscanoccur)
Hepaticimpairment
usewithcautioninsevere
impairmentÑnoinformationavailable
Renalimpairment
monitorrenalfunctioninrenal
diseaseorpredispositiontorenalimpairment(e.g.in
tumour-inducedhypercalcaemia)
avoidÑtoxicityin
avoid
hypophosphataemia,transientrisein
bodytemperature,feverandinßuenza-likesymptoms
Endocrinesystem
hypernatraemia;osteonecrosisofthejaw(see
MHRA/CHMadvice,p.389);isolatedcasesofsei-
zures,hallucinations,thrombocytopenia,haematuria,
RISEDRONATESODIUM
oesophagealabnormalitiesandotherfactors
whichdelaytransitoremptying(e.g.strictureor
achalasiaÑseealsounderSide-effects);correct
hypocalcaemiabeforestarting,correctotherdistur-
SODIUMCLODRONATE
monitorrenalandhepaticfunctionand
whitecellcount;alsomonitorserumcalciumand
phosphateperiodically;renaldysfunctionreportedin
patientsreceivingconcomitantNSAIDs;maintain
adequateßuidintakeduringtreatment;consider
dentalcheck-upbeforeinitiatingbisphosphonate(risk
ofosteonecrosisofthejaw,seeMHRA/CHMadvice,
p.389);
Appendix1(bisphosphonates)
Contra-indications
acutegastro-intestinalinßamm-
atoryconditions
Renalimpairment
usehalfnormaldoseifestimated
glomerularÞltrationrate10Ð30mL/minute/1.73m
avoidifestimatedglomerularÞltrationratelessthan
10mL/minute/1.73m
avoid
noinformationavailable
nausea,diarrhoea;skinreactions;bron-
veryrarely
osteonecrosisofthejaw(see
MHRA/CHMadvice,p.389)
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seenotesabove,specialistuseonly
Counselling
Avoidfoodfor1hourbeforeandafteroral
treatment,particularlycalcium-containingproductse.g.
milk;alsoavoidironandmineralsupplementsandantacids;
maintainadequateßuidintake
(BayerSchering)
Capsules
Endocrinesystem
Otherendocrinedrugs
Bromocriptineandother
dopaminergicdrugs
Drugsaffectinggonadotrophins
(Recombinanthumaninsulin-likegrowthfac-
tor-I;rhIGF-I)
correcthypothyroidismbeforeinitiating
Endocrinesystem
Indicationanddose
rowthfailureinchildrenwithsevereprimary
insulin-likegrowthfactor-IdeÞciency
Bysubcutaneousinjection
Child2–18years
initially40micrograms/kg
twicedailyfor1week,iftoleratedincreasedosein
stepsof40micrograms/kgtomax.120micr-
ograms/kgtwicedaily;discontinueifnoresponse
within1year
Counselling
Doseshouldbeadministeredjustbeforeor
afterfood;donotincreasedoseifadoseismissed
Reducedoseifhypoglycaemiaoccursdespiteadequate
foodintake;withholdinjectionifpatientunabletoeat
(Ipsen)
Endocrinesystem
Vaginalandvulval
infections
EffectivespeciÞctreatmentsareavailableforthecom-
monvaginalinfections.
Fungalinfections
Vaginalfungalinfectionsarenotnormallyaproblemin
youngergirlsbutcanoccurinadolescents.
canbetreatedlocallywithcream,butisalmost
invariablyassociatedwithvaginalinfectionwhich
shouldalsobetreated.
Vaginalcandidiasis
,rarein
girlsbeforepuberty,canbetreatedwithantifungal
pessariesorcreaminsertedhighintothevagina(includ-
ingduringmenstruation),however,thesearenotrecom-
mendedforpre-pubertalgirlsandtreatmentwithan
externalcreammaybemoreappropriate.Single-dose
intravaginalpreparationsofferanadvantagewhencom-
plianceisaproblem.Localirritationcanoccuron
applicationofvaginalantifungalproducts.
drugs(clotrimazole,econazole,fenticona-
zole,andmiconazole)areeffectiveagainstcandidain
shortcoursesof1to3daysaccordingtothepreparation
used;treatmentcanberepeatedifinitialcoursefailsto
controlsymptomsorifsymptomsrecur.Vaginalappli-
cationsmaybesupplementedwithantifungalcreamfor
vulvitisandtotreatothersuperÞcialsitesofinfection.
Oraltreatmentofvaginalinfectionwithßuconazole
(section5.2.1)maybeconsideredforgirlspost-puberty.
Vulvovaginalcandidiasisinpregnancy
Vulvova-
ginalcandidiasisiscommonduringpregnancyandcan
betreatedwithvaginalapplicationofanimidazole(such
asclotrimazole),andatopicalimidazolecreamfor
vulvitis.Pregnantwomenneedalongerdurationof
treatment,usuallyabout7days,tocleartheinfection.
Thereislimitedabsorptionofimidazolesfromtheskin
andvagina.Oralantifungaltreatmentshouldbeavoided
duringpregnancy.
Recurrentvulvovaginalcandidiasis
Recurrentvul-
vovaginalcandidiasisisveryrareinchildren,butcan
occuriftherearepredisposingfactorssuchasanti-
PREPARATIONSFORVAGINALAND
VULVALCANDIDIASIS
avoidintravaginalpreparations(particularly
thosethatrequireuseofanapplicator)inyounggirls
whoarenotsexuallyactive,unlessthereisnoalter-
seenotesabove
occasionallocalirritation
Licenseduse
consultproductliteratureforindivi-
dualpreparations
Indicationanddose
Seenotesaboveandunderpreparationsbelow
A
PREPARATIONSFOROTHER
VAGINALINFECTIONS
avoidintravaginalpreparations(particularly
thosethatrequiretheuseofanapplicator)inyoung
girlswhoarenotsexuallyactive,unlessthereisno
alternative.
Contraceptives
Combinedhormonalcontraceptives
Progestogen-onlycontraceptives
Spermicidalcontraceptives
Contraceptivedevices
Emergencycontraception
TheFraserGuidelines
shouldbefollowedwhenpre-
scribingcontraceptionforwomenunder16years.The
UKMedicalEligibilityCriteriaforContraceptiveUse
(availableat
www.fsrh.org
)ispublishedbytheFacultyof
SexualandReproductiveHealthcare;itcategorisesthe
SeeDepartmentofHealthGuidance(July2004):Best
practiceguidancefordoctorsandotherhealthprofes-
sionalsontheprovisionofadviceandtreatmenttoyoung
peopleunder16oncontraception,sexualandreproductive
health.Availableat
www.dh.gov.uk
7.3Contraceptives
BNFC2011–
progestogensisverysmallandwellbelowtherisk
associatedwithpregnancy.Theriskofvenousthrom-
boembolisminwomenusingacombinedoralcontra-
persistentvomitingorseverediarrhoealastingmore
than24hours,additionalprecautionsshouldbeused
duringandfor7days(9daysfor
)afterrecovery
(seealsounderMissedpill,above).Ifthevomitingand
weakness,motordisturbances,verymarkednumbness
suddenlyaffectingonesideoronepartofbody;
hepatitis,jaundice,liverenlargement;
veryhighbloodpressure;
prolongedimmobilityaftersurgeryorleginjury;
COMBINEDHORMONAL
CONTRACEPTIVES
seenotesabove;alsoriskfactorsforvenous
thromboembolism(seebelowandalsonotesabove),
arterialdiseaseandmigraine,seebelow;personalor
familyhistoryofhypertriglyceridaemia(increasedrisk
ofpancreatitis);hyperprolactinaemia(seekspecialist
advice);historyofseveredepressionespeciallyif
inducedbyhormonalcontraceptive;undiagnosed
breastmass;genemutationsassociatedwithbreast
cancer(e.g.BRCA1);sickle-celldisease;inßamm-
atoryboweldiseaseincludingCrohnÕsdisease;
reducedefÞcacyofcontraceptivepatchinwomen
withbody-weight
90kg;activetrophoblasticdis-
day4ofcycleorlater,additionalprecautions
CombinedOralContraceptives
SeeRiskofVenousThromboembolism(innotesabove)beforeprescribing
Typeofpreparation
content
CombinedOralContraceptives(
continued
SeeRiskofVenousThromboembolism(innotesabove)beforeprescribing
TypeofpreparationOestrogen
content
7.3.1Combinedhormonalcontraceptives
BNFC2011–
contraceptives
Oralprogestogen-onlycontraceptives
Parenteralprogestogen-only
contraceptives
Intra-uterineprogestogen-onlydevice
7.3.2.1
Oralprogestogen-only
contraceptives
Oralprogestogen-onlypreparationsmayofferasuitable
alternativewhenoestrogensarecontra-indicated
(includingthosepatientswithvenousthrombosisora
pasthistoryorpredispositiontovenousthrombosis),
buthaveahigherfailureratethancombinedprepara-
tions.Theyaresuitableforheavysmokers,andforthose
TheFacultyofSexualandReproductiveHealthcare
recommendsemergencycontraception(seep.408)if
ORALPROGESTOGEN-ONLY
CONTRACEPTIVES
(Progestogen-onlypill,ÔPOPÕ)
arterialdisease;sex-steroiddependentcan-
cer;pastectopicpregnancy;malabsorptionsyn-
Indicationanddose
Bymouth
7.3.2.2
Parenteralprogestogen-only
contraceptives
Reductioninbonemineraldensityand,rarely,osteo-
porosisandosteoporoticfractureshavealsobeen
PARENTERALPROGESTOGEN-ONLY
CONTRACEPTIVES
seenotesaboveandunderpreparations;
possibleriskofbreastcancer,seeoralprogestogen-
onlycontraceptives(section7.3.2.1);historyduring
Injectablepreparations
(Pzer)
(aqueoussuspension),medroxyprogester-
Nexplanon
TA
7.3.2.3
Intra-uterineprogestogen-only
device
Theprogestogen-onlyintra-uterinesystem,
levonorgestrel
directlyintotheuterinecavity.
Itisusedasacontraceptive,forthetreatmentof
primarymenorrhagiaandforthepreventionofendo-
Initially,changesinthepatternand
durationofmenstrualbleeding(spottingorprolonged
INTRA-UTERINEPROGESTOGEN-
ONLYSYSTEM
seenotesabove;historyofdepression;
advanceduterineatrophy;systemiclupuserythe-
matosuswithpositive(orunknown)antiphospholipid
antibodies;notsuitableforemergencycontraception;
seenotesaboveandAppendix1(pro-
Contra-indications
seenotesabove
Hepaticimpairment
seeOralProgestogen-only
Contraceptives,section7.3.2.1
avoid;ifpregnancyoccursremovesystem
progestogen-onlycontraceptivesdo
notaffectlactation
seenotesabove;alsoabdominalpain,
shouldprovidefullcounselling,backed,whereavail-
INTRA-UTERINECONTRACEPTIVE
seenotesabove;alsoanaemia,menorrhagia
(progestogenintra-uterinesystemmightbeprefer-
Neo-Safe
Intra-uterinedevice
,copperwire,woundonverticalstemof
T-shapedplasticcarrier,surfaceareaapprox.380mm
impregnatedwithbariumsulphateforradio-opacity,threads
Rubbercontraceptivecaps
TypeAContraceptivePessary
Opaquerubber,sizes1(50mm),2(55mm),3(60mm),4
Siliconecontraceptivecaps
SiliconeContraceptivePessary
Rubbercontraceptivediaphragms
Siliconecontraceptivediaphragms
womenaccordingly].Thereisnoneedtoincreasethe
doseforemergencycontraceptionifthepatientistaking
antibacterialsthatarenotenzymeinducers.
seenotesabove;pastectopicpregnancy;
severemalabsorptionsyndromes;activetrophoblastic
seeunderDoxazosin(section2.5.4)
Contra-indications
seeunderDoxazosin(section
Hepaticimpairment
seeunderDoxazosin(section
seeunderDoxazosin(section2.5.4)
BNFC2011–
7.4Drugsforgenito-urinarydisorders
seeunderDoxazosin(section2.5.4)
seeunderDoxazosin(section2.5.4)
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ysfunctionalvoiding
(seenotesabove)
Bymouth
Child4–12years
initially0.5mgdailyincreased
atmonthlyintervalsaccordingtoresponse;max-
imum2mgdaily
hild12–18years
initially1mgdaily,dosemay
bedoubledatintervalsof1monthaccordingto
response;usualmaintenance2Ð4mgdaily;max.
8mgdaily
ypertension
section2.5.4
Section2.5.4
TAMSULOSINHYDROCHLORIDE
carewithinitialdose(posturalhypotension);
cataractsurgery(riskofintra-operativeßoppyiris
Appendix1(alpha-blockers)
Mayaffectperformanceofskilledtaskse.g.driving
Contra-indications
historyofposturalhypotension
Hepaticimpairment
avoidinsevereimpairment
Renalimpairment
usewithcautionifestimated
glomerularÞltrationratelessthan10mL/minute/
1.73m
dizziness,headache,asthenia;abnormal
lesscommonly
nausea,vomiting,consti-
pation,diarrhoea,palpitation,posturalhypotension,
syncope,rhinitis,rash,pruritus,andurticaria;
angioedemaandpriapism;alsodrowsiness,
blurredvision,drymouth,andoedema;
alsoreported
intra-operativeßoppyirissyndrome
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ysfunctionalvoiding
(seenotesabove)
Bymouth
Child12–18years
400microgramsoncedaily
Tamsulosinhydrochloride
OXYBUTYNINHYDROCHLORIDE
seenotesabove;acuteporphyria(section
Contra-indications
seenotesabove
Hepaticimpairment
manufactureradvisescaution
Renalimpairment
manufactureradvisescaution
manufactureradvisesavoidunlessessen-
tialÑtoxicityin
animal
manufactureradvisesavoidÑpresent
inmilkin
seenotesabove;alsodizziness;
commonly
anorexia,facialßushing;
nightter-
Licenseduse
notlicensedforuseinchildrenunder5
years;intravesicalinstillationnotlicensedforusein
Indicationanddose
rinaryfrequency,urgencyandincontinence,
neurogenicbladderinstability
Bymouth
Child2–5years
1.25Ð2.5mg2Ð3timesdaily;
7.4.2Drugsforurinaryfrequency,enuresis,andincontinence
BNFC2011–
Child5–12years
2.5Ð3mgtwicedaily,increased
to5mg2Ð3timesdaily
hild12–18years
5mg2Ð3timesdaily,
increasedifnecessarytomax.5mg4timesdaily
Byintravesicalinstillation
Child2–18years
5mg2Ð3timesdaily
octurnalenuresisassociatedwithoveractive
Bymouth
Child5–18years
2.5Ð3mgtwicedailyincreased
to5mg2Ð3timesdaily(lastdosebeforebedtime)
OxybutyninHydrochloride
ModiÞedrelease
Lyrinel
TOLTERODINETARTRATE
seenotesabove;historyofQT-intervalpro-
longation;concomitantusewithotherdrugsknownto
prolongQTinterval
Contra-indications
seenotesabove
Hepaticimpairment
reducedose;avoid
ModiÞedrelease
1hourbeforetakingdesmopressinuntil8hoursafter.
Whenstoppingtreatmentwithdesmopressin,gradual
withdrawalshouldbeconsidered.
Nocturnalenuresisassociatedwithdaytimesymptoms
(overactivebladder)canbemanagedwithanti-
muscarinicdrugs(seeUrinaryincontinence,p.410)in
combinationwithdesmopressin.Treatmentshouldbe
prescribedonlyafterspecialistassessmentandshould
becontinuedfor3months;thecoursecanberepeatedif
necessary.
Thetricyclicantidepressant
(section4.3.1)
maybeconsideredforchildrenwhohavenotresponded
toallothertreatmentsandhaveundergonespecialist
assessment,however,behaviouraldisturbancescan
occurandrelapseiscommonafterwithdrawal.Treat-
mentshouldnotnormallyexceed3monthsunlessa
physicalexaminationismadeandthechildisfully
reassessed;toxicityfollowingoverdosagewithtricyclics
isofparticularconcern.
Drugsusedinurological
Lidocainegel
isausefultopicalapplicationin
POTASSIUMCITRATE
cardiacdisease;
Appendix1
(potassiumsalts)
Renalimpairment
closemonitoringrequiredÑhigh
riskofhyperkalaemia;avoidinsevereimpairment
hyperkalaemiaonprolongedhigh
dosage,milddiuresis
Indicationanddose
eliefofdiscomfortinmildurinary-tractinfec-
tions,alkalinisationofurine
fordoseseepre-
parationsbelow
PotassiumCitrateMixtureBP
(PotassiumCitrateOralSolution)
Oralsolution
,potassiumcitrate30%,citricacid
monohydrate5%inasuitablevehiclewithalemon
ßavour.Extemporaneouspreparationsshouldbe
recentlypreparedaccordingtothefollowingformula:
potassiumcitrate3g,citricacidmonohydrate500mg,
syrup2.5mL,quillaiatincture0.1mL,lemonspirit
0.05mL,double-strengthchloroformwater3mL,
waterto10mL.Containsabout28mmolK
/10mL.
Label:27
Bymouth
Child1–6years
5mL3timesdailywelldilutedwith
water
Child6–18years
10mL3timesdailywelldilutedwith
water
Proprietarybrandsofpotassiumcitrateareonsaleto
thepublicforthereliefofdiscomfortinmildurinary-tract
Bladderinstillationsand
urologicalsurgery
Bladderinfection
Varioussolutionsareavailableas
irrigationsorwashouts.
(section13.11.2)canbeusedin
themanagementofcommoninfectionsofthebladder
butitisineffectiveagainstmost
Pseudomonas
spp.
Solutionscontainingchlorhexidine1in5000(0.02%)
areused,buttheymayirritatethemucosaandcause
burningandhaematuria(inwhichcasetheyshouldbe
discontinued);sterile
sodiumchloridesolution0.9%
(physiologicalsaline)isusuallyadequateandispre-
ferredasamechanicalirrigant.
Dissolutionofbloodclots
Drugsforerectile
dysfunction
Thissectionisnotincludedin
BNFforChildren
.Ado-
lescentspresentingwitherectiledysfunctionshouldbe
referredtoaspecialist.
BNFC2011–
7.4.5Drugsforerectiledysfunction
Malignantdiseaseand
immunosuppression
Cytotoxicdrugs
Alkylatingdrugs
Cytotoxicantibiotics
Malignantdiseaseandimmunosuppression
Intrathecalchemotherapy
AHealthServiceCircular(HSC2008/001)provides
guidanceontheintroductionofsafepracticeinNHS
Trustswhereintrathecalchemotherapyisadminis-
tered;writtenlocalguidancecoveringallaspectsof
nationalguidanceshouldbeavailable.Supportfor
trainingprogrammesisalsoavailable.
Copies,andfurtherinformationmaybeobtained
DepartmentofHealth
POBox777
LondonSE16XH
Fax:01623724524
www.dh.gov.uk
Safesystemrequirementsforcytotoxicmedicines:
Cytotoxicdrugsforthetreatmentofcancershould
begivenaspartofawiderpathwayofcarethatis
co-ordinatedbyamulti-disciplinaryteam;
Cytotoxicdrugsshouldbeprescribed,dispensed
andadministeredonlyinthecontextofawritten
protocolortreatmentplan;
Injectablecytotoxicdrugsshouldonlybedispensed
iftheyarepreparedforadministration;
Oralcytotoxicmedicinesshouldbedispensedwith
cleardirectionsforuse.
Risksofincorrectdosingoforalanti-cancer
Side-effectsofcytotoxicdrugsand
theirmanagement
Side-effectscommontomostcytotoxicdrugsaredis-
cussedbelowwhilstside-effectscharacteristicofapar-
ticulardrugorclassofdrugs(e.g.neurotoxicitywith
vincaalkaloids)arementionedintheappropriatesec-
tions.ManufacturersÕproductliterature,hospital-trust
protocols,andtreatmentprotocolsshouldbeconsulted
Malignantdiseaseandimmunosuppression
symptomsvaryaccordingtothedose,tootherdrugs
administered,andtotheindividualÕssusceptibilityto
Malignantdiseaseandimmunosuppression
Dexrazoxane
,anironchelator,islicensedinadultsfor
thepreventionofchroniccumulativecardiotoxicity
causedbydoxorubicinorepirubicintreatmentin
seenotesabove;monitorfullbloodcount
Hepaticimpairment
monitorliverfunction
Renalimpairment
usewithcautionÑriskofaccu-
mulation;manufacturerof
Cardioxane
reducedoseby50%ifcreatinineclearancelessthan
40mL/minute/1.73m
avoidunlessessential(toxicityin
studies);ensureeffectivecontraceptionduringandfor
3monthsaftertreatmentinmenandwomen
discontinuebreast-feeding
nausea,vomiting,dyspepsia,abdominal
pain,diarrhoea,stomatitis,drymouth,anorexia;
dyspnoea;dizziness,syncope,asthenia,paraesthesia,
tremor,fatigue,drowsiness;pyrexia;vaginal
haemorrhage;myalgia;blooddisorders(including
anaemia,leucopenia,neutropenia,andthrombocyto-
penia);alopecia,pruritus;peripheraloedema,injec-
tion-sitereactionsincludingphlebitis;
alsoreported
secondarymalignancies
Indicationanddose
reventionofanthracycline-inducedcardio-
(seenotesabove)
Byintravenousinfusion,30minutespriorto
anthracyclineadministration
10Ð20timesthedoxorubicin-equivalentdose
(dependingontreatmentprotocol)
10timesthe
epirubicin-equivalentdose
intravenousinfusion
eachvialwith25mLWaterforInjectionsthendilute
contentsofeachvialwith25Ð100mLCompound
SodiumLactate;giveover15minutes
Cardioxane
Intravenousinfusion
,powderforreconstitution,
ALLOPURINOL
ensureadequateßuidintake;forhyperuric-
aemiaassociatedwithcancertherapy,allopurinol
treatmentshouldbestartedbeforecancertherapy;
Appendix1(allopurinol)
Hepaticimpairment
reducedose,monitorhepatic
Renalimpairment
manufactureradvisesreducedose
orincreasedoseintervalinsevereimpairment;adjust
dosetomaintainplasma-oxipurinolconcentration
below100micromol/litre
toxicitynotreported;manufacturer
advisesuseonlyifnosaferalternativeanddisease
carriesriskformotherorchild
presentinmilkÑnotknowntobe
harmful
rashes(
withdraw
therapy;ifrashmild
re-introducecautiouslybut
immediately
ifrecurrenceÑhypersensitivityreactionsoccurrarely
andincludeexfoliation,fever,lymphadenopathy,
arthralgia,andeosinophiliaresemblingStevens-
Johnsonortoxicepidermalnecrolysis,vasculitis,
hepatitis,renalimpairment,and
veryrarely
gastro-intestinaldisorders;
malaise,headache,
vertigo,drowsiness,visualandtastedisturbances,
hypertension,alopecia,hepatotoxicity,paraesthesia
andneuropathy,blooddisorders(includingleuco-
penia,thrombocytopenia,haemolyticanaemiaand
aplasticanaemia)
Indicationanddose
rophylaxisofhyperuricaemiaassociatedwith
cancerchemotherapy,prophylaxisofhyperur-
icaemicnephropathy,enzymedisorderscaus-
ingincreasedserumuratee.g.Lesch-Nyhan
Bymouth
Child1month–15years
10Ð20mg/kgdaily
(max.400mgdaily),preferablyafterfood
hild15–18years
initially100mgdaily,
increasedaccordingtoresponse;max.900mg
daily(dosesover300mgdailygivenindivided
doses);preferablyafterfood
Allopurinol
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
monitorcloselyforhypersensitivity;atopic
allergies;mayinterferewithtestforuricacidÑconsult
productliterature
Contra-indications
G6PDdeÞciency(section9.1.5)
BNFC2011–
8.1Cytotoxicdrugs
Malignantdiseaseandimmunosuppression
manufactureradvisesavoidÑnoinforma-
tionavailable
manufactureradvisesavoidÑno
informationavailable
fever;nausea,vomiting;lessfrequently
diarrhoea,headache,hypersensitivityreactions
(includingrash,bronchospasmandanaphylaxis);
FOLINICACID
avoidsimultaneousadministrationof
Calciumfolinate
(Calciumleucovorin)
CalciumFolinate
Disodiumfolinate
,folinicacid(asdisodiumsalt)50mg/mL,
Malignantdiseaseandimmunosuppression
LEVOFOLINICACID
Levofolinicacidisanisomeroffolinicacid
seeFolinicacid
SafePractice
Intrathecalinjection
seeFolinicacid
seeFolinicacid
seeFolinicacid
Indicationanddose
Calciumlevofolinate
(Calciumlevoleucovorin)
CalciumLevofolinate
Disodiumlevofolinate
LevofolinicAcid
Contra-indications
hypersensitivitytothiol-contain-
ingcompounds
notknowntobeharmful
nausea,vomiting,colic,diarrhoea,fati-
gue,headache,limbandjointpains,depression,irrit-
ability,rash,hypotensionandtachycardia;rarely
hypersensitivityreactions(morecommoninpatients
withauto-immunedisorders)
Licenseduse
notlicensedforuseinchildren
Indicationanddose
rothelialtoxicityfollowingoxazaphosphorine
therapy
Byintravenousinjectionorbycontinuous
intravenousinfusion
Seenotesabove.Consultlocaltreatmentprotocol
(Busulphan)
seesection8.1andnotesabove;monitorfull
bloodcountregularlythroughouttreatment;monitor
liverfunction;previousmediastinalorpulmonary
radiationtherapy;avoidinacuteporphyria(butsee
section9.8.2);
Appendix1(busulfan)
Hepaticimpairment
manufactureradvisesmonitor
hepaticfunctionÑnoinformationavailable
avoid(teratogenicin
animals
);manufac-
turersadviseeffectivecontraceptionduringandfor6
monthsaftertreatmentinmenorwomen;seealso
PregnancyandReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
hepatotoxicity(includinghepaticveno-occlusivedis-
ease,hyperbilirubinaemia,jaundice,andÞbrosis);
cardiactamponadeinthalassaemia;pneumonia,skin
hyperpigmentation;
progressivepulmonary
BNFC2011–
8.1.1Alkylatingdrugs
Malignantdiseaseandimmunosuppression
Þbrosis,seizures,aplasticanaemia,visualdistur-
bances,hypersensitivityreactions(includingurticaria,
erythema);
veryrarely
myastheniagravis,gynaeco-
Indicationanddose
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
CHLORAMBUCIL
seesection8.1andnotesabove;monitorfull
bloodcountregularlythroughouttreatment;
increasedseizureriskinchildrenwithnephrotic
syndromeorhistoryofepilepsy;avoidinacutepor-
phyria(butseesection9.8.2)
Hepaticimpairment
manufactureradvisesconsider
dosereductioninsevereimpairmentÑlimitedinfor-
mationavailable
avoid;manufactureradviseseffective
contraceptionduringtreatmentinmenorwomen;see
alsoPregnancyandReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
commonly
skinrash(possibleprogressiontoStevens-
Johnsonsyndromeandtoxicepidermalnecrolysis);
seizures,hepatotoxicityandjaundice;
irreversiblebone-marrowsuppression,pulm-
onaryÞbrosis,tremor,peripheralneuropathy,sterile
cystitis,sterilityinprepubertalandpubertalmales
Licenseduse
notlicensedforuseinnephrotic
Indicationanddose
odgkinÕsdisease
Bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
CYCLOPHOSPHAMIDE
seesection8.1andnotesabove;previousor
concurrentmediastinalirradiationÑriskofcardio-
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
8.1.1Alkylatingdrugs
BNFC2011–
Malignantdiseaseandimmunosuppression
seesection8.1andnotesabove;ensure
satisfactoryelectrolytebalance,andrenalfunction
beforeeachcourse(riskoftubulardysfunction,Fan-
seesection8.1andnotesabove;monitorfull
bloodcountbeforeandthroughouttreatment;for
high-doseintravenousadministrationestablishade-
quatehydration(seenotesabove),consideruseof
BLEOMYCIN
seesection8.1;ensuremonitoringofpulm-
onaryfunctionÑinvestigateanyshortnessofbreath
beforeinitiation;cautioninhandlingÑirritanttotis-
Contra-indications
acutepulmonaryinfectionorsig-
niÞcantlyreducedlungfunction
Renalimpairment
reducedoseÑconsultlocaltreat-
Malignantdiseaseandimmunosuppression
(ActinomycinD)
seesection8.1andnotesabove;cautionin
handlingÑirritanttotissues
Hepaticimpairment
considerdosereductionifraised
serumbilirubinorbiliaryobstruction;consultlocal
treatmentprotocols
avoid(teratogenicin
animal
studies);see
alsoPregnancyandReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;
commonly
cheilitis,dysphagia;fever,malaise,
seesection8.1andnotesabove;cautionin
handlingÑirritanttotissues
Contra-indications
myocardialinsufÞciency,recent
myocardialinfarction,severearrhythmia;previous
treatmentwithmaximumcumulativedosesofdau-
norubicinorotheranthracycline
Hepaticimpairment
reducedoseaccordingtoserum
bilirubinconcentrationÑconsultlocaltreatmentpro-
Lipidformulation
DaunoXome
Concentrateforintravenousinfusion
,daunorubicin
DOXORUBICINHYDROCHLORIDE
seesection8.1andnotesabove;cautionin
handlingÑirritanttotissues;
Appendix
1(doxorubicin)
Contra-indications
severemyocardialinsufÞciency,
recentmyocardialinfarction,severearrhythmia;pre-
vioustreatmentwithmaximumcumulativedosesof
doxorubicinorotheranthracycline
Hepaticimpairment
reducedoseaccordingtobili-
rubinconcentrationÑconsultlocaltreatmentproto-
EPIRUBICINHYDROCHLORIDE
seesection8.1andnotesabove;cautionin
handlingÑirritanttotissues
Contra-indications
severemyocardialinsufÞciency,
recentmyocardialinfarction,severearrhythmia,
unstableangina,myocardiopathy;previoustreatment
withmaximumcumulativedosesofepirubicinor
otheranthracycline
Hepaticimpairment
reducedoseaccordingtobili-
rubinconcentrationÑconsultlocaltreatmentproto-
Malignantdiseaseandimmunosuppression
Epirubicinhydrochloride
seesection8.1andnotesabove
Hepaticimpairment
usewithcautionÑconsultlocal
treatmentprotocol
avoid;effectivecontraceptionduringand
foratleast6monthsaftertreatmentinmenor
women;seealsoPregnancyandReproductiveFunc-
tion,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;transi-
entblue-greendiscolorationofurine;lesscommonly
gastro-intestinalbleeding,anorexia,allergicreactions,
dyspnoea,fatigue,fever,amenorrhoea,andtransient
bluediscolorationofskinandnails
Licenseduse
notlicensedforuseinchildren
Indicationanddose
cutemyeloidleukaemia,recurrentacute
lymphoblasticleukaemia
Byintravenousinfusion
CLOFARABINE
seesection8.1;cardiacdisease
Hepaticimpairment
manufactureradvisescautionin
mildtomoderateimpairment;avoidinsevere
impairment
Renalimpairment
manufactureradvisescautionin
mildtomoderateimpairment;avoidinsevere
impairment
manufactureradvisesavoid(teratogenicin
studies);seealsoPregnancyandReproductive
Function,p.416
discontinuebreast-feeding
BNFC2011–
Malignantdiseaseandimmunosuppression
seesection8.1;alsodiarrhoea,abdo-
minalpain,jaundice;tachycardia,ßushing,hypo-
tension,pericardialeffusion,oedema,haematoma;
CYTARABINE
seesection8.1andnotesabove;
Appendix1(cytarabine)
Hepaticimpairment
reducedose
Renalimpairment
consultlocaltreatmentprotocols
avoid(teratogenicin
animal
studies);see
alsoPregnancyandReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;
ÔcytarabinesyndromeÕÑ6Ð12hoursafterintravenous
administrationÑcharacterisedbyfeverandmalaise,
myalgia,bonepain,maculopapularrash,andocca-
sionallychestpain;
lesscommonly
(considerprophylacticcorticosteroideyedrops),
neurotoxicity,renalandhepaticdysfunction,jaundice;
severespinalcordtoxicityfollowingintrathecal
Licenseduse
intrathecalinjectionnot
licensedforuseinchildren
Indicationanddose
cutelymphoblasticleukaemia,acutemyeloid
leukaemia,non-HodgkinÕslymphoma
Byintravenousinjection,byintravenousinfu-
sion,orbysubcutaneousinjection
Lipidformulationforintrathecaluse
DepoCyte
Intrathecalinjection
,cytarabineencapsulatedin
FLUDARABINEPHOSPHATE
seesection8.1andnotesabove;monitorfor
signsofhaemolysis;monitorforneurologicaltoxicity;
worseningofexistingandincreasedsusceptibilityto
skincancer;
Appendix1(ßudarabine)
Contra-indications
haemolyticanaemia
Renalimpairment
reducedosebyupto50%if
creatinineclearance30Ð70mL/minute/1.73m
avoidifcreatinineclearancelessthan30mL/minute/
1.73m
avoid(embryotoxicandteratogenicin
studies);manufactureradviseseffective
contraceptionduringandforatleast6monthsafter
treatmentinmenorwomen;seealsoPregnancyand
ReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
diarrhoea,anorexia;oedema;pneumonia,cough;
peripheralneuropathy,visualdisturbances;chills,
fever,malaise,weakness;rash;
lesscommonly
intestinalhaemorrhage,pulmonarytoxicity(including
pulmonaryinÞltrates,pneumonitis,andÞbrosis),and
heartfailure,arrhythmia,coma,
seizures,agitation,myelodysplasticsyndrome,acute
myeloidleukaemia,opticneuropathy,blindness,Ste-
vens-Johnsonsyndrome,toxicepidermalnecrolysis,
skincancer,andhaemorrhagiccystitis
Licenseduse
notlicensedforuseinchildren
Indicationanddose
oorprognosisorrelapsedacutemyeloid
leukaemia,relapsedacutelymphoblasticleuk-
aemia,conditioningbeforebonemarrow
Bymouth,byintravenousinjection,orby
intravenousinfusion
MERCAPTOPURINE
seesection8.1andnotesabove;thiopurine
Malignantdiseaseandimmunosuppression
pancreatitis,fever,crystalluriawithhaematuria,rash,
andhyperpigmentation;
veryrarely
Licenseduse
notlicensedforuseinchildrenfor
acutelymphoblasticlymphomaorT-cellnon-
Hodgkinslymphoma
Indicationanddose
cutelymphoblasticleukaemia,lymphoblastic
Bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
reatmentofearlystageBurkittÕslymphoma,
non-HodgkinÕslymphoma,osteogenicsarco-
ma,someCNStumoursincludinginfantbrain
tumours,acutelymphoblasticleukaemia
Byintravenousinjectionorinfusion
Oralpreparations
Section10.1.3
seesection8.1andnotesabove;previousor
concurrentintrathecalchemotherapyorcraniospinal
irradiation(increasedriskofneurotoxicity)
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.cyclingordriving)
avoid(teratogenicin
animal
manufactureradviseseffectivecontraceptionduring
andforatleast3monthsaftertreatmentinmenand
women;seealsoPregnancyandReproductiveFunc-
tion,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
constipation,diarrhoea;confusion,seizures,drowsi-
ness,peripheralneurologicaldisorders,demyelina-
tion,hypoesthesia,paraesthesia,ataxia,tremor,
headache,asthenia,fatigue;pyrexia;hypoglycaemia,
electrolytedisturbances;arthralgia;benignand
malignanttumoursalsoreported
Indicationanddose
-cellacutelymphoblasticleukaemia,T-cell
lymphoblasticlymphoma
Byintravenousinfusion
(Thioguanine)
seesection8.1andnotesabove;thiopurine
Malignantdiseaseandimmunosuppression
liverfunctionweeklyÑdiscontinueiflivertoxicity
:Appendix1(tioguanine)
Hepaticimpairment
reducedose
Renalimpairment
reducedose
avoid(teratogenicityreportedwhenmen
receivingtioguaninehavefatheredchildren);ensure
effectivecontraceptionduringtreatmentinmenor
women;seealsoPregnancyandReproductiveFunc-
tion,p.416
discontinuebreast-feeding
seesection8.1;alsostomatitisand
hepatotoxicity;
rarely
intestinalnecrosisandperfora-
Indicationanddose
nfantacutelymphoblasticleukaemia
Bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Vincaalkaloidsand
VINBLASTINESULPHATE
seesection8.1andnotesabove;cautionin
Appendix1(vinblastine)
Contra-indications
seenotesabove
SafePractice
Intrathecalinjection
Hepaticimpairment
dosereductionmaybeneces-
Malignantdiseaseandimmunosuppression
Indicationanddose
odgkinÕsdiseaseandotherlymphomas
Byintravenousinjection
VINCRISTINESULPHATE
seesection8.1andnotesabove;neuro-
musculardisease;ileus;cautioninhandling;
Appendix1(vincristine)
Contra-indications
seenotesabove
SafePractice
Intrathecalinjection
Hepaticimpairment
dosereductionmaybeneces-
seesection8.1andnotesabove;consider
monitoringcardiacfunction;monitorelectrolytes
(fatalarrhythmiaspossibleifhypokalaemia);previous
treatmentwithanthracyclines;alsocautioninhand-
lingÑirritanttoskinandtissues
Hepaticimpairment
manufactureradvisesreduce
initialdoseby20Ð30%
Renalimpairment
manufactureradvisesreduceiniti-
aldoseby20Ð30%
avoid(teratogenicandtoxicin
studies);mayreducefertility;seealsoPregnancyand
ReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1;mucositis,phlebitis;
commonly
diarrhoea,cardiotoxicity,haematuria,
renalimpairment,hepatotoxicity,skinrash;
acuterenalfailure,grandmalseizures
Licenseduse
notlicensedforuseinchildren
Indicationanddose
cutemyeloidleukaemia
Byintravenousinfusion
CRISANTASPASE
seesection8.1andnotesabove
Contra-indications
historyofpancreatitisrelatedto
asparaginasetherapy
avoid;seealsoPregnancyandReproduc-
tiveFunction,p.416
discontinuebreast-feeding
seesection8.1;alsoliverdysfunction,
pancreatitis,diarrhoea;coagulationdisorders;
Malignantdiseaseandimmunosuppression
Indicationanddose
cutelymphoblasticleukaemia,acutemyeloid
leukaemia,non-HodgkinÕslymphoma
Byintravenous,intramuscularorsubcutaneous
injection
Preparationsofasparaginasederivedfrom
chiacoli
areavailablebuttheyarenotlicensed,they
Medac
asparaginase,
ase,and
Oncaspar
pegaspargase.
Dacarbazineandtemozolomide
isacomponentofacommonlyused
combinationforHodgkinÕsdisease(ABVDÑdoxorubi-
cin[previously
Adriamycin
],bleomycin,vinblastine,
anddacarbazine).Itisgiven
intravenously
Temozolomide
isstructurallyrelatedtodacarbazine
andisusedinchildrenforsecond-linetreatmentof
malignantglioma.
seesection8.1;cautioninhandling
Hepaticimpairment
dosereductionmayberequired
incombinedhepaticandrenalimpairment;avoidin
severeimpairment
Renalimpairment
dosereductionmayberequiredin
combinedrenalandhepaticimpairment;avoidin
severeimpairment
avoid(carcinogenicandteratogenicin
studies);ensureeffectivecontraceptionduring
andforatleast6monthsaftertreatmentinmenor
women;seealsoPregnancyandReproductiveFunc-
tion,p.416
discontinuebreast-feeding
seesection8.1;
lesscom-
facialßushing,confusion,headache,seizures,
facialparaesthesia,inßuenza-likesymptoms,blurred
vision,renalimpairment,rash;
diarrhoea,
hepatotoxicityincludinglivernecrosisandhepatic
veinthrombosis,photosensitivity,irritanttoskinand
tissues,injection-sitereactions
Indicationanddose
odgkinÕsdisease,paediatricsolidtumours
Byintravenousinjectionorbyintravenous
TEMOZOLOMIDE
seesection8.1;
Appendix1
Hepaticimpairment
usewithcautioninsevere
impairmentÑnoinformationavailable
Renalimpairment
manufactureradvisescautionÑno
informationavailable
avoid(teratogenicandembryotoxicin
studies);manufactureradvisesadequate
contraceptionduringtreatment;menshouldavoid
fatheringachildduringandforatleast6monthsafter
treatment;seealsoPregnancyandReproductive
Function,p.416
discontinuebreast-feeding
seesection8.1
Indicationanddose
reatmentofmalignantglioma
Bymouth
IMATINIB
seesection8.1;cardiacdisease;monitorfor
Malignantdiseaseandimmunosuppression
taxis;dryskin,sweating,rash,pruritus,photosensit-
lesscommonly
gastriculceration,pancreatitis,
hepaticdysfunction(rarelyhepaticfailure,hepatic
necrosis),dysphagia,heartfailure,tachycardia,palpi-
tation,syncope,hypertension,hypotension,cold
extremities,cough,acuterespiratoryfailure,depres-
MITOTANE
seenotesabove;riskofaccumulationin
overweightpatients;monitorplasma-mitotanecon-
centrationÑconsultproductliterature;avoidinacute
porphyria(section9.8.2);
Appendix1
Skilledtasks
Centralnervoussystemtoxicitymayaffect
performanceofskilledtasks
Counselling
Childrenandtheircarersshouldbewarnedto
contactdoctorimmediatelyifinjury,infection,orillness
occurs(becauseoftheriskofacuteadrenalinsufÞciency)
Hepaticimpairment
manufactureradvisescautionin
mildtomoderateimpairmentÑmonitoringofplasma-
mitotaneconcentrationrecommended;avoidin
severeimpairment
Renalimpairment
manufactureradvisescautionin
mildtomoderaterenalimpairmentÑmonitoringof
plasma-mitotaneconcentrationrecommended;avoid
insevereimpairment
manufactureradvisesavoidÑwomenof
child-bearingageshoulduseeffectivecontraception
duringandaftertreatment;seealsoPregnancyand
ReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
gastro-intestinaldisturbances(includingnausea,
vomiting,diarrhoea,epigastricdiscomfort),anorexia,
liverdisorders;hypercholesterolaemia,hypertrigly-
ceridaemia;ataxia,confusion,asthenia,myasthenia,
paraesthesia,drowsiness,neuropathy,cognitive
impairment,movementdisorder,dizziness,headache;
gynaecomastia;prolongedbleedingtime,leucopenia,
thrombocytopenia,anaemia;rash;
rarely
vation,hypertension,posturalhypotension,ßushing,
pyrexia,haematuria,proteinuria,haemorrhagiccyst-
itis,hypouricaemia,visualdisturbancesandocular
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ymptomatictreatmentofadvancedorinoper-
ableadrenocorticalcarcinoma
Bymouth
CARBOPLATIN
seesection8.1andnotesabove;consider
therapeuticdrugmonitoring;
:Appendix
1(platinumcompounds)
Renalimpairment
reducedoseandmonitorhaema-
Malignantdiseaseandimmunosuppression
Indicationanddose
tage4neuroblastoma,germcelltumours,
low-gradegliomas(includingastrocytomas),
neuroectodermaltumours(includingmedullo-
CISPLATIN
seesection8.1andnotesabove;monitorfull
bloodcount,renalfunction,audiology,andplasma
electrolytes;
Appendix1(platinum
Renalimpairment
avoidifpossibleÑnephrotoxic
avoid(teratogenicandtoxicin
studies);manufactureradviseseffectivecontraception
duringandforatleast3monthsaftertreatmentin
menorwomen;seealsoPregnancyandReproductive
Function,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;also
peripheralneuropathy;hypophosphataemia,hypo-
calcaemia,hyperuricaemiaalsoreported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
steogenicsarcoma,stage4neuroblastoma,
somelivertumours,infantbraintumours,
intracranialgerm-celltumours
Byintravenousinfusion
seesection8.1andnotesabove;
Appendix1(procarbazine)
Hepaticimpairment
cautioninmildtomoderate
impairment;avoidinsevereimpairment
Renalimpairment
cautioninmildtomoderate
impairment;avoidinsevereimpairment
avoid(teratogenicin
animal
studiesand
isolatedreportsinhumans);seealsoPregnancyand
ReproductiveFunction,p.416
discontinuebreast-feeding
seesection8.1andnotesabove;hyper-
sensitivityrash(discontinuetreatment)
Indicationanddose
odgkinÕslymphoma,gliomas
Bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Malignantdiseaseandimmunosuppression
Drugsaffectingthe
immuneresponse
Antiproliferativeimmunosuppressants
Corticosteroidsandother
immunosuppressants
Rituximabandalemtuzumab
Otherimmunomodulatingdrugs
Immunosuppressanttherapy
Immunosuppressantsareusedtosuppressrejectionin
immunosuppressants
Azathioprine
iswidelyusedfortransplantrecipients
anditisalsousedtotreatanumberofauto-immune
conditions(seesection10.1.3),usuallywhencortico-
steroidtherapyaloneprovidesinadequatecontrol.Itis
AZATHIOPRINE
Malignantdiseaseandimmunosuppression
bonemarrowsuppressione.g.inexplicablebruisingor
bleeding,infection
Contra-indications
hypersensitivitytomercapto-
Hepaticimpairment
reducedose;monitorliverfunc-
tion;seealsoCautions
Renalimpairment
reducedose;seealsoCautions
seesection8.2;treatmentshouldnotnor-
mallybeinitiatedduringpregnancy
presentinmilkinlowconcentration;
noevidenceofharminsmallstudiesÑuseifpotential
beneÞtoutweighsrisk
hypersensitivityreactions(including
malaise,dizziness,vomiting,diarrhoea,fever,rigors,
myalgia,arthralgia,rash,hypotensionandinterstitial
nephritisÑcallingforimmediatewithdrawal);dose-
relatedbonemarrowsuppression(seealsoCautions);
liverimpairment,cholestaticjaundice,hairlossand
increasedsusceptibilitytoinfectionsandcolitisin
patientsalsoreceivingcorticosteroids;nausea;
rarely
pancreatitis,pneumonitis,hepaticveno-occlusive
disease,lymphoma
Indicationanddose
uppressionoftransplantrejection
Bymouth,or(iforalroutenotpossible)by
intravenousinfusion(seealsonotebelow)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Malignantdiseaseandimmunosuppression
rophylaxisofacuterejectioninhepatic
transplantationincombinationwithacortico-
steroidandciclosporinortacrolimus
Bymouth
Tacrolimus
isalsoacalcineurininhibitor.Althoughnot
chemicallyrelatedtociclosporinithasasimilarmodeof
actionandside-effects.
Sirolimus
isanon-calcineurininhibitingimmunosup-
isamonoclonalantibodythatpreventsT-
lymphocyteproliferation;itisusedforprophylaxisof
acuterejectioninallogeneicrenaltransplantation.Itis
givenwithciclosporinandcorticosteroidimmunosup-
pressionregimens;itsuseshouldbeconÞnedtospecia-
listcentres.
Antithymocyteimmunoglobulin
(rabbit)isusedfor
theprophylaxisoforganrejectioninrenalandheart
allograftrecipientsandforthetreatmentofcortico-
steroid-resistantallograftrejectioninrenaltransplanta-
IMMUNOGLOBULIN(RABBIT)
seenotesabove;monitorbloodcount
Contra-indications
manufactureradvisesuseonlyifpotential
beneÞtoutweighsriskÑnoinformationavailable
manufactureradvisesavoidÑno
informationavailable
nausea,vomiting,dysphagia,diarrhoea;
hypotension;infusion-relatedreactions(including
cytokinereleasesyndromeandanaphylaxis,seenotes
above),serumsickness;fever,shivering,increased
susceptibilitytoinfection;increasedsusceptibilityto
malignancy;lymphopenia,neutropenia,thrombocy-
topenia;myalgia;pruritus,rash
BNFC2011–
20128.2.2Corticosteroidsandotherimmunosuppressants
Malignantdiseaseandimmunosuppression
Indicationanddose
earttransplantation
Byintravenousinfusionoveratleast6hours
Child1month–18years
1Ð2.5mg/kgdailyfor3Ð
5daysstartingthedayoftransplantation
Toavoidexcessivedosageinobesepatients,cal-
culatedoseonthebasisofidealbodyweight
enaltransplantation
Byintravenousinfusionoveratleast6hours
Child1–18years
1Ð1.5mg/kgdailyfor3Ð9days
startingthedayoftransplantation
Toavoidexcessivedosageinobesepatients,cal-
culatedoseonthebasisofidealbodyweight
orticosteroid-resistantrenalgraftrejection
Byintravenousinfusionoveratleast6hours
Child1–18years
1.5mg/kgdailyfor7Ð14days
Toavoidexcessivedosageinobesepatients,cal-
culatedoseonthebasisofidealbodyweight
For
continuousintravenousinfusion
reconstituteeachvialwith5mLwaterforinjectionsto
produceasolutionof5mg/mL;gentlyrotatetodis-
solve.DiluterequisitedosewithGlucose5%
iumChloride0.9%toanapprox.concentrationof
0.5mg/mL;begininfusionimmediatelyafterdilution;
givethroughanin-lineÞlter(poresize0.22micron);
incompatiblewithunfractionatedheparinandhydro-
cortisoneinglucoseinfusionÑprecipitationreported
Thymoglobuline
Intravenousinfusion
,powderforreconstitution,
manufactureradvisesavoidÑnoinforma-
tionavailable;adequatecontraceptionmustbeused
duringtreatmentandfor16weeksafterlastdose
manufactureradvisesavoidÑno
informationavailable
severehypersensitivityreactionsand
cytokinereleasesyndromereported
Indicationanddose
rophylaxisofacuterejectioninallogeneic
renaltransplantationusedincombinationwith
ciclosporinandcorticosteroid-containing
immunosuppressionregimens
Byintravenousinjectionorbyintravenous
A
CICLOSPORIN
(Cyclosporin)
monitorkidneyfunctionÑdosedependent
increaseinserumcreatinineandureaduringÞrstfew
weeksmaynecessitatediscontinuation(exclude
rejectionofkidneytransplant);monitorliverfunction
(seealsoHepaticImpairmentbelow);monitorblood
pressureÑdiscontinueifhypertensiondevelopsthat
cannotbecontrolledbyantihypertensives;hyper-
uricaemia;monitorserumpotassiumespeciallyin
renaldysfunction(riskofhyperkalaemia);monitor
serummagnesium;measurebloodlipidsbefore
treatmentandthereafterasappropriate;monitor
wholebloodciclosporinconcentration(troughlevel
dependentonindicationÑconsultlocaltreatment
Malignantdiseaseandimmunosuppression
Indicationanddose
reventionofgraftrejectionfollowingbone-
marrow,kidney,liver,pancreas,heart,lung,
andheart-lungtransplantation,prophylaxis
andtreatmentofgraft-versus-hostdisease
Bymouthorbyintravenousinfusion
Concentrateforintravenousinfusion
(oily),ciclos-
monitorrenalfunctionwhengivenwith
ciclosporin;monitorwholeblood-sirolimustrough
concentration(Afro-Caribbeanpatientsmayrequire
higherdoses);hyperlipidaemia(monitorlipids);
monitorurineproteins;increasedsusceptibilityto
infection(especiallyurinary-tractinfection);increased
susceptibilitytolymphomaandothermalignancies,
particularlyoftheskin(limitexposuretoUVlight);
:Appendix1(sirolimus)
Hepaticimpairment
monitorblood-sirolimustrough
concentration;dosereductionmaybenecessary,
Malignantdiseaseandimmunosuppression
TACROLIMUS
monitorbloodpressure,ECG(
important
seecardiomyopathybelow),fastingblood-glucose
concentration,haematologicalandneurological
topiceczema(topicaluse)
section13.5.3
Important
Prograf
,and
(tacrolimus):seriousmedicationerrors
Thereare3differentoralformulationsoftacrolimus:
,and
areimmediate-release
capsulestakentwicedaily,onceinthemorningandoncein
theevening;
granulesareusedtoprepareanimmediate-
releaseoralsuspensionwhichistakentwicedaily,oncein
themorningandonceintheevening;
isaprolonged-releasecapsulethatistaken
oncedailyinthemorning.
Malignantdiseaseandimmunosuppression
Prophylaxisofgraftrejectionfollowinghearttrans-
followingantibodyinduction
,starting
within5daysoftransplantation
Bymouth
initially50Ð150micrograms/kgtwicedaily,
adjustedaccordingtowhole-bloodconcentration
Child1month–18years
initially50Ð150micrograms/
kgtwicedaily,adjustedaccordingtowhole-bloodcon-
Allograftrejectionresistanttoconventionalimmu-
nosuppressivetherapy
Consultlocaltreatmentprotocol
Modigraf
,tacrolimus(asmonohydrate),200micr-
Capsules
,tacrolimus(asmonohydrate)500micr-
Malignantdiseaseandimmunosuppression
Prophylaxisofgraftrejectionfollowinghearttrans-
followingantibodyinduction
,starting
within5daysoftransplantation
Bymouth
initially50Ð150micrograms/kgtwicedaily,
adjustedaccordingtowhole-bloodconcentration
Child1month–18years
initially50Ð150micrograms/
kgtwicedaily,adjustedaccordingtowhole-bloodcon-
Allograftrejectionresistanttoconventionalimmu-
nosuppressivetherapy
Consultlocaltreatmentprotocol
(Dexcel)
Capsules
ModiÞedrelease
Advagraf
isnotlicensedforuseinchildren
Capsules
,m/r,tacrolimus(asmonohydrate)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Rituximaband
alemtuzumab
,amonoclonalantibodywhichcauseslysis
ofBlymphocytes,hasbeenusedasacomponentofthe
treatmentofpost-transplantationlymphoproliferative
disease,non-HodgkinÕslymphoma,HodgkinÕslymph-
oma,andseverecasesofresistantimmunemodulated
diseaseincludingidiopathicthrombocytopeniapurpura,
haemolyticanaemia,andsystemiclupuserythemato-
sus.Fullresuscitationfacilitiesshouldbeathandandas
withothercytotoxics,treatmentshouldbeundertaken
undertheclosesupervisionofaspecialist.
Rituximabshouldbeusedwithcautioninchildren
receivingcardiotoxicchemotherapyorwithahistory
ofcardiovasculardisease;inadultsexacerbationof
angina,arrhythmia,andheartfailurehavebeen
reported.Transienthypotensionoccursfrequentlydur-
inginfusionandantihypertensivesmayneedtobe
withheldfor12hoursbeforeinfusion.Progressivemulti-
focalleucoencephalopathy(whichisusuallyfatalor
causesseveredisability)hasbeenreportedinassocia-
tionwithrituximab;childrentreatedwithrituximab
shouldbemonitoredforcognitive,neurological,or
psychiatricsignsandsymptoms.Ifprogressivemulti-
focalleucoencephalopathyissuspected,suspendtreat-
mentuntilithasbeenexcluded.
Infusion-relatedside-effects(includingcytokinerelease
syndrome)arereportedcommonlywithrituximaband
occurpredominantlyduringtheÞrstinfusion;they
includefeverandchills,nauseaandvomiting,allergic
reactions(suchasrash,pruritus,angioedema,broncho-
spasmanddyspnoea),ßushingandtumourpain.Chil-
Malignantdiseaseandimmunosuppression
,anothermonoclonalantibodythat
causeslysisofBandTlymphocytes,hasbeenusedin
childrenforconditioningtherapybeforeallogeneicbone
marrowtransplantation.Incommonwithrituximab,it
causesinfusion-relatedside-effectsincludingcytokine
releasesyndrome(seeabove)andpremedicationwith
(Roche)
Concentrateforintravenousinfusion
,rituximab
Otherimmunomodulating
Interferonalfa
Interferonalfa
hasshownsomeantitumoureffectand
mayhavearoleininducingearlyregressionoflife-
threateningcorticosteroid-resistanthaemangiomasof
infancy.Interferonalfapreparationsarealsousedin
thetreatmentofchronichepatitisB,andchronichepat-
itisCideallyincombinationwithribavirin(section
5.3.3).Interferonalfashouldalwaysbeusedunderthe
closesupervisionofaspecialist.Side-effectsaredose-
related,butcommonlyincludeanorexia,nausea,inßu-
INTERFERONALFA
consultproductliteratureandlocaltreat-
Malignantdiseaseandimmunosuppression
hronicactivehepatitisCinfection
seeunder
preparationsbelow
(Schering-Plough)
,interferonalfa-2b(rbe)10millionunits/mL,
INTERFERONGAMMA-1b
(Immuneinterferon)
seizuredisorders(includingseizuresasso-
ciatedwithfever);cardiacdisease(includingischae-
mia,congestiveheartfailure,andarrhythmias);
monitorbeforeandduringtreatment:haematological
tests(includingfullbloodcount,differentialwhitecell
historyofrecurrentinfectionorpredisposi-
tiontoinfection;monitorneutrophilcountbefore
startingtreatment,1Ð2monthsafterstartingtreat-
ment,andperiodicallythereafter;childrenshould
receiveallrecommendedvaccinations(including
pneumococcalandinactivatedinßuenzavaccine)
beforestartingtreatment;avoidlivevaccinesunless
potentialbeneÞtoutweighsriskÑconsultproductlit-
eratureforfurtherinformationandsection14.1,
p.599
Tuberculosis
Childrenshouldbeevaluatedforlatentand
activetuberculosisbeforestartingtreatmentandmonitored
forsignsandsymptomsoftuberculosisduringandafter
Contra-indications
severeactiveinfection(seealso
Cautions);neutropenia;concomitantusewithtumour
necrosisfactorinhibitors(possibleincreasedriskof
Hepaticimpairment
noinformationavailable
Renalimpairment
limitedinformationavailablebut
manufactureradvisesnodoseadjustmentrequired
manufactureradvisesavoidunlesspoten-
tialbeneÞtoutweighsrisk;effectivecontraception
8.2.4Otherimmunomodulatingdrugs
BNFC2011–
Malignantdiseaseandimmunosuppression
requiredduringtreatmentandforupto3monthsafter
lastdose
considerifbeneÞtoutweighsriskÑ
notknownifpresentinhumanmilk
vertigo,increasedsusceptibilitytoinfec-
tion,injection-sitereactions
Indicationanddose
ryopyrin-associatedperiodicsyndromes
Bysubcutaneousinjection
Child4–18years
ody-weight15–40kg
2mg/kgevery8weeks.If
clinicalresponsenotachieved7daysafterstarting
treatment,arepeatdoseof2mg/kgcanbecon-
sidered;ifafullresponseisthenachieved,subse-
quentdosingshouldbe4mg/kgevery8weeks
ody-weightover40kg
150mgevery8weeks.If
clinicalresponsenotachieved7daysafterstarting
treatment,arepeatdoseof150mgcanbecon-
sidered;ifafullresponseisthenachieved,subse-
quentdosingshouldbe300mgevery8weeks
,powderforreconstitution,canakinumab,
asthmaandchronicobstructivepulmonary
diseaseÑconsiderprophylacticbronchodilatorther-
apy;historyofautoimmune,inßammatory,orcol-
lagendisease;monitorrenalfunction,hepaticfunc-
Indicationanddose
Seenotesabove
Byintravenousinfusion(over1hour)
Malignantdiseaseandimmunosuppression
Nutritionandblood
Anaemiasandsomeotherblood
Iron-deÞciencyanaemias
Oraliron
Parenteraliron
Drugsusedinmegaloblastic
anaemias
Drugsusedinhypoplastic,
haemolytic,andrenalanaemias
9.1.1.1
Oraliron
Ironsaltsshouldbegivenbymouthunlessthereare
goodreasonsforusinganotherroute.
Nutritionandblood
Treatmentofiron-deÞciencyanaemia
Theoral
doseof
elementaliron
totreatdeÞciencyis3Ð6mg/kg
(max.200mg)dailygivenin2Ð3divideddoses.Iron
supplementationmayalsoberequiredtoproducean
FERROUSSULPHATE
Appendix1(iron)
seenotesabove
Indicationanddose
ron-deÞciencyanaemia,prophylaxisofiron
seenotesaboveandpreparations
FerrousSulphate
FERROUSFUMARATE
Appendix1(iron)
seenotesabove
Indicationanddose
ron-deÞciencyanaemia,prophylaxisofiron
seenotesaboveandpreparations
Fersaday
Nutritionandblood
Fersamal
FERROUSGLUCONATE
Appendix1(iron)
seenotesabove
Indicationanddose
ron-deÞciencyanaemia
seenotesaboveand
FerrousGluconate
POLYSACCHARIDE-IRONCOMPLEX
Appendix1(iron)
seenotesabove
Indicationanddose
ron-deÞciencyanaemia,prophylaxisofiron
seenotesaboveandpreparation
,brown,sugar-free,polysaccharide-ironcomplex
9.1.1.2
Parenteraliron
Ironcanbeadministeredparenterallyas
irondextran
ironsucrose
,or
ferriccarboxymaltose
.Parenteraliron
isgenerallyreservedforusewhenoraltherapyis
unsuccessfulbecausethechildcannottolerateoral
iron,ordoesnottakeitreliably,orifthereiscontinuing
bloodloss,orinmalabsorption.
Manychildrenwithchronicrenalfailurewhoarereceiv-
inghaemodialysis(andsomewhoarereceivingperito-
nealdialysis)alsorequireironbytheintravenousroute
Nutritionandblood
Anaphylacticreactionscanoccurwithparenteraliron
complexes;facilitiesforcardiopulmonaryresuscitation
mustbeavailable.Dependingonthepreparation,a
smalltestdosemayberequired.Ifchildrencomplain
ofacutesymptomsparticularlynausea,backpain,
breathlessness,ordevelophypotension,theinfusion
shouldbestopped.
FERRICCARBOXYMALTOSE
Aferriccarboxymaltosecomplexcontaining5%
(50mg/mL)ofiron
hypersensitivitycanoccurwithparenteral
ironandfacilitiesforcardiopulmonaryresuscitation
mustbeavailable;oralironshouldnotbegiven
concomitantly;allergicdisordersincludingasthma
andeczema;infection(discontinueifongoingbac-
Hepaticimpairment
usewithcaution;avoidincon-
ditionswhereironoverloadincreasesriskofimpair-
avoidinÞrsttrimester;crossesthepla-
centain
animal
IRONDEXTRAN
Acomplexofferrichydroxidewithsucrosecontaining
5%(50mg/mL)ofiron
oralironnottobegivenuntil5daysafterlast
Anaphylacticreactionscanoccurwithpar-
enteralironandatestdoseisrecommendedbefore
dose;thepatientshouldbecarefullyobservedfor60minutes
aftertheÞrsttestdoseandfor15minutesaftersubsequent
testdoses.Facilitiesforcardiopulmonaryresuscitationmust
beavailable;riskofallergicreactionsincreasedinimmuneor
inßammatoryconditions
Contra-indications
historyofallergicdisorders
includingasthma,andeczema;infection;active
rheumatoidarthritis
Hepaticimpairment
avoidinsevereimpairment
Renalimpairment
avoidinacuterenalfailure
avoidinÞrsttrimester
lesscommonly
nausea,vomiting,abdo-
minalpain,ßushing,dyspnoea,anaphylacticreactions
(seeAnaphylaxisabove),numbness,cramps,blurred
vision,pruritus,andrash;
rarely
diarrhoea,chestpain,
hypotension,angioedema,arrhythmias,tachycardia,
dizziness,restlessness,fatigue,seizures,tremor,
impairedconsciousness,myalgia,arthralgia,sweat-
ing,andinjection-sitereactions;
veryrarely
hyper-
tension,palpitation,headache,paraesthesia,haemo-
lysis,andtransientdeafness
Licenseduse
notlicensedforuseinchildrenunder
14years
Indicationanddose
ron-deÞciencyanaemia
seenotesabove
Byslowintravenousinjectionorbyintravenous
Calculatedaccordingtobody-weightandiron
deÞcit,consultproductliterature
CosmoFer
IRONSUCROSE
Acomplexofferrichydroxidewithsucrosecontaining
2%(20mg/mL)ofiron
oralirontherapyshouldnotbegivenuntil5
daysafterlastinjection;infection(discontinueif
ongoingbacteraemia)
Anaphylacticreactionscanoccurwithpar-
enteralironandatestdoseisrecommendedbeforetheÞrst
dose;thepatientshouldbecarefullyobservedfor15min-
utes.Facilitiesforcardiopulmonaryresuscitationmustbe
available
Contra-indications
historyofallergicdisorders
includingasthma,eczema,andanaphylaxis
Hepaticimpairment
usewithcaution;avoidincon-
ditionswhereironoverloadincreasesriskofimpair-
avoidinÞrsttrimester
tastedisturbances;
lesscommonly
nausea,vomiting,abdominalpain,diarrhoea,hypo-
tension,tachycardia,ßushing,palpitation,chestpain,
bronchospasm,dyspnoea,headache,dizziness,fever,
myalgia,pruritus,rash,andinjection-sitereactions;
peripheraloedema,anaphylacticreactions(see
Anaphylaxisabove),fatigue,asthenia,andparaes-
thesia;confusion,arthralgia,andincreasedsweating
alsoreported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ron-deÞciencyanaemia
seenotesabove
Byslowintravenousinjectionorbyintravenous
Calculatedaccordingtobody-weightandiron
deÞcit,consultproductliterature
Venofer
Nutritionandblood
administerbothsubstancesafterthebonemarrowtest
whileplasmaassayresultsareawaited.Normally,how-
ever,appropriatetreatmentshouldnotbeinstituted
untiltheresultsoftestsareavailable.
VitaminB
isusedinthetreatmentofmegaloblastosis
causedby
prolongednitrousoxideanaesthesia
,which
inactivatesthevitamin,andintheraredisordersof
congenitaltranscobalaminIIdeÞciency
Folinicacid
isalsoeffectiveinthetreatmentoffolate-
deÞcientmegaloblasticanaemiabutitisnormallyonly
usedinassociationwithcytotoxicdrugs(seesection
8.1);itisgivenascalciumfolinate.
Preventionofneuraltubedefects
Folicacidsup-
plementstakenbeforeandduringpregnancycanreduce
theoccurrenceofneuraltubedefects.Theriskofa
neuraltubedefectoccurringinachildshouldbe
assessedandfolicacidgivenasfollows:
Womenatalowriskofconceivingachildwitha
neuraltubedefectshouldbeadvisedtotakefolic
acidasamedicinalorfoodsupplementatadoseof
400microgramsdailybeforeconceptionanduntil
week12ofpregnancy.Womenwhohavenotbeen
takingfolicacidandwhosuspecttheyarepregnant
shouldstartatonceandcontinueuntilweek12of
pregnancy.
Couplesareatahighriskofconceivingachildwith
aneuraltubedefectifeitherpartnerhasaneural
tubedefect(oreitherpartnerhasafamilyhistoryof
neuraltubedefects),iftheyhavehadaprevious
pregnancyaffectedbyaneuraltubedefect,orifthe
womanhascoeliacdisease(orothermalabsorption
HYDROXOCOBALAMIN
shouldnotbegivenbeforediagnosisfully
establishedbutseealsonotesabove;
Appendix1(hydroxocobalamin)
presentinmilkbutnotknowntobe
harmful
nausea,headache,dizziness;fever,
hypersensitivityreactions(includingrashandpru-
ritus);injection-sitereactions;hypokalaemiaand
thrombocytosisduringinitialtreatment;chromaturia
Licenseduse
licensedforuseinchildren(agenot
speciÞedbymanufacturers);notlicensedforusein
Nutritionandblood
acrocyticanaemiawithneurologicalinvolve-
Byintramuscularinjection
Child1monthÐ18years
initially1mgonalter-
natedaysuntilnofurtherimprovement,then1mg
every2months
rophylaxisofmacrocyticanaemiasassociated
withvitaminB
Byintramuscularinjection
Child1monthÐ18years
1mgevery2Ð3months
eberÕsopticatrophy
Byintramuscularinjection
Initially1mgdailyfor2weeks,then1mgtwice
weeklyuntilnofurtherimprovement,thereafter
1mgevery1Ð3months
ongenitaltranscobalaminIIdeÞciency
Byintramuscularinjection
1mg3timesaweek,reduceafter1year
to1mgonceweeklyorasappropriate
Child1monthÐ18years
1mg3timesaweek,
reduceafter1yearto1mgonceweeklyoras
appropriate
FOLICACID
shouldneverbegivenaloneforvitaminB
deÞciencystates(mayprecipitatesubacutecombined
degenerationofthespinalcord);
Appendix1(folates)
rarelygastro-intestinaldisturbances
Licenseduse
Nutritionandblood
teroidsareusedinhypoplasticandhaemolyticanae-
mias.
Antilymphocyteimmunoglobulin
givenintravenously
throughacentrallineover12Ð18hourseachdayfor5
daysproducesaresponseinabout50%ofcasesof
aplasticanaemia
;theresponseratemaybe
increasedwhenciclosporinisgivenaswell.Severe
reactionsarecommonintheÞrst2daysandprofound
immunosuppressioncanoccur;antilymphocyte
immunoglobulinshouldbegivenunderspecialistsuper-
visionwithappropriateresuscitationfacilities.Alterna-
Nutritionandblood
cutaneously
intravenously
onceweekly
orsub-
cutaneously
onceevery2weeks
orsubcuta-
neously
onceeverymonth
Subcutaneousroutepreferredinpatientsnoton
haemodialysis.Reducedosebyapproximately25%ifrisein
haemoglobinconcentrationexceeds2g/100mLover4
weeksorifhaemoglobinconcentrationexceeds12g/
100mL;ifhaemoglobinconcentrationcontinuestorise,
despitedosereduction,suspendtreatmentuntilhaemoglo-
binconcentrationdecreasesandthenrestartatadose
approximately25%lowerthanthepreviousdose.When
changingroutegivesamedosethenadjustaccordingto
weeklyorfortnightlyhaemoglobinmeasurements.Adjust
dosesnotmorefrequentlythanevery2weeksduring
maintenancetreatment.
diarrhoea,nausea,vomiting;dose-
dependentincreaseinbloodpressureoraggravation
ofhypertension;inisolatedpatientswithnormalor
lowbloodpressure,hypertensivecrisiswith
encephalopathy-likesymptomsandgeneralisedtonic-
clonicseizuresrequiringimmediatemedicalattention;
Nutritionandblood
weeks;maintenancedose,body-weightunder10kg
usually75Ð150units/kg3timesweekly,body-weight10Ð
30kgusually60Ð150units/kg3timesweekly,body-
weight30Ð60kgusually30Ð100units/kg3timesweekly,
body-weightover60kgusually75Ð300units/kgweekly
(asasingledoseorindivideddoses)
Reducedosebyapproximately25%ifriseinhaemo-
globinconcentrationexceeds2g/100mLover4weeksorif
haemoglobinconcentrationexceeds12g/100mL;ifhae-
moglobinconcentrationcontinuestorise,despitedose
reduction,suspendtreatmentuntilhaemoglobinconcentra-
tiondecreasesandthenrestartatadoseapproximately25%
lowerthanthepreviousdose
Nutritionandblood
tionsincludeskinulceration,renalfailure,andincreased
susceptibilitytoinfection.Pneumococcalvaccine(sec-
tion14.4),haemophilusinßuenzaetypebvaccine(sec-
tion14.4),anannualinßuenzavaccine(section14.4),
andprophylacticpenicillin(Table2,section5.1)reduce
theriskofinfection.HepatitisBvaccine(section14.4)
shouldbeconsideredifthechildisnotimmune.
Inmostformsofsickle-celldisease,varyingdegreesof
haemolyticanaemiaarepresentaccompaniedby
increasederythropoiesis;thismayincreasefolate
requirementsandfolatesupplementationmaybeneces-
sary(section9.1.2).
Hydroxycarbamide
canreducethefrequencyofcrises
andtheneedforbloodtransfusions.Hydroxycarbamide
shouldbeconsidered,inconsultationwithaspecialist
centre,forchildrenwhohaverecurrentepisodesof
acutepain(morethan3admissionsintheprevious12
months,orwhoareverysymptomaticinthecommu-
nity)orwhohavehad2ormoreepisodesofacutesickle
chestsyndromeinthelast2years(or1episoderequir-
ingventilatorysupport).BeneÞcialeffectsofhydroxy-
carbamidemaynotbecomeevidentforseveralmonths.
Myelosuppression,andskinreactionsarethemost
commonside-effects.
seesection8.1andnotesabove;alsomoni-
torrenalandhepaticfunctionbeforeandduring
treatment;monitorfullbloodcountbeforetreatment,
thenevery2weeksfortheÞrst2monthsandthen
every2monthsthereafter(orevery2weeksifon
max.dose);legulcers(reviewtreatmentifcutaneous
vasculiticulcerationsdevelop);
Appen-
dix1(hydroxycarbamide)
Hepaticimpairment
manufactureradvisescautionin
mildtomoderateimpairment;avoidinsevere
impairment
Renalimpairment
reduceinitialdoseby50%ifesti-
matedglomerularÞltrationratelessthan60mL/
minute/1.73m
;avoidifestimatedglomerularÞltra-
tionratelessthan30mL/minute/1.73m
avoid(teratogenicin
animal
manufactureradviseseffectivecontraceptionbefore
andduringtreatment;seealsosection8.1
discontinuebreast-feeding
seesection8.1andnotesabove;also
lesscommonly
dizziness,andrash;
rarely
reducedspermcountandactivity;fever,amenor-
rhoea,bleeding,andhypomagnesaemiaalsoreported
Indicationanddose
ickle-celldisease(seenotesabove)
Bymouth
Child2Ð18years
initially10Ð15mg/kgonce
daily,increasedevery12weeksinstepsof5mg/
kgdailyaccordingtoresponse;usualdose15Ð
30mg/kgdaily(max.35mg/kgdaily)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Ironoverload
Severetissueironoverloadcanoccurinaplasticand
otherrefractoryanaemias,mainlyastheresultof
repeatedbloodtransfusions.Itisaparticularproblem
inrefractoryanaemiaswithhyperplasticbonemarrow,
especially
thalassaemiamajor
,whereexcessiveiron
absorptionfromthegutandinappropriateirontherapy
canaddtothetissuesiderosis.
Ironoverloadassociatedwithhaemochromatosiscan
betreatedwithrepeatedvenesection.Venesectionmay
alsobeusedforpatientswhohavereceivedmultiple
transfusionsandwhosebonemarrowhasrecovered.
Wherevenesectioniscontra-indicated,andinthalass-
aemia,thelong-termadministrationoftheironchelat-
ingcompound
desferrioxaminemesilate
isuseful.
Subcutaneousinfusionsofdesferrioxaminearegiven
over8Ð12hours,3Ð7timesaweek;thedoseshould
reßectthedegreeofironoverload.Theinitialdose
shouldnotexceed30mg/kg.Forestablishedoverload
eyeandearexaminationsrequiredbefore
treatmentandannuallyduringtreatment;monitor
body-weight,heightandsexualdevelopment
annually;monitorserum-ferritinconcentration
BNFC2011–
20129.1.3Drugsusedinhypoplastic,haemolytic,renalanaemias
Nutritionandblood
monthly;riskofgastro-intestinalulcerationand
monitorneutrophilcountweeklyanddis-
continuetreatmentifneutropeniadevelops
Blooddisorders
Patientsortheircarersshouldbetoldhow
torecognisesignsofneutropeniaandadvisedtoseek
immediatemedicalattentionifsymptomssuchasfeveror
sorethroatdevelop
Contra-indications
historyofagranulocytosisor
recurrentneutropenia
Hepaticimpairment
manufactureradvisesmonitor
liverfunctionÑinterrupttreatmentifpersistentele-
vationinserumalanineaminotransferase
Renalimpairment
manufactureradvisescautionÑno
informationavailable
manufactureradvisesavoidbefore
intendedconceptionandduringpregnancyÑterato-
genicandembryotoxicin
animal
studies;contra-
ceptionadvisedingirlsofchild-bearingpotential
manufactureradvisesavoidÑno
informationavailable
gastro-intestinaldisturbances(reducing
doseandincreasinggraduallymayimprovetoler-
DESFERRIOXAMINEMESILATE
(DeferoxamineMesilate)
eyeandearexaminationsbeforetreatment
andat3-monthintervalsduringtreatment;monitor
body-weightandheightinchildrenat3-monthinter-
valsÑriskofgrowthrestrictionwithexcessivedoses;
aluminium-relatedencephalopathy(mayexacerbate
neurologicaldysfunction);
Appendix1
(desferrioxamine)
Renalimpairment
usewithcaution
teratogenicin
studies,manufac-
tureradvisesuseonlyifpotentialbeneÞtoutweighs
manufactureradvisesuseonlyif
potentialbeneÞtoutweighsriskÑnoinformation
available
nausea,vomiting,abdominalpain,
Nutritionandblood
vulsions,andparaesthesia),renalimpairment;muscle
spasmsalsoreported
Indicationanddose
hronicironoverload
seenotesabove
luminiumoverloadindialysispatients
Byintravenousinfusion
Child1monthÐ18years
5mg/kgonceweekly
ronpoisoning
SeeEmergencyTreatmentofPoisoning,p.30
For
intravenous
subcutaneous
,reconstitutepowderwithWaterforInjection
toaconcentrationof100mg/mL;dilutewithGlucose
SodiumChloride0.9%.In
haemodialysis
haemoÞltration
administeroverthelasthourof
dialysis(maybegivenviathedialysisÞstula).
peritoneal
:maybeaddedtodialysisßuid.InCAPD
givepriortothelastexchangeoftheday.
Splenectomyisconsideredinchronicthrombocyto-
cardiovasculardiseaseÑassesscardiac
functionbeforeandduringtreatment;concomitant
aspirininpatientsatriskofhaemorrhage;monitorfull
Nutritionandblood
G6PDdeÞciency
Glucose6-phosphatedehydrogenase(G6PD)deÞciency
ishighlyprevalentinindividualsoriginatingfrommost
partsofAfrica,frommostpartsofAsia,fromOceania,
andfromSouthernEurope;itcanalsooccur,rarely,in
anyotherindividuals.G6PDdeÞciencyismorecommon
inmalesthanitisinfemales.
IndividualswithG6PDdeÞciencyaresusceptibleto
developingacutehaemolyticanaemiawhentheytake
anumberofcommondrugs.Theyarealsosusceptible
todevelopingacutehaemolyticanaemiawhentheyeat
favabeans(broadbeans,
Viciafaba
);thisistermed
andcanbemoresevereinchildrenorwhenthe
freshfavabeansareeatenraw.
WhenprescribingdrugsforchildrenwithG6PDdeÞ-
ciency,thefollowingthreepointsshouldbekeptin
Drugswith
riskofhaemolysisin
someG6PD-deÞcientindividuals
Aspirin
(acceptableuptoadoseofatleast1gdaily
inmostG6PD-deÞcientindividuals)
(acceptableinacutemalariaandmal-
ariachemoprophylaxis)
,water-solublederivatives(e.g.
menadiolsodiumphosphate)
Probenecid
Nutritionandblood
Therehavebeenreportsoftoxicity
animal
studiesandmanufacturersadvisenotto
usegranulocyte-colonystimulatingfactorsduring
pregnancyunlessthepotentialbeneÞtoutweighsthe
Thereisnoevidencefortheuseof
granulocyte-colonystimulatingfactorsduringbreast-
feedingandmanufacturersadviseavoidinguse.
Side-effectsofgranulocyte-colonystimu-
latingfactorsincludegastro-intestinaldisturbances,
FILGRASTIM
(Recombinanthumangranulocyte-colonysti-
mulatingfactor,G-CSF)
seenotesabove;alsoregularmorphological
Nutritionandblood
TA
(Recombinanthumangranulocyte-colonysti-
mulatingfactor,rHuG-CSF)
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsosplenicruptureand
toxicepidermalnecrolysis
Licenseduse
notlicensedforuseinchildrenfor
cytotoxic-inducedneutropenia,mobilisationof
peripheralbloodprogenitorcells(monotherapyor
adjunctivetherapy),orfollowingperipheralstem
cellstransplantation
Indicationanddose
ollowingperipheralstemcellsorbone-marrow
Byintravenousinfusionover30minutesorby
subcutaneousinjection
Child2Ð18years
150micrograms/m
startedthedayaftertransplantation,continued
untilneutrophilcountstableinacceptablerange
(max.28days)
ytotoxic-inducedneutropenia
Bysubcutaneousinjection
Child2Ð18years
150micrograms/m
Nutritionandblood
ElectrolytecontentÑgastro-intestinal
9.2.1.1
Oralpotassium
Compensationforpotassiumlossisespeciallyneces-
sary:
inchildreninwhomsecondaryhyperaldosteronism
occurs,e.g.renalarterystenosis,renaltubuledis-
order,thenephroticsyndrome,andsevereheart
inchildrenwithexcessivelossesofpotassiuminthe
faeces,e.g.chronicdiarrhoeaassociatedwithintes-
tinalmalabsorptionorlaxativeabuse;
inthosetakingdigoxinoranti-arrhythmicdrugs,
POTASSIUMCHLORIDE
seenotesabove;cardiacdisease;
modiÞed-releasepreparations
,intestinalstricture,
historyofpepticulcer,hiatushernia;
Appendix1(potassiumsalts)
Contra-indications
plasma-potassiumconcentration
above5mmol/litre
Renalimpairment
closemonitoringrequiredÑriskof
hyperkalaemia;avoidinsevereimpairment
nausea,vomiting,abdominalpain,diarr-
hoea,ßatulence;
withmodiÞed-releasepreparations
gastro-intestinalobstruction,ulceration,andbleeding
alsoreported
Indicationanddose
Nutritionandblood
(HKPharma)
ModiÞed-releasepreparations
POLYSTYRENESULPHONATERESINS
impactionofresinwithexcessivedosageor
inadequatedilution;monitorforelectrolytedistur-
bances(stopifplasma-potassiumconcentration
below5mmol/litre);
sodium-containingresin
congestiveheartfailure,hypertension,andoedema;
Appendix1(polystyrenesulphonate
Contra-indications
obstructiveboweldisease;neo-
nateswithreducedgutmotility;
calcium-containing
inhyperparathyroidism,multiplemyeloma,sar-
manufacturersadviseuseonlyif
potentialbeneÞtoutweighsriskÑnoinformation
available
faecalimpactionfollowingrectaladmin-
9.2.1.2
Oralsodiumandwater
Sodiumchlorideisindicatedinstatesofsodiumdeple-
SODIUMCHLORIDE
Indicationanddose
Seealsosection9.2.2
9.2.1Oralpreparationsforuidandelectrolyteimbalance
BNFC2011–
Nutritionandblood
odiumsupplementationinneonates
Bymouth
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Oralrehydrationtherapy(ORT)
Diarrhoeainchildrenisusuallyself-limiting,however,in
childrenunder6monthsofage,andmoreparticularlyin
thoseunder3months,symptomsofdehydrationmaybe
lessobviousandthereisariskofrapidandsevere
ORALREHYDRATIONSALTS(ORS)
Licenseduse
Relief
notlicensedforuse
inchildrenunder3months
Indicationanddose
luidandelectrolytelossindiarrhoea
seenotes
Bymouth
Child1monthÐ1year
1Ð1½timesusualfeed
hild1Ð12years
200mLaftereveryloose
hild12Ð18years
200Ð400mLaftereveryloose
UKformulations
Afterreconstitutionanyunusedsolutionshouldbedis-
cardednolaterthan1hourafterpreparationunlessstoredina
refrigeratorwhenitmaybekeptforupto24hours.
Oralpowder
,sodiumchloride470mg,potassium
chloride300mg,disodiumhydrogencitrate530mg,
WHOformulation
OralRehydrationSalts
Nutritionandblood
9.2.1.3
Oralbicarbonate
Sodiumbicarbonate
isgivenbymouthfor
chronic
acidoticstates
suchasuraemicacidosisorrenaltubular
SODIUMBICARBONATE
seenotesabove;avoidinrespiratoryaci-
Appendix1(antacids)
Indicationanddose
enalacidosis
(seealsonotesabove)
Bymouth
initially1Ð2mmol/kgdailyindivided
doses,adjustedaccordingtoresponse
Child1monthÐ18years
initially1Ð2mmol/kg
dailyindivideddoses,adjustedaccordingto
manufacturersorspecialistimportingcompanies,seep.809,
andthestrengthofsodiumbicarbonateshouldbestatedon
theprescription
POTASSIUMBICARBONATE
cardiacdisease,
Appendix1
(potassiumsalts)
Contra-indications
hypochloraemia;plasma-potas-
siumconcentrationabove5mmol/litre
Renalimpairment
closemonitoringrequiredÑhigh
riskofhyperkalaemia;avoidinsevereimpairment
nausea,vomiting,abdominalpain,diarr-
hoea,andßatulence
9.2.2.1
Electrolytesandwater
assubstratefrommusclebreakdown.Maintenance
ßuidsareintendedonlytoprovidehydrationfora
shortperioduntilenteralorparenteralnutritioncan
beestablished.
Nutritionandblood
Fluidrequirementsforchildrenover1
24-hourßuidrequirement
10kg
100mL/kg
10–20kg100mL/kgfortherst10kg
+50mL/kgforeach1kgbody-weightover
10kg
Over20kg100mL/kgfortherst10kg
+50mL/kgforeach1kgbody-weight
Nutritionandblood
hypernatraemiaandhyponatraemiacancauseÞtsand
rarelybraindamage.Sodiumindrugpreparations,
deliveredviacontinuousinfusions,orininfusionsto
maintainthepatencyofintravascularorumbilicallines,
canresultinsigniÞcantamountsofsodiumbeingdeliv-
ered,(e.g.1mL/hourof0.9%sodiumchlorideinfused
over24hoursisequivalentto3.6mmol/dayofsodium).
SODIUMCHLORIDE
restrictintakeinimpairedrenalfunction,
cardiacfailure,hypertension,peripheralandpulm-
onaryoedema,toxaemiaofpregnancy;seealsonotes
administrationoflargedosesmaygive
risetosodiumaccumulationandoedema
Indicationanddose
lectrolyteimbalance
seenotesabove,alsosec-
tion9.2.1.2
SodiumChloride
Withotheringredients
Seeaboveforwarningonhyponatraemia
SodiumChlorideandGlucose
GLUCOSE
(DextroseMonohydrate)
GlucoseBPisthemonohydratebutGlucoseIntra-
venousInfusionBPisasterilesolutionofanhydrousglucose
orglucosemonohydrate,potencybeingexpressedinterms
ofanhydrousglucose
glucoseinjectionsespeciallyifhyper-
tonicmayhavealowpHandmaycausevenous
irritationandthrombophlebitis
Indicationanddose
luidreplacement
seenotesabove
rovisionofenergy
section9.3
section6.1.4
Nutritionandblood
Intravenouspotassium
Potassiumchlorideandsodiumchloride
intravenous
infusionistheinitialtreatmentforthecorrectionof
severehypokalaemia
andwhensufÞcientpotassium
cannotbetakenbymouth.Ready-mixedinfusionsolu-
tionsshouldbeusedwhenpossible(seeunderSafe
Practicebelow);forperipheralintravenousinfusion,
theconcentrationofpotassiumshouldnotusually
exceed40mmol/litre.Potassiuminfusionsshouldbe
givenslowlyoveratleast2Ð3hoursandataratenot
exceeding0.2mmol/kg/hourwithspecialistadviceand
ECGmonitoringindifÞcultcases.Higherconcentra-
tionsofpotassiumchlorideorfasterinfusionratesmay
POTASSIUMCHLORIDE
forperipheralintravenousinfusionthecon-
centrationofsolutionshouldnotusuallyexceed3g
(40mmol)/litre;specialistadviceandECGmonitor-
ing(seenotesabove);
Appendix1
(potassiumsalts)
Contra-indications
plasma-potassiumconcentration
above5mmol/litre
Renalimpairment
closemonitoringrequiredÑhigh
riskofhyperkalaemia;avoidinsevereimpairment
rapidinfusiontoxictoheart
Indicationanddose
lectrolyteimbalance
seealsooralpotassium
supplements,section9.2.1.1
Byslowintravenousinfusion
DependingonthedeÞcitorthedailymaintenance
requirements,seealsonotesabove
1Ð2mmol/kgdaily
Child1monthÐ18years
1Ð2mmol/kgdaily
seenotesabove
PotassiumChlorideandGlucose
SODIUMBICARBONATE
Indicationanddose
Nutritionandblood
enalhyperkalaemia
Byslowintravenousinjection
1mmol/kgdaily
Child1monthÐ18years
1mmol/kgdaily
enalacidosis
section9.2.1.3
SodiumBicarbonate
Intravenousinfusion
,usualstrengthsodiumbicarb-
onate1.26%(12.6g,150mmoleachofNa
/litre);variousotherstrengthsavailable
AvailablefromÔspecial-orderÕmanufacturersorspe-
cialistimportingcompanies,seep.809
Water
WaterforInjections
9.2.2.2
Plasmaandplasmasubstitutes
Albuminsolutions
,preparedfromwholeblood,con-
tainsolubleproteinsandelectrolytesbutnoclotting
factors,bloodgroupantibodies,orplasmacholines-
terases;theymaybegivenwithoutregardtothereci-
pientÕsbloodgroup.
Albuminisusuallyusedaftertheacutephaseofillness
tocorrectaplasma-volumedeÞcit;hypoalbuminaemia
itselfisnotanappropriateindication.Theuseof
albuminsolutionsinacuteplasmaorbloodlossmay
bewasteful;plasmasubstitutesaremoreappropriate.
Concentratedalbuminsolutionsmayalsobeusedto
obtainadiuresisinhypoalbuminaemicpatients(e.g.in
nephroticsyndrome).
Recentevidencedoesnotsupportthepreviousview
thattheuseofalbuminincreasesmortality.
Plasmaandplasmasubstitutesareoftenusedinvery
illchildrenwhoseconditionisunstable.Therefore,
closemonitoringisrequiredandßuidandelectrolyte
therapyshouldbeadjustedaccordingtothechildÕs
conditionatalltimes.
ALBUMINSOLUTION
(HumanAlbuminSolution)
Asolutioncontainingproteinderivedfromplasma,
serum,ornormalplacentas;atleast95%ofthe
proteinisalbumin.Thesolutionmaybeisotonic
(containing3.5Ð5%protein)orconcentrated(con-
taining15Ð25%protein).
historyofcardiacorcirculatorydisease
(administerslowlytoavoidrapidriseinbloodpres-
sureandcardiacfailure,andmonitorcardiovascular
andrespiratoryfunction);increasedcapillaryperme-
ability;correctdehydrationwhenadministeringcon-
centratedsolution
Contra-indications
cardiacfailure;severeanaemia
hypersensitivityreactions(including
anaphylaxis)withnausea,vomiting,increasedsaliva-
tion,fever,tachycardia,hypotensionandchills
Indicationanddose
Seenotesaboveandunderpreparations,below
Isotonicsolutions
Indications:
acuteorsub-acutelossofplasmavolume
e.g.inburns,pancreatitis,trauma,andcomplications
ofsurgery;plasmaexchange
Availableas:
HumanAlbuminSolution4.5%
100-,250-and400-mLbottlesÑBaxter);
Human
AlbuminSolution5%
(250-and500-mLbottlesÑ
Albunorm
5%(100-,250-,and500-mL
bottlesÑOctapharma);
(100-and250-
mLbottlesÑOctapharma);
Zenalb
(50-,100-,
250-,and500-mLbottlesÑBPL)
Concentratedsolutions(20%)
Indications:
severehypoalbuminaemiaassociated
withlowplasmavolumeandgeneralisedoedema
wheresaltandwaterrestrictionwithplasmavolume
expansionarerequired;adjunctinthetreatmentof
hyperbilirubinaemiabyexchangetransfusioninthe
newborn;paracentesisoflargevolumeascitesasso-
ciatedwithportalhypertension
Availableas:
HumanAlbuminSolution20%
(50-and
100-mLvialsÑBaxter);
20%(50-and
100-mLbottlesÑOctapharma);
20%(50-
and100-mLbagsÑBaxter);
(50-and
100-mLbottlesÑOctapharma);
Zenalb
and100-mLbottlesÑBPL)
9.2.2Parenteralpreparationsforuid&electrolyteimbalance
BNFC2011–
Nutritionandblood
Plasmasubstitutes
andthe
GELATIN
Thegelatinispartiallydegraded
seenotesabove
manufacturerof
avoidattheendofpregnancy
seenotesabove
Indicationanddose
owbloodvolumeinhypovolaemicshock,
burnsandcardiopulmonarybypass
Byintravenousinfusion
Initially10Ð20mL/kgofa3.5Ð4%solution(see
notesabove)
Gelofusine
Intravenousinfusion
,succinylatedgelatin(modiÞed
ßuidgelatin,averagemolecularweight30000)40g
(4%),Na
154mmol,Cl
(FreseniusKabi)
Intravenousinfusion
,pentastarch(weightaverage
molecularweight200000)10%insodiumchloride
Nutritionandblood
Voluven
(FreseniusKabi)
Intravenousinfusion
Hypertonicsolution
(FreseniusKabi)
Intravenousinfusion
Nutritionandblood
Electrolytes
areusuallyprovidedasthechloridesaltsof
1000kcal=4200kJ;1000kJ=238.8kcal.Allentriesare
Excludesprotein-oraminoacid-derivedenergy
Foruseinneonatesandchildrenonly
BNFC2011–
9.3Intravenousnutrition
Nutritionandblood
(FreseniusKabi)
,traceelementsforadditionto
Vamin
solutionsandglucoseintravenousinfusions,tracesof
Fe
,Zn
,Mn
,Cu
,Cr
,Se
,Mo
.For
VitlipidN
(FreseniusKabi)
Emulsion,adult
,vitaminA330units,ergocalciferol
20units,
-alphatocopherol1unit,phytomenadione
15micrograms/mL.Foradditionto
Intralipid
.For
Nutritionandblood
SAPROPTERINDIHYDROCHLORIDE
Nutritionandblood
Nutritionandblood
drenover6years;theintakeofelectrolytes,vitamins
andmineralsshouldbecarefullyassessedandmodiÞed
complicationsinchildrenwhocannottoleratespeciÞc
aminoacidsitisimportanttoensurethecorrectsupple-
mentissupplied.
Preparations(Borderlinesubstances)
SeeAppen-
dix2.
Minerals
Calciumandmagnesium
Seesection9.1.1forironsalts.
Calciumandmagnesium
Calciumsupplements
Hypercalcaemiaandhypercalciuria
9.5.1.1
Calciumsupplements
Calciumsupplementsareusuallyonlyrequiredwhere
Nutritionandblood
CALCIUMSALTS
seenotesabove;sarcoidosis;historyof
nephrolithiasis;avoidcalciumchlorideinrespiratory
acidosisorrespiratoryfailure;
:Appendix
1(antacids,calciumsalts)
Contra-indications
conditionsassociatedwithhyper-
calcaemiaandhypercalciuria(e.g.someformsof
malignantdisease);seealsoCalciumGluconate
injection,below
Renalimpairment
usewithcaution;riskofhypercal-
caemiaandrenalcalculi
gastro-intestinaldisturbances,constipa-
tion;bradycardia,arrhythmias;withinjection,per-
ipheralvasodilatation,fallinbloodpressure,injection-
sitereactions,severetissuedamagewithextravasa-
Indicationanddose
eenotesabove;calciumdeÞciency
Bymouth
0.25mmol/kg4timesaday,adjustedto
Child1monthÐ4years
0.25mmol/kg4timesa
day,adjustedtoresponse
hild5Ð12years
0.2mmol/kg4timesaday,
adjustedtoresponse
hild12Ð18years
10mmol4timesaday,
adjustedtoresponse
cutehypocalcaemia,urgentcorrection;
hyperkalaemia(preventionofarrhythmias)
Byslowintravenousinjectionover5Ð10min-
0.11mmol/kg(0.5mL/kgofcalcium
gluconate10%)asasingledose.[Someunitsusea
doseof0.46mmol/kg(2mL/kgcalciumgluconate
10%)forhypocalcaemiainlinewithUSpractice]
Child1monthÐ18years
0.11mmol/kg(0.5mL/
kgcalciumgluconate10%),max4.5mmol(20mL
calciumgluconate10%)
cutehypocalcaemia,maintenance
Bycontinuousintravenousinfusion
0.5mmol/kgdailyover24hours,
adjustedtoresponse,useoralrouteassoonas
possibleduetoriskofextravasation
Child1monthÐ2years
1mmol/kgdaily(usual
max8.8mmol)over24hours,useoralrouteas
soonaspossibleduetoriskofextravasation
hild2Ð18years
8.8mmolover24hours,use
oralrouteassoonaspossibleduetoriskof
extravasation
Oralpreparations
CalciumGluconate
Parenteralpreparations
CalciumGluconate
Nutritionandblood
,calciumchloridedihydrate13.4%(calcium
36mgorCa
WithvitaminD
Section9.6.4
9.5.1.2
Hypercalcaemiaand
hypercalciuria
Severehypercalcaemia
Severehypercalcaemiacalls
9.5.1.3
Magnesium
Magnesiumisanessentialconstituentofmanyenzyme
systems,particularlythoseinvolvedinenergygenera-
MAGNESIUMSULPHATE
seenotesabove;inseverehypomagnes-
aemiaadministerinitiallyviacontrolledinfusion
device(preferablysyringepump);monitorblood
pressure,respiratoryrate,urinaryoutputandforsigns
ofoverdosage(lossofpatellarreßexes,weakness,
nausea,sensationofwarmth,ßushing,drowsiness,
doublevision,andslurredspeech);
Appendix1(magnesium,parenteral)
Hepaticimpairment
avoidinhepaticcomaifriskof
renalfailure
Renalimpairment
avoidorreducedose;increased
riskoftoxicity
sufÞcientmaycrosstheplacentain
motherstreatedwithhighdosese.g.inpre-eclampsia,
causinghypotoniaandrespiratorydepressionin
generallyassociatedwithhypermagne-
saemia,nausea,vomiting,thirst,ßushingofskin,
hypotension,arrhythmias,coma,respiratorydepres-
sion,drowsiness,confusion,lossoftendonreßexes,
muscleweakness
Indicationanddose
eonatalhypocalcaemia
Bydeepintramuscularinjectionorintravenous
0.4mmol/kgMg
(100mg/kgmagnes-
iumsulphate)12hourlyfor2Ð3doses
ypomagnesaemia
Byintravenousinjectionoveratleast10min-
0.4mmol/kgMg
(100mg/kgmagnes-
iumsulphate)6Ð12hourlyasnecessary
BNFC2011–
9.5.1Calciumandmagnesium
Nutritionandblood
Child1monthÐ12years
0.2mmol/kgMg
(50mg/kgmagnesiumsulphate)12hourlyas
necessary
hild12Ð18years
4mmolMg
(1gmagnesium
sulphate)12hourlyasnecessary
orsadedepointes
(consultlocalguidelines)
Byintravenousinjectionover10Ð15minutes
Child1monthÐ18years
0.1Ð0.2mmol/kg(25Ð
50mg/kgmagnesiumsulphate);max.8mmol(2g
magnesiumsulphate);doserepeatedonceif
necessary
ersistentpulmonaryhypertension
section2.5.1
evereacuteasthma
section3.1
Diluteto10%(100mgin1mL)with
Glucose5
10%,SodiumChloride0.45
GlucoseandSodiumChloridecombinations.Upto
20%solutionmaybegiveninßuidrestriction.Rateof
administrationshouldnotexceed10mg/kg/minute
ofmagnesiumsulphate
Magnesiumsulphate1gequivalenttoMg
approx.
4mmol
MagnesiumSulphate
-ASPARTATE
seeunderMagnesiumSulphate
Renalimpairment
avoidorreducedose;increased
riskoftoxicity
seeunderMagnesiumSulphate;also
diarrhoea
Licenseduse
classiÞedasaFoodforSpecialMedi-
calPurposesforuseinchildrenover2years
Indicationanddose
ypomagnesaemia
Bymouth
Child1monthÐ2years
initially0.2mmol/kgof
3timesdailydissolvedinwater,dose
adjustedasrequired
hild2Ð10years
MAGNESIUMGLYCEROPHOSPHATE
seeunderMagnesiumSulphate
Renalimpairment
avoidorreducedose;increased
riskoftoxicity
seeunderMagnesiumSulphate;also
diarrhoea
Licenseduse
notlicensed
Indicationanddose
ypomagnesaemia
Bymouth
Child1monthÐ12years
initially0.2mmol/kg
3timesdaily,doseadjustedasrequired
hild12Ð18years
initially4Ð8mmolMg
timesdaily,doseadjustedasrequired
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Phosphorus
Phosphatesupplements
Phosphate-bindingagents
9.5.2.1
Phosphatesupplements
Oralphosphatesupplementsmayberequiredinaddi-
tiontovitaminDinchildrenwithhypophosphataemic
Nutritionandblood
PhosphateisnottheÞrstchoiceforthetreatmentof
hypercalcaemiabecauseoftheriskofprecipitationof
calciumphosphateinthekidneyandothertissues.If
used,thechildshouldbewellhydratedandelectrolytes
PhosphatedeÞciencymayoccurinvery
low-birthweightinfantsandmaycompromisebone
growthifnotcorrected.Parenterallyfedinfantsmay
beatriskofphosphatedeÞciencyduetothelimited
solubilityofphosphate.Someunitsroutinelysupple-
mentexpressedbreastmilkwithphosphate,although
theeffectontheosmolalityofthemilkshouldbe
PHOSPHATE
seenotesabove,alsocardiacdisease,dia-
Phosphate-Sandoz
(HKPharma)
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Variousstrengthsandsaltsavailable,cautionelectro-
lyteload
(FreseniusKabi)
Intravenousinfusion
,phosphates(providingphos-
phate100mmol/litre,potassium19mmol/litre,sod-
9.5.2.2
Phosphate-bindingagents
Calcium-containingpreparationsareusedasphos-
phate-bindingagentsinthemanagementofhyper-
phosphataemiacomplicatingrenalfailure.Aluminium-
containingpreparationsarerarelyusedasphosphate-
bindingagentsandcancausealuminiumaccumulation.
Sevelamerhydrochloride
islicensedforthetreatment
ofhyperphosphataemiainadultsonhaemodialysisor
peritonealdialysis.Althoughexperienceislimitedin
childrensevelamermaybeusefulwhenhypercalcaemia
preventstheuseofcalciumcarbonate.
ALUMINIUMHYDROXIDE
seenotesabove;
Appendix1
constipation;hyperaluminaemia
Capsules
,green/red,driedaluminiumhydroxide
475mg(lowNa
Nutritionandblood
CALCIUMSALTS
Appendix1(antacids,calcium
Contra-indications
hypercalcaemia,hypercalciuria
hypercalcaemia
Indicationanddose
hosphatebindinginrenalfailureandhyper-
phosphataemia
Bymouth
Child1monthÐ1year
120mgcalciumcarbonate
3Ð4timesdailywithfeeds,adjustedasnecessary
hild1Ð6years
300mgcalciumcarbonate3Ð4
timesdailypriortoorwithmeals,adjustedas
necessary
hild6Ð12years
600mgcalciumcarbonate3Ð4
timesdailypriortoorwithmeals,adjustedas
necessary
hild12Ð18years
1.25gcalciumcarbonate3Ð4
timesdailypriortoorwithmeals,adjustedas
necessary
Section9.5.1.1
Calcichew
Section9.5.1.1
Section9.5.1.1
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
SEVELAMERHYDROCHLORIDE
gastro-intestinaldisorders;
Appendix1(sevelamer)
Contra-indications
bowelobstruction
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
manufactureradvisesuseonlyif
potentialbeneÞtoutweighsrisk
nausea,vomiting,abdominalpain,con-
stipation,diarrhoea,dyspepsia,ßatulence;
veryrarely
intestinalobstruction;
alsoreported
intestinalper-
foration,ileus,diverticulitis,pruritus,andrash
Licenseduse
notlicensedforuseinchildrenunder
18years
Indicationanddose
yperphosphataemiainpatientsonhaemo-
dialysisorperitonealdialysis
Bymouth
Child12Ð18years
initially0.8Ð1.6g3timesdaily
withmeals,thenadjustedaccordingtoplasma-
phosphateconcentration
Sodiumßuoride2.2mgprovidesapprox.1mgßuoride
Contra-indications
notforareaswheredrinkingwater
isßuoridated
Nutritionandblood
Child3Ð6years
500microgramsdaily
hild6yearsandover
1mgdaily
Tablets
Counselling
Oraldrops
Fluoridesupplementsnotconsiderednecessarybelow6
monthsofage(seenotesabove)
En-De-Kay
(=paediatricdrops),sugar-free,sodium
ßuoride550micrograms(F
250micrograms)/
Mouthwashes
Rinsemouthfor1minuteandspitout
Counselling
Avoideating,drinking,orrinsingmouthfor15
minutesafteruse
Duraphat
(Colgate-Palmolive)
Weeklydentalrinse
(=mouthwash),blue,sodium
FluoriGard
(Colgate-Palmolive)
(=gel),stannousßuoride0.4%inglycerol
Toothpastes
Duraphat
(Colgate-Palmolive)
‘2800ppm’toothpaste
,sodiumßuoride
Nutritionandblood
‘5000ppm’toothpaste
,sodiumßuoride
ZINCSULPHATE
:Appendix1(zinc)
Renalimpairment
accumulationmayoccurinacute
renalfailure
Nutritionandblood
VITAMINA
VITAMINSAandD
seenotesaboveandsection9.6.4;prolonged
excessiveingestionofvitaminsAandDcanleadto
hypervitaminosis;
Appendix1(vita-
seenotesabove
seenotesaboveandsection9.6.4
Licenseduse
notlicensedinchildrenunder6
monthsofage
Indicationanddose
Seenotesaboveandsection9.6.4
reventionofvitaminAandDdeÞciency
individualpreparationsfordoseinformation
VitaminsAandD
VitaminsAandD
Child1Ð18years
1capsuledaily
VitaminsA,CandD
HealthyStartChildrenÕsVitaminDrops
PreventionofvitamindeÞciency
Bymouth
Child1monthÐ5years
5dropsdaily(5dropscontain
vitaminAapprox.700units,vitaminDapprox.300units,
ascorbicacidapprox.20mg)
HealthyStartVitaminsforwomen
(containingascor-
bicacid,vitaminD,andfolicacid)arealsoavailablefreeof
chargetowomenontheHealthyStartSchemeduring
pregnancyanduntiltheirbabyisoneyearold,oralterna-
tivelymaybeavailabledirecttothepublicÑfurtherinfor-
mationforhealthcareprofessionalscanbeaccessedat
http://tinyurl.com/3yckebe
.BeneÞciariescancontacttheir
midwifeorhealthvisitorforfurtherinformationonwhereto
obtainsupplies.
VitaminBgroup
DeÞciencyoftheBvitamins,otherthanvitaminB
(section9.1.2),israreintheUKandisusuallytreatedby
preparationscontainingthiamine(B
),andriboßavin
).Othermembers(orsubstancestraditionallyclassi-
Þedasmembers)ofthevitaminBcomplexsuchas
aminobenzoicacid,biotin,choline,inositol,andpanto-
thenicacidorpanthenolmaybeincludedinvitaminB
preparations,butthereisnoevidenceoftheirvalueas
supplements;however,theycanbeusedinthemanage-
Nutritionandblood
(section9.1.2).Pyridoxineisalsousedinsideroblastic
anaemia(section9.1.3).Rarely,seizuresintheneonatal
periodorduringinfancyrespondtopyridoxinetreat-
ment;pyridoxineshouldbetriedinallcasesofearly-
RIBOFLAVIN
(Riboßavine,vitaminB
seenotesabove
crossestheplacentabutnoadverseeffects
reported,informationathighdoseslimited
presentinbreastmilkbutnoadverse
effectsreported,informationathighdoseslimited
brightyellowurine
Licenseduse
notlicensedinchildren
Indicationanddose
Seealsonotesabove
OralvitaminBcomplexpreparations
Seebelow
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
(VitaminB
anaphylacticshockmayoccasionallyfollow
injection(seeMHRA/CHMadvicebelow)
MHRA/CHMadvice(September2007)
Althoughpotentiallyseriousallergicadversereactions
mayrarelyoccurduring,orshortlyafter,parenteral
administration,theCHMhasrecommendedthat:
1.Thisshouldnotprecludetheuseofparenteral
thiamineinpatientswherethisrouteofadmin-
istrationisrequired,particularlyinpatientsat
riskofWernicke-Korsakoffsyndromewhere
treatmentwiththiamineisessential;
2.Intravenousadministrationshouldbebyinfu-
sionover30minutes;
3.Facilitiesfortreatinganaphylaxis(includingre-
suscitationfacilities)shouldbeavailablewhen
parenteralthiamineisadministered.
severelythiamine-deÞcientmothers
OralvitaminBcomplexpreparations
Seebelow
PYRIDOXINEHYDROCHLORIDE
(VitaminB
seenotesabove;riskofcardiovascularcol-
lapsewithintravenousinjectionÑresuscitationfacil-
itiesmustbeavailable,monitorclosely;
Appendix1(vitamins)
sensoryneuropathyreportedwithhigh
dosesgivenforextendedperiods
Licenseduse
notlicensedforuseinchildren
9.6.2VitaminBgroup
BNFC2011–
Nutritionandblood
Indicationanddose
Seealsonotesabove
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
OralvitaminBcomplexpreparations
Othermultivitaminpreparationsareinsection9.6.7.
ASCORBICACID
(VitaminC)
Appendix1(vitamins)
Contra-indications
hyperoxaluria
nausea,diarrhoea;headache,fatigue;
hyperoxaluria
Licenseduse
Nutritionandblood
ERGOCALCIFEROL
(Calciferol,VitaminD
seenotesabove;monitorplasma-calcium
concentrationinpatientsreceivinghighdosesandin
renalimpairment;
:Appendix1(vita-
Contra-indications
Nutritionandblood
utritionalorphysiologicalsupplement;pre-
Pharmacologicalstrengths
(seenotesabove)
TheBPdirectsthatwhencalciferolisprescribedordemanded,
colecalciferolorergocalciferolshouldbedispensedorsupplied
Ergocalciferol
Important
Dailysupplements
ALFACALCIDOL
-Hydroxycholecalciferol)
seeunderErgocalciferol;alsonephrolithiasis
Contra-indications
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol;also
nephrocalcinosis,pruritus,rash,andurticaria
Indicationanddose
Seealsonotesabove
CALCITRIOL
(1,25-Dihydroxycholecalciferol)
seeunderErgocalciferol;monitorplasma
calcium,phosphate,andcreatinineduringdosage
Contra-indications
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seealsonotesabove
BNFC2011–
9.6.4VitaminD
Nutritionandblood
COLECALCIFEROL
(Cholecalciferol,vitaminD
seeunderErgocalciferol
Contra-indications
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol
seeunderErgocalciferol
Licenseduse
+D600
notlicensedfor
useinchildrenunder2years;
,and
+D1200
notlicensed
foruseinchildrenunder12years;
Calcichew-D
500mg/
400unit
,and
notlicensedforusein
children(agerangenotspeciÞedbymanufacturers);
CalfovitD3
NatecalD3
notlicensedforuse
inchildrenunder18years
Indicationanddose
SeeunderErgocalciferolandnotesaboveÑalterna-
tivetoErgocalciferol,seealsoPharmacological
Colecalciferol
VariousformulationsavailablefromÔspecial-orderÕ
manufacturersorspecialistimportingcompanies,see
p.809
Withcalcium
Forprescribinginformationoncalcium,seesection
(ProStrakan)
Nutritionandblood
15mmol),colecalciferolconcentrate4mg,providing
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
VitaminE
(Tocopherols)
ThedailyrequirementofvitaminEhasnotbeenwell
deÞned.VitaminEsupplementsaregiventochildren
withfatmalabsorptionsuchasincysticÞbrosisand
Child1monthÐ12years
initially100mgdaily,
adjustedaccordingtoresponse;upto200mg/kg
dailymayberequired
hild12Ð18years
initially200mgdaily,adjusted
accordingtoresponse;upto200mg/kgdailymay
berequired
Byintramuscularinjection
10mg/kgonceamonth
Child1monthÐ18years
10mg/kg(max.100mg)
onceamonth
ALPHATOCOPHEROL
predispositiontothrombosis;
Appendix1(vitamins)
Contra-indications
Nutritionandblood
VitaminK
VitaminKisnecessaryfortheproductionofblood
clottingfactorsandproteinsnecessaryforthenormal
calciÞcationofbone.
BecausevitaminKisfatsoluble,childrenwithfatmal-
absorption,especiallyinbiliaryobstructionorhepatic
disease,maybecomedeÞcient.Fororaladministration
topreventvitaminKdeÞciencyinmalabsorptionsyn-
MENADIOLSODIUMPHOSPHATE
G6PDdeÞciency(section9.1.5)andvitamin
EdeÞciency(riskofhaemolysis);
Appendix1(vitamins)
Contra-indications
neonatesandinfants
avoidinlatepregnancyandlabourunless
beneÞtoutweighsriskofneonatalhaemolyticanae-
mia,hyperbilirubinaemia,andkernicterusinneonate
Indicationanddose
Seenotesabove
upplementationinvitaminKmalabsorption
Bymouth
Child1Ð12years
5Ð10mgdaily,adjustedas
necessary
hild12Ð18years
10Ð20mgdaily,adjustedas
necessary
MenadiolPhosphate
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
(VitaminK
intravenousinjectionsshouldbegivenvery
slowlyÑriskofvascularcollapse(seealsobelow);
Appendix1(vitamins)
useifpotentialbeneÞtoutweighsrisk
presentinmilk,butseenotesabove
Indicationanddose
eonatalprophylaxisofvitamin-KdeÞciency
seenotesabove
eonatalhypoprothrombinaemiaorvitamin-K
deÞciencybleeding
Byintravenousinjection
1mgrepeated8hourlyifnecessary
eonatalbiliaryatresiaandliverdisease
Bymouth
1mgdaily
eversalofcoumarinanticoagulationwhen
continuedanticoagulationrequiredorifno
signiÞcantbleeding
(seealsosection2.8.2)Ñseek
specialistadvice
Byintravenousinjection
Child1monthÐ18years
15Ð30micrograms/kg
(max.1mg)asasingledose,repeatedasnecessary
eversalofcoumarinanticoagulationwhen
anticoagulationnotrequiredorifsigniÞcant
bleeding;treatmentofhaemorrhageasso-
ciatedwithvitamin-KdeÞciency
(seealsosection
2.8.2)Ñseekspecialistadvice
Byintravenousinjection
Child1monthÐ18years
250Ð300micrograms/
kg(max.10mg)asasingledose
9.6.6VitaminK
BNFC2011–
Nutritionandblood
(Neoceuticals)
Capsules
,brown,phytomenadione1mginanoily
Colloidalformulation
(Roche)
,phytomenadione10mg/mLinamixed
MULTIVITAMINPREPARATIONS
seeindividualvitamins;vitaminAconcen-
trationofpreparationsvaries
Contra-indications
seeindividualvitamins
seeindividualvitamins
Licenseduse
notlicensedforusein
childrenunder6weeks
Indicationanddose
Seeunderpreparationsbelow
Vitamins
Capsules
,ascorbicacid15mg,nicotinamide7.5mg,
riboßavin500micrograms,thiaminehydrochloride
Nutritionandblood
2micrograms,folicacid100micrograms,nicotin-
amide7.5mg,pantothenicacid2mg,pyridoxine
1mg,riboßavin1mg,thiamine1.5mg,vitaminA
1250units,vitaminD
200units,vitaminE5mg,vit-
aminK
25micrograms),mineralsandtraceelements
(chromium50micrograms,copper1mg,iodine
75micrograms,iron5mg,magnesium1mg,manga-
nese1.25mg,molybdenum50micrograms,selenium
continuedprescribingandsupplyshouldbemadein
primarycare.
AlderHeyChildrenÕsHospital
MedicinesInformationCentre
Tel:(0151)2525381
concomitantnephrotoxicdrugs(increased
riskoftoxicity);monitorurineforproteinuria;monitor
Nutritionandblood
initiallynausea,anorexia,fever,andskin
reactions;tasteloss(mineralsupplementsnot
recommended);blooddisordersincludingthrombo-
cytopenia,leucopenia,agranulocytosisandaplastic
anaemia;proteinuria,rarelyhaematuria(withdraw
immediatelyandseekspecialistadvice);haemolytic
anaemia,pancreatitis,cholestaticjaundice,nephrotic
syndrome,lupuserythematosus-likesyndrome,
myastheniagravis-likesyndrome,neuropathy(espe-
ciallyifneurologicalinvolvementinWilsonÕsdis-
easeÑprophylacticpyridoxinerecommended,see
section9.6.2,polymyositis(rarelywithcardiacinvol-
vement),dermatomyositis,mouthulcers,stomatitis,
alopecia,bronchiolitisandpneumonitis,pemphigus,
GoodpastureÕssyndrome,andStevens-Johnson
syndromealsoreported;maleandfemalebreast
enlargementreported;innon-rheumatoidconditions
rheumatoidarthritis-likesyndromealsoreported;late
rashes(considerwithdrawingtreatment)
Indicationanddose
ilsonÕsdisease
Bymouth
Child1monthÐ12years
2.5mg/kgtwicedaily
beforefood,increasedat1Ð2weekintervalsto
10mg/kgtwicedaily
hild12Ð18years
0.75Ð1gtwicedailybefore
food,max.2gdailyfor1year;usualmaintenance
dose0.75Ð1gdaily
ystinuria
Bymouth
Child1monthÐ12years
5Ð10mg/kgtwicedaily
beforefood,adjustedtomaintainurinarycystine
below200mg/litre;maintainadequateßuidintake
hild12Ð18years
0.5Ð1.5gtwicedailybefore
food,adjustedtomaintainurinarycystinebelow
200mg/litre;maintainadequateßuidintake
TRIENTINEDIHYDROCHLORIDE
seenotesabove;
Appendix1
teratogenicin
studiesÑuseonlyif
beneÞtoutweighsrisk;monitormaternalandneonatal
serum-copperconcentrations
nausea,rash;
veryrarely
anaemia;duo-
denitisandcolitisalsoreported
Indicationanddose
ilsonÕsdiseaseinpatientsintolerantof
penicillamine
Bymouth
Child2Ð12years
0.6Ð1.5gdailyin2Ð4divided
dosesbeforefood,adjustedaccordingtoresponse;
reducedoseandincreasefrequencyifnauseaisa
hild12Ð18years
1.2Ð2.4gdailyin2Ð4divided
dosesbeforefood,adjustedaccordingtoresponse;
reducedoseandincreasefrequencyifnauseaisa
TrientineDihydrochloride
Capsules
,trientinedihydrochloride300mg.Label:6,
Nutritionandblood
Licenseduse
notlicensedforusebyintravenous
Nutritionandblood
Miglustat
,aninhibitorofglucosylceramidesynthase,is
licensedinadultsforthetreatmentofmildtomoderate
typeIGaucherÕsdiseaseinpatientsforwhomimiglu-
ceraseisunsuitable;itisgivenbymouth.
monitorforimigluceraseantibodies;when
VELAGLUCERASEALFA
monitorimmunoglobulinG(IgG)antibody
concentrationinsevereinfusion-relatedreactionsorif
thereisalackorlossofeffectwithvelaglucerasealfa
Infusion-relatedreactions
Infusion-relatedreactionsvery
common;managebyslowingtheinfusionrate,orinter-
ruptingtheinfusion,orminimisebypre-treatmentwithan
manufactureradvisesusewithcau-
tionÑnoinformationavailable
nausea,abdominalpain,tachycardia,
hypertension,hypotension,ßushing,headache,dizzi-
ness,malaise,pyrexia,arthralgia,bonepain,back
pain,hypersensitivityreactions,rash,urticaria
Indicationanddose
aucherÕsdiseasetypeI
(specialistuseonly)
Byintravenousinfusion
Child4Ð18years
60units/kgonceevery2
weeks;adjustedaccordingtoresponseto15Ð
60units/kgonceevery2weeks
intravenousinfusion
,reconstitute
each400-unitvialwith4.3mLwaterforinjections;
diluterequisitedosein100mLSodiumChloride0.9%
andgiveover60minutesthrougha0.22micronÞlter;
startinfusionwithin24hoursofreconstitution
(ShireHGT)
Intravenousinfusion
,powderforreconstitution,
respiratorydisease;acutefebrileorrespir-
atoryillness(considerdelayingtreatment)
Infusion-relatedreactions
Seenotesabove
manufactureradvisesavoidunlessessen-
manufactureradvisesavoidÑno
informationavailable
abdominalpain,umbilicalhernia,gas-
troenteritis;chestpain,hypertension;dyspnoea,
apnoea,nasalcongestion;rigors,malaise,areßexia;
pharyngitis;conjunctivitis,cornealopacity;earpain;
facialoedema
BNFC2011–
Nutritionandblood
Indicationanddose
ucopolysaccharidosisVI
(specialistuseonly)
Byintravenousinfusion
Child5Ð18years
1mg/kgonceweekly
intravenousinfusion
,diluterequi-
sitedosewithSodiumChloride0.9%toaÞnalvolume
of250mLandmixgently;infusethrougha0.2micron
in-lineÞlter;giveapprox.2.5%ofthetotalvolume
over1hour,theninfuseremainingvolumeovernext3
hours;ifbody-weightunder20kgandatriskofßuid
overload,diluterequisitedosein100mLSodium
Chloride0.9%andgiveoveratleast4hours
Concentrateforintravenousinfusion
,galsulfase
severerespiratorydisease;acutefebrile
respiratoryillness(considerdelayingtreatment)
Infusion-relatedreactions
Seenotesabove
Contra-indications
womenofchild-bearingpotential
manufactureradvisesavoid
manufactureradvisesavoidÑpresent
inmilkin
gastro-intestinaldisturbances,swollen
tongue;arrhythmia,tachycardia,chestpain,cyanosis,
peripheraloedema,hypertension,hypotension,
ßushing;bronchospasm,hypoxia,cough,wheezing,
tachypnoea,dyspnoea;headache,dizziness,tremor;
pyrexia;arthralgia;facialoedema,urticaria,pruritus,
rash,infusion-siteswelling,erythema;pulmonary
embolismandanaphylaxisalsoreported
Indicationanddose
ucopolysaccharidosisII
(specialistuseonly)
Byintravenousinfusion
Child5Ð18years
500micrograms/kgonce
weekly
intravenousinfusion
,diluterequi-
sitedosein100mLSodiumChloride0.9%andmix
gently(donotshake);giveover3hours(gradually
reducedto1hourifnoinfusion-relatedreactions)
(ShireHGT)
Concentrateforintravenousinfusion
,idursulfase
monitorimmunoglobulinG(IgG)antibody
Appendix1(laronidase)
Infusion-relatedreactions
Seenotesabove
manufactureradvisesavoidunlessessen-
tialÑnoinformationavailable
manufactureradvisesavoidÑno
informationavailable
nausea,vomiting,diarrhoea,abdominal
pain;coldextremities,pallor,ßushing,tachycardia,
bloodpressurechanges;dyspnoea,cough,angio-
edema,anaphylaxis;headache,paraesthesia,dizzi-
ness,fatigue,restlessness;inßuenza-likesymptoms;
MERCAPTAMINE
(Cysteamine)
leucocyte-cystineconcentrationandhae-
matologicalmonitoringrequiredÑconsultproduct
literature;doseofphosphatesupplementmayneedto
beadjustediftransferringfromphosphocysteamineto
Contra-indications
hypersensitivitytopenicillamine
avoidÑteratogenicandtoxicin
avoid
breathandbodyodour,nausea,vomi-
ting,diarrhoea,anorexia,abdominalpain,gastroen-
teritis,dyspepsia,encephalopathy,headache,malaise,
fever,rash;
lesscommonly
gastro-intestinalulcer,
seizures,hallucinations,nervousness,leucopenia,
nephroticsyndrome
Licenseduse
eyedropsnotlicensed
Indicationanddose
ephropathiccystinosis
(specialistuseonly)
Bymouth
initiallyone-sixthtoone-quarterofthe
expectedmaintenancedose,increasedgradually
over4Ð6weeks;maintenance,1.3g/m
(approx.
50mg/kg)dailyin4divideddoses
Nutritionandblood
Child1monthÐ12yearsorunder50kg
one-sixthtoone-quarteroftheexpectedmainte-
nancedose,increasedgraduallyover4Ð6weeks;
maintenance,1.3g/m
(approx.50mg/kg)dailyin
4divideddoses
hild12Ð18yearsorover50kg
initiallyone-
sixthtoone-quarteroftheexpectedmaintenance
dose,increasedgraduallyover4Ð6weeks;main-
tenance,2gdailyin4divideddoses
Cystagon
(OrphanEurope)
Capsules
Eyedrops
Mercaptamine
ALGLUCOSIDASEALFA
cardiacandrespiratorydysfunctionÑmoni-
torclosely;monitorimmunoglobulinG(IgG)antibody
Infusion-relatedreactions
Infusion-relatedreactionsvery
throughalowprotein-bindingin-lineÞlter
(0.2micron)ataninitialrateof1mg/kg/hour
increasedby2mg/kg/hourevery30minutestomax.
7mg/kg/hour
Intravenousinfusion
,powderforreconstitution,
monitorplasmapHandchloride
Contra-indications
nottobeusedinthetreatmentof
arginasedeÞciency
noinformationavailable
noinformationavailable
intravenousinjectiononly:nausea,
vomiting;ßushing,hypotension;headache,numb-
Nutritionandblood
aintenancetreatmentofhyperammonaemia
CARGLUMICACID
manufactureradvisesavoidunlessessen-
tialÑnoinformationavailable
manufactureradvisesavoidÑpresent
inmilkin
Indicationanddose
yperammonaemiadueto
50mg/kgtwicedaily;totaldailydosemayalter-
nativelybegivenin3Ð4divideddoses
Child1monthÐ18years
initially50Ð125mg/kg
twicedailyimmediatelybeforefood,adjusted
accordingtoplasma-ammoniaconcentration;
maintenance5Ð50mg/kgtwicedaily;totaldaily
dosemayalternativelybegivenin3Ð4divided
(OrphanEurope)
noinformationavailable
noinformationavailable
Indicationanddose
arbamylphosphatesynthasedeÞciency,
ornithinecarbamyltransferasedeÞciency
Bymouth
150mg/kgdailyin3Ð4divideddoses,
adjustedaccordingtoresponse
Child1monthÐ18years
150mg/kgdailyin3Ð4
divideddoses,adjustedaccordingtoresponse
CitrullinePowder
SODIUMBENZOATE
seenotesabove;neonates(riskofkernic-
terusandincreasedside-effects);
Appendix1(sodiumbenzoate)
Renalimpairment
seenotesabove
noinformationavailable
noinformationavailable
nausea,vomiting,anorexia;irritability,
Nutritionandblood
foradministration
bymouth
,oral
solutionorpowdermaybeadministeredinfruit
drinks;lesssolubleinacidicdrinks
SodiumBenzoate
SODIUMPHENYLBUTYRATE
seenotesabove;congestiveheartfailure;
Appendix1(sodiumphenylbutyrate)
Hepaticimpairment
manufactureradvisesusewith
Renalimpairment
manufactureradvisesusewith
caution;seealsonotesabove
avoidÑtoxicityin
studies;manu-
factureradvisesadequatecontraceptioninwomenof
child-bearingpotential
manufactureradvisesavoidÑno
informationavailable
amenorrhoeaandirregularmenstrual
Nutritionandblood
Indicationanddose
djunctivetreatmentofhomocystinuria
cialistuseonly)
Bymouth
50mg/kgtwicedaily,doseandfre-
quencyadjustedaccordingtoresponse;max.
75mg/kgtwicedaily
Child1monthÐ10years
50mg/kgtwicedaily,
doseandfrequencyadjustedaccordingto
response;max.75mg/kgtwicedaily
hild10Ð18years
3gtwicedaily,adjusted
accordingtoresponse;max.10gtwicedaily
Powdershouldbemixedwithwater,
(VitaminH)
noinformationavailable
noinformationavailable
Indicationanddose
solatedcarboxylasedefects
Bymouthorbyslowintravenousinjection
5mgoncedaily,adjustedaccordingto
response;usualmaintenance10Ð50mgdaily,
higherdosesmayberequired
Child1monthÐ18years
10mgoncedaily,
adjustedaccordingtoresponse;usualmainte-
nance10Ð50mgdailybutupto100mgdailymay
berequired
MIGLUSTAT
monitorcognitiveandneurologicalfunction,
slit-lampexaminationofeyesrecommended
beforetreatment;monitorliverfunctionregularly;
Nutritionandblood
Indicationanddose
ereditarytyrosinaemiatypeI
(incombination
(Ubiquinone,Co-enzymeQ10)
gencyoutsideofÞcehoursfromtheon-callpharmacist
StThomasÕHospital
Tel:(020)71887188
HAEMARGINATE
(Humanhemin)
manufactureradvisesavoidunlessessen-
manufactureradvisesavoidunless
essentialÑnoinformationavailable
rarely
hypersensitivityreactionsand
fever;painandthrombophlebitisatinjectionsite
Indicationanddose
cuteporphyrias(acuteintermittentporphyria,
porphyriavariegata,hereditarycoproporphyr-
Byintravenousinfusion
Child1monthÐ18years
3mg/kgoncedaily
(max.250mgdaily)for4days;ifresponseinade-
quate,repeat4-daycoursewithclosebiochemical
(OrphanEurope)
Concentrateforintravenousinfusion
,haemarginate
Nutritionandblood
Drugsunsafeforuseinacute
www.porphyria-europe.org
andalsofrom:
WelshMedicinesInformationCentre
UniversityHospitalofWales
Cardiff,CF144XW
Tel:(029)20742979/3877
Quitemodestchangesinchemicalstructurecanleadto
changesinporphyrinogenicitybutwherepossiblegeneral
statementshavebeenmadeaboutgroupsofdrugs;these
shouldbecheckedÞrst.
Unsafedruggroups(checkÞrst)
Alkylatingdrugs
ContactWelshMedicinesInformationCentreforfurtheradvice.
Nutritionandblood
Differencesinanti-inßammatoryactivity
inßammatoryeffectmaynotbeachieved(ormaynotbe
clinicallyassessable)forupto3weeks.However,in
juvenileidiopathicarthritisNSAIDsmaytake4Ð12
weekstobeeffective.Ifappropriateresponsesarenot
obtainedwithinthesetimes,anotherNSAIDshouldbe
tried.Theavailabilityofappropriateformulationsneeds
tobeconsideredwhenprescribingNSAIDsforchildren.
NSAIDsreducetheproductionofprostaglandinsby
inhibitingtheenzymecyclo-oxygenase.Theyvaryin
theirselectivityforinhibitingdifferenttypesofcyclo-
oxygenase;selectiveinhibitionofcyclo-oxygenase-2is
associatedwithlessgastro-intestinalintolerance.How-
ever,inchildrengastro-intestinalsymptomsarerarein
thosetakingNSAIDsforshortperiods.Theroleof
Hepaticimpairment
NSAIDsshouldbeusedwith
cautioninchildrenwithhepaticimpairment;thereisan
increasedriskofgastro-intestinalbleedingandßuid
DICLOFENACPOTASSIUM
seenotesabove;avoidinacuteporphyria
(section9.8.2)
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
avoidinsevereimpairment;see
alsonotesabove
seenotesabove
amountinmilktoosmalltobe
harmful;seealsonotesabove
seenotesabove
Indicationanddose
DICLOFENACSODIUM
seenotesabove;avoidinacuteporphyria
(section9.8.2)
Contra-indications
seenotesabove;avoidinjections
containingbenzylalcoholinneonates(seeprepara-
tionsbelow)
Intravenoususe
Additionalcontra-indicationsinclude
concomitantNSAIDoranticoagulantuse(includinglow-
doseheparins),historyofhaemorrhagicdiathesis,historyof
conÞrmedorsuspectedcerebrovascularbleeding,opera-
tionswithhighriskofhaemorrhage,historyofasthma,
moderateorsevererenalimpairment,hypovolaemia,dehy-
Hepaticimpairment
seenotesabove
Renalimpairment
avoidinsevereimpairment;see
alsoIntravenousUseandnotesabove
seenotesabove
amountinmilktoosmalltobe
harmful;seealsonotesabove
BNFC2011–
10.1.1Non-steroidalanti-inammatorydrugs
seenotesabove;suppositoriesmay
causerectalirritation;injectionsitereactions
Licenseduse
notlicensedforuseinchildrenunder1
year;
notlicensedforuseinchildren
under6yearsexceptforuseinchildrenover1year
forjuvenileidiopathicarthritis;soliddoseforms
containingmorethan25mgnotlicensedforusein
notlicensedforuseinchildren
Indicationanddose
nßammationandmildtomoderatepain
Bymouthorbyrectum
Child6monthsÐ18years
0.3Ð1mg/kg(max.
50mg)3timesdaily
ostoperativepain
Byrectum
Child6Ð18years
0.5Ð1mg/kg(max.75mg)
twicedailyformax.4days;totaldailydosemay
alternativelybegivenin3divideddoses
Byintravenousinfusionordeepintramuscular
injectionintoglutealmuscle
Child2Ð18years
0.3Ð1mg/kgonceortwice
dailyformax.2days(max.150mgdaily)
ainandinßammationinrheumaticdisease
includingjuvenileidiopathicarthritis
Bymouth
Child6monthsÐ18years
1.5Ð2.5mg/kg(max.
75mg)twicedaily;totaldailydosemayalterna-
tivelybegivenin3divideddoses
intravenousinfusion
,dilute75mg
with100Ð500mLGlucose5%
SodiumChloride
0.9%(previouslybufferedwith0.5mLSodium
Bicarbonate8.4%solution
with1mLSodium
Bicarbonate4.2%solution);giveover30Ð120minutes
DiclofenacSodium
ModiÞedrelease
DiclomaxSR
Capsules
Renalimpairment
avoidifestimatedglomerularÞl-
trationratelessthan30mL/minute/1.73m
;seealso
notesabove
manufactureradvisesavoid(teratogenicin
studies);seealsonotesabove
manufactureradvisesavoidÑpresent
inmilkin
studies;seealsonotesabove
seenotesabove;alsopalpitation,fatigue,
inßuenza-likesymptoms,ecchymosis;
lesscommonly
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
avoidinsevereimpairment;see
alsonotesabove
seenotesabove
amounttoosmalltobeharmful,but
somemanufacturersadviseavoid;seealsonotes
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder3
monthsorbody-weightunder5kg
Indicationanddose
ildtomoderatepain,painandinßammation
ofsoft-tissueinjuries,pyrexiawithdiscomfort
Bymouth
Child1Ð3months
5mg/kg3Ð4timesdaily
hild3Ð6months
50mg3timesdaily;max.
30mg/kgdailyin3Ð4divideddoses
hild6monthsÐ1year
50mg3Ð4timesdaily;
max.30mg/kgdailyin3Ð4divideddoses
hild1Ð4years
100mg3timesdaily;max.
30mg/kgdailyin3Ð4divideddoses
hild4Ð7years
150mg3timesdaily;max.
30mg/kgdailyin3Ð4divideddoses
hild7Ð10years
200mg3timesdaily;max.
30mg/kg(max.2.4g)dailyin3Ð4divideddoses
hild10Ð12years
300mg3timesdaily;max.
30mg/kg(max.2.4g)dailyin3Ð4divideddoses
hild12Ð18years
initially300Ð400mg3Ð4times
daily;increasedifnecessarytomax.600mg4
timesdaily;maintenancedoseof200Ð400mg3
timesdailymaybeadequate
ainandinßammationinrheumaticdisease
includingjuvenileidiopathicarthritis
Bymouth
Child3monthsÐ18years
30Ð40mg/kg(max.
2.4g)dailyin3Ð4divideddoses;insystemic
juvenileidiopathicarthritisupto60mg/kg(max.
2.4g)daily[unlicensed]in4Ð6divideddoses
ost-immunisationpyrexiaininfants
(seealso
p.600)
Bymouth
Child2Ð3months
50mgasasingledose
repeatedonceafter6hoursifnecessary
losureofpatentductusarteriosusinneonates
seesection2.14
ModiÞedrelease
Spansule
(=capsulem/r),maroon/pink,enclosing
ModiÞedrelease
MEFENAMICACID
seenotesabove;epilepsy;acuteporphyria
(section9.8.2)
Contra-indications
seenotesabove;inßammatory
boweldisease
Hepaticimpairment
seenotesabove
Renalimpairment
avoidinsevereimpairment;see
alsonotesabove
seenotesabove
amounttoosmalltobeharmfulbut
manufactureradvisesavoid;seealsonotesabove
seenotesabove;alsodiarrhoeaorrashes
(withdrawtreatment),stomatitis;
lesscommonly
paraesthesiaandfatigue;
rarely
hypotension,palpita-
tion,glucoseintolerance,thrombocytopenia,haemo-
lyticanaemia(positiveCoombsÕtest),andaplastic
Indicationanddose
cutepainincludingdysmenorrhoea,menorr-
Bymouth
Child12Ð18years
500mg3timesdaily
MefenamicAcid
MELOXICAM
seenotesabove
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
avoidifestimatedglomerularÞl-
trationratelessthan25mL/minute/1.73m
;seealso
notesabove
seenotesabove
presentinmilkin
manufactureradvisesavoid;seealsonotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder
16years
Indicationanddose
eliefofpainandinßammationinjuvenile
Meloxicam
seenotesabove;
Appendix1
Contra-indications
seenotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
avoidifestimatedglomerularÞl-
trationratelessthan30mL/minute/1.73m
;seealso
notesabove
seenotesabove
amounttoosmalltobeharmfulbut
manufactureradvisesavoid;seealsonotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder5
yearsforjuvenileidiopathicarthritis;notlicensed
foruseinchildrenunder16yearsformusculo-
seenotesaboveandCHMPadvicebelow
Contra-indications
inßammatoryboweldisease;see
alsonotesabove
Hepaticimpairment
seenotesabove
Renalimpairment
seenotesabove
seenotesabove
amounttoosmalltobeharmful;see
alsonotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
eliefofpainandinßammationinjuvenile
idiopathicarthritis
Bymouth
Child6Ð18yearsandbody-weightunder15kg
5mgdaily
hild6Ð18yearsandbody-weight16Ð25kg
10mgdaily
hild6Ð18yearsandbody-weight26Ð45kg
15mgdaily
hild6Ð18yearsandbody-weightover46kg
20mgdaily
CHMPadvice
Piroxicam(June2007)
TheCHMPhasrecommendedrestrictionsontheuse
ofpiroxicambecauseoftheincreasedriskofgastro-
intestinalsideeffectsandseriousskinreactions.The
CHMPhasadvisedthat:
piroxicamshouldbeinitiatedonlybyphysiciansexperi-
encedintreatinginßammatoryordegenerativerheumatic
piroxicamshouldnotbeusedasÞrst-linetreatment
inadults,useofpiroxicamshouldbelimitedtothesymp-
tomaticreliefofosteoarthritis,rheumatoidarthritis,and
ankylosingspondylitis
piroxicamdoseshouldnotexceed20mgdaily
piroxicamshouldnolongerbeusedforthetreatmentof
acutepainfulandinßammatoryconditions
treatmentshouldbereviewed2weeksafterinitiating
piroxicam,andperiodicallythereafter
concomitantadministrationofagastro-protectiveagent
(section1.3)shouldbeconsidered
Topicalpreparationscontainingpiroxicamarenot
affectedbytheserestrictions
Piroxicam
10.1.2.1
Systemiccorticosteroids
Thegeneralactions,uses,andcautionsofcorticoster-
oidsaredescribedinsection6.3.Inchildrenwithrheu-
maticdiseasescorticosteroidsshouldbereservedfor
speciÞcindications(e.g.whenotheranti-inßammatory
drugsareunsuccessful)andshouldbeusedonlyunder
thesupervisionofaspecialist.
Systemiccorticosteroidsmaybeconsideredforthe
managementofjuvenileidiopathicarthritisinsystemic
diseaseorwhenseveraljointsareaffected.Systemic
corticosteroidsmayalsobeconsideredinsevere,pos-
siblylife-threateningconditionssuchassystemiclupus
erythematosus,systemicvasculitis,juveniledermato-
10.1.2.2
Localcorticosteroidinjections
Corticosteroidsareinjectedlocallyforananti-inßamm-
atoryeffect.Ininßammatoryconditionsofthejoints,
includingjuvenileidiopathicarthritis,theyaregivenby
intra-articularinjection
asmonotherapy,orasan
adjuncttolong-termtherapytoreduceswellingand
deformityinoneorafewjoints.Asepticprecautions
(e.g.ano-touchtechnique)areessential,asisaclinician
skilledinthetechnique;infectedareasshouldbe
avoidedandgeneralanaesthesia,orlocalanaesthesia,
orconscioussedationshouldbeused.Occasionallyan
acuteinßammatoryreactiondevelopsafteranintra-
articularorsoft-tissueinjectionofacorticosteroid.
Thismaybeareactiontothemicrocrystallinesuspen-
sionofthecorticosteroidused,butmustbedistin-
guishedfromsepsisintroducedintotheinjectionsite.
LOCALCORTICOSTEROID
seenotesaboveandconsultproductlitera-
ture;seealsosection6.3.2
Contra-indications
seenotesaboveandconsultpro-
ductliterature;avoidinjectionscontainingbenzyl
alcoholinneonates(seepreparationbelow)
seenotesaboveandconsultproduct
Licenseduse
toxicity,hairdepigmentation,hairloss,anddiscolora-
tionofskin,nails,andmucousmembranes.Side-effects
thatoccurrarelyincludeblooddisorders(including
thrombocytopenia,agranulocytosis,andaplasticanae-
mia),mentalchanges(includingemotionaldisturbances
andpsychosis),myopathy(includingcardiomyopathy
andneuromyopathy),acutegeneralisedexanthematous
pustulosis,exfoliativedermatitis,Stevens-Johnson
syndrome,photosensitivity,andhepaticdamage;angio-
edemaandbronchospasmhavealsobeenreported.
Important
:verytoxicinoverdosageÑimmediate
advicefrompoisonscentresessential(seealsop.29).
HYDROXYCHLOROQUINESULPHATE
seenotesabove
Hepaticimpairment
usewithcautioninmoderateto
severeimpairment
Renalimpairment
manufactureradvisescautionand
monitoringofplasma-hydroxychloroquineconcen-
trationinsevereimpairment
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
uvenileidiopathicarthritis,systemicand
discoidlupuserythematosus,dermatological
conditionscausedoraggravatedbysunlight
Bymouth
Child1monthÐ18years
basedonidealbody-
weight,5Ð6.5mg/kg(max.400mg)oncedaily
Hydroxychloroquine
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Drugsaffectingtheimmuneresponse
notbeenestablishedÑinchildrenover2yearsadoseof
5mgweekly[unlicensedindication],maybegivenona
AZATHIOPRINE
section8.2.1
Contra-indications
section8.2.1
Hepaticimpairment
section8.2.1
Renalimpairment
section8.2.1
section8.2.1
section8.2.1
section8.2.1
Indicationanddose
ystemiclupuserythematosus,vasculitis,
auto-immuneconditionsusuallywhencortico-
steroidtherapyalonehasprovedinadequate
seealsonotesabove
Bymouth
Child1monthÐ18years
initially1mg/kgdaily,
adjustedaccordingtoresponsetomax.3mg/kg
daily(considerwithdrawalifnoimprovement
within3months)
nßammatoryboweldisease
section1.5.3
ransplantationrejection
section8.2.1
Section8.2.1
Parenteralpreparations
Seealsosection8.1.3
ABATACEPT
predispositiontoinfection(screenforlatent
tuberculosisandviralhepatitis);donotinitiateuntil
activeinfectionsarecontrolled;childrenshouldbe
broughtuptodatewithcurrentimmunisationsche-
dule(section14.1)beforeinitiatingtherapy;progres-
sivemultifocalleucoencephalopathyÑdiscontinue
treatmentifneurologicalsymptomspresent;
Appendix1(abatacept)
Contra-indications
severeinfection(seealsoCau-
manufactureradvisesavoidunlessessen-
tialÑeffectivecontraceptionrequiredduringtreat-
mentandfor14weeksafterlastdose
presentinmilkin
manufactureradvisesavoidbreast-feedingduring
treatmentandfor14weeksafterlastdose
abdominalpain,diarrhoea,dyspepsia,
nausea;ßushing,hypertension;cough;dizziness,fati-
gue,headache;infection,rhinitis;rash;
lesscommonly
gastritis,stomatitis,tachycardia,bradycardia,palpi-
tation,hypotension,dyspnoea,paraesthesia,weight
predispositiontoinfection;monitorfor
infectionsbefore,during,andfor5monthsafter
treatment(seealsoTuberculosisbelow);donotiniti-
ateuntilactiveinfectionsarecontrolled;discontinueif
newseriousinfectiondevelops;hepatitisBvirusÑ
monitorforactiveinfection;childrenshouldbe
broughtuptodatewithcurrentimmunisationsche-
dule(section14.1)beforeinitiatingtherapy;mildheart
failure(discontinueifsymptomsdeveloporworsenÑ
avoidinmoderateorsevereheartfailure);demyeli-
natingCNSdisorders(riskofexacerbation);historyor
developmentofmalignancy;monitorfornon-
melanomaskincancerbeforeandduringtreatment,
especiallyinchildrenwithhistoryofPUVAtreatment
forpsoriasisorextensiveimmunosuppressantther-
apy;
:Appendix1(adalimumab)
Tuberculosis
Childrenshouldbeevaluatedfortuberculosis
beforetreatment.Activetuberculosisshouldbetreatedwith
standardtreatment(section5.1.9)foratleast2months
beforestartingadalimumab.Childrenwhohavepreviously
receivedadequatetreatmentfortuberculosiscanstartada-
limumabbutshouldbemonitoredevery3monthsfor
possiblerecurrence.Inthosewithoutactivetuberculosisbut
whowerepreviouslynottreatedadequately,chemoprophy-
hepatitisCinfection;childrenshouldbebroughtupto
datewithcurrentimmunisationschedule(section
14.1)beforeinitiatingtherapy;heartfailure(riskof
exacerbation);historyorincreasedriskofdemyeli-
natingdisorders;historyordevelopmentofmalig-
nancy;monitorforskincancerbeforeandduring
treatmentparticularlyinthoseatrisk(includingchil-
drenwithpsoriasisorahistoryofPUVAtreatment);
seesection1.5.1andnotesabove
Contra-indications
seesection1.5.1
Hepaticimpairment
section1.5.1
Renalimpairment
section1.5.1
section1.5.1
section1.5.1
seesection1.5.1andnotesabove
Licenseduse
notlicensedforuseinchildrenfor
juvenileidiopathicarthritis
Indicationanddose
uvenileidiopathicarthritis(seealsonotes
Bymouth
Child2Ð18years
initially5mg/kgtwicedailyfor
1week,then10mg/kgtwicedailyfor1week,then
20mg/kgtwicedailyfor1week,maintenance
dose20Ð25mg/kgtwicedaily;
Child2–12years
max.2gdaily,
Child12–18years
max.3gdaily
Section1.5.1
Goutandcytotoxic-
inducedhyperuricaemia
Thissectionisnotincludedin
BNFforChildren
.Forthe
roleofallopurinolandrasburicaseintheprophylaxisof
hyperuricaemiaassociatedwithcancerchemotherapy
andinenzymedisorderscausingincreasedserumurate,
seesection8.1.Themanagementofgoutinadolescents
requiresspecialistsupervision.
BNFC2011–
10.1.4Goutandcytotoxic-inducedhyperuricaemia
Otherdrugsforrheumatic
ClassiÞcationnotusedin
BNFforChildren
Drugsusedin
neuromusculardisorders
Drugsthatenhanceneuromuscular
transmission
asthma(
extreme
caution),bradycardia,
arrhythmias,recentmyocardialinfarction,epilepsy,
hypotension,parkinsonism,vagotonia,pepticulcer-
ation,hyperthyroidism;atropineorotherantidoteto
muscariniceffectsmaybenecessary(particularly
whenneostigmineisgivenbyinjection),butnotgiven
routinelybecauseitmaymasksignsofoverdosage;
Childupto6years
initially7.5mgrepeatedat
suitableintervalsthroughouttheday,totaldaily
dose15Ð90mg
hild6Ð12years
initially15mgrepeatedatsui-
tableintervalsthroughouttheday,totaldailydose
15Ð90mg
hild12Ð18years
initially15Ð30mgrepeatedat
suitableintervalsthroughouttheday,totaldaily
dose75Ð300mg(butmax.mostcantolerateis
180mgdaily)
Bysubcutaneousorintramuscularinjection(as
Section15.1.6
EDROPHONIUMCHLORIDE
seeunderNeostigmine;haveresuscitation
extreme
cautioninrespiratorydistress(see
notesabove)andinasthma
Severecholinergicreactionscanbecounteractedby
injectionofatropinesulphate(whichshouldalwaysbe
available)
Contra-indications
seeunderNeostigmine
seeunderNeostigmine
seeunderNeostigmine
seeunderNeostigmine
Indicationanddose
iagnostictestformyastheniagravis
Byintravenousinjection
Child1monthÐ12years
20micrograms/kgfol-
lowedafter30seconds(ifnoadversereactionhas
occurred)by80micrograms/kg
hild12Ð18years
2mgfollowedafter30sec-
onds(ifnoadversereactionhasoccurred)by8mg
PYRIDOSTIGMINEBROMIDE
seeunderNeostigmine;weakermuscarinic
Contra-indications
seeunderNeostigmine
Renalimpairment
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Immunosuppressanttherapy
Acourseof
corticosteroids
(section6.3)isanestab-
lishedtreatmentinseverecasesofmyastheniagravis
andmaybeparticularlyusefulwhenantibodiestothe
Sedationandoccasionallyextensorhypotonusare
disadvantages.Otherbenzodiazepinesalsohave
muscle-relaxantproperties.
BACLOFEN
psychiatricillness;respiratoryimpairment;
epilepsy;historyofpepticulcer(avoidoralroutein
maintenancedoseof0.75Ð2mg/kg(max.40mg)
dailyindivideddoses(
20Ð30mgdailyindivided
doses);reviewtreatmentifnobeneÞtwithin6
hild6Ð8years
initially300micrograms/kgdaily
in4divideddoses,increasedgraduallytousual
maintenancedoseof0.75Ð2mg/kg(max.40mg)
dailyindivideddoses(
30Ð40mgdailyindivided
doses);reviewtreatmentifnobeneÞtwithin6
hild8Ð10years
initially300micrograms/kg
dailyin4divideddoses,increasedgraduallyto
usualmaintenancedoseof0.75Ð2mg/kg(max.
60mg)dailyindivideddoses;reviewtreatmentif
nobeneÞtwithin6weeks
hild10Ð18years
initially5mg3timesdaily
increasedgradually;usualmaintenancedoseupto
60mgdailyindivideddoses(max.100mgdaily);
reviewtreatmentifnobeneÞtwithin6weeks
everechronicspasticityofcerebralorigin
unresponsivetooralantispasticdrugs(ororal
therapynottolerated),asalternativetoabla-
tiveneurosurgicalproceduresÑspecialistuse
Byintrathecalinjection
Child4Ð18years
testdose
25micrograms
Byintrathecalinjection
Lioresal
Intrathecalinjection
,baclofen,50micrograms/mL,
DANTROLENESODIUM
impairedcardiacandpulmonaryfunction;
therapeuticeffectmaytakeafewweekstodevelopÑ
discontinueifnoresponsewithin45days;
Appendix1(musclerelaxants)
Hepatotoxicity
Potentiallylife-threateninghepatotoxicity
reported,usuallyifdosesgreaterthan400mgdailyused,in
females,ifhistoryofliverdisorders,orconcomitantuseof
hepatotoxicdrugs;testliverfunctionbeforeandatintervals
duringtherapyÑdiscontinueifabnormalliverfunctiontests
orsymptomsofliverdisorder(counselling,seebelow);re-
DIAZEPAM
section4.8.2
Contra-indications
section4.8.2
Hepaticimpairment
section4.8.2
Renalimpairment
section4.8.2
section4.8.2
section4.8.2
section4.8.2;alsohypotonia
Indicationanddose
usclespasmincerebralspasticityorin
Parenteralpreparations
Section4.8.2
BNFC2011–
Drugsforthereliefof
soft-tissueinßammation
andtopicalpainrelief
Enzymes
Rubefacients,topicalNSAIDs,
capsaicin,andpoultices
Extravasation
Localguidelinesforthemanagementofextravasa-
tionshouldbefollowedwheretheyexistorspecialist
advicesought.
Extravasationinjuryfollowsleakageofdrugsorintra-
venousßuidsfromtheveinsorinadvertentadministra-
tionintothesubcutaneousorsubdermaltissue.Itmust
bedealtwith
promptly
topreventtissuenecrosis.
Acidicoralkalinepreparationsandthosewithanosmo-
laritygreaterthanthatofplasmacancauseextravasa-
Administrationofdrugstothe
Controlofmicrobialcontami-
Anti-infectiveeyepreparations
Antibacterials
Antifungals
Antivirals
Corticosteroidsandotheranti-
inßammatorypreparations
Corticosteroids
Otheranti-inßammatorypre-
parations
Mydriaticsandcycloplegics
Treatmentofglaucoma
corticosteroidsforconditionsnotrespondingtotopical
therapy.Thedrugdiffusesthroughthecorneaandsclera
totheanteriorandposteriorchambersandvitreous
humour.However,becausethedose-volumeislimited,
thisrouteissuitableonlyfordrugswhicharereadily
soluble.
Drugssuchasantimicrobialsandcorticosteroidsmay
beadministeredsystemicallytotreataneyecondition.
Preservativesandsensitisers
Informationonpre-
servativesandonsubstancesidentiÞedasskinsensiti-
sers(section13.1.3)isprovidedunderpreparation
entries.
Controlofmicrobial
Preparationsfortheeyeshouldbesterilewhenissued.
Eyedropsinmultiple-applicationcontainersincludea
preservativebutcareshouldneverthelessbetakento
avoidcontaminationofthecontentsduringuse.
Eyedropsinmultiple-applicationcontainersfor
shouldnotbeusedformorethan4weeksafterÞrst
opening(unlessotherwisestated).
Eyedropsforusein
hospitalwards
arenormallydis-
carded1weekafterÞrstopening(24hoursifpreserva-
tive-free).Individualcontainersshouldbeprovidedfor
eachchild,andforeacheyeiftherearespecialconcerns
aboutcontamination.Containersusedbeforeanopera-
tionshouldbediscardedatthetimeoftheoperationand
freshcontainerssupplied.Afreshsupplyshouldalsobe
providedupondischargefromhospital;inspecialist
ophthalmologyunitsitmaybeacceptabletoissue
eye-dropbottlesthathavebeendispensedtothepatient
onthedayofdischarge.
out-patientdepartments
single-applicationpacks
shouldpreferablybeused;ifmultiple-application
packsareused,theyshouldbediscardedattheendof
eachday.Inclinicsforeyediseasesandinaccidentand
emergencydepartments,wherethedangersofinfection
arehigh,single-applicationpacksshouldbeused;ifa
multiple-applicationpackisused,itshouldbediscarded
aftersingleuse.
Diagnosticdyes(section11.8.2)shouldbeusedonly
fromsingle-applicationpacks.
eyesurgery
single-applicationcontainersshouldbe
usedifpossible;ifamultiple-applicationpackisused,it
shouldbediscardedaftersingleuse.Preparationsused
duringintra-ocularproceduresandothersthatmay
Otherantibacterialeyedropsmaybepreparedasepti-
callyinaspecialistmanufacturingunitfrommaterial
suppliedforinjection,seesection11.8.
Antibacterialeyedropsareusedtotreat
acutebacterialconjunctivitisinneonates(ophthalmia
neonatorum);wherepossiblethecausativemicro-
organismshouldbeidentiÞed.
neomycin
eyedropsareusedtotreatmildconjunctiv-
itis;moreseriousinfectionsalsorequireasystemic
antibacterial.Failuretorespondtoinitialtreatment
requiresfurtherinvestigation;chlamydialinfectionis
oneofthemostfrequentcausesofneonatalconjunctiv-
itisandshouldbeconsidered.
Gonococcaleyeinfections
aretreatedwithasingle-dose
ofparenteral
ceftriaxone
eyeinfections
shouldbemanagedwithoral
erythro-
mycin
CHLORAMPHENICOL
transientstinging;seealsonotesabove
Indicationanddose
Seenotesabove
Chloramphenicol
Singleuse
Chloramphenicol
(Bausch&Lomb)
Eyedrops
CIPROFLOXACIN
notrecommendedforchildrenunder1year
manufactureradvisesuseonlyifpotential
beneÞtoutweighsrisk
manufactureradvisescaution
localburninganditching;lidmargin
crusting;hyperaemia;tastedisturbances;corneal
staining,keratitis,lidoedema,lacrimation,photo-
phobia,cornealinÞltrates;nauseaandvisualdistur-
bancesreported
Licenseduse
eyeointmentnotlicensedforusein
childrenunder1year
Indicationanddose
uperÞcialbacterialinfections
Seenotesabove
ornealulcer
Applyeyedropsthroughoutdayandnight,day1
applyevery15minutesfor6hoursthenevery30
minutes,day2applyeveryhour,days3Ð14apply
every4hours(max.durationoftreatment21days)
Applyeyeointmentthroughoutdayandnight;
apply1.25cmointmentevery1Ð2hoursfor2days
thenevery4hoursfornext12days
Ciloxan
Ophthalmicsolution
(=eyedrops),ciproßoxacin(as
FUSIDICACID
Indicationanddose
Seenotesaboveandunderpreparationbelow
Eyedrops
,m/r,fusidicacid1%ingelbasis(liquiÞes
GENTAMICIN
Indicationanddose
Seenotesabove
(forearoreye),gentamicin0.3%(assulphate).
LEVOFLOXACIN
manufactureradvisesavoidÑsystemic
quinoloneshavecausedarthropathyin
manufactureradvisesavoid
transientocularirritation,visualdistur-
bances,lidmargincrusting,lidorconjunctival
oedema,hyperaemia,conjunctivalfollicles,photo-
phobia,headache,rhinitis
Licenseduse
notlicensedforuseinchildrenunder1
year
Indicationanddose
Seenotesabove
(KestrelOphthalmics)
Eyedrops
MOXIFLOXACIN
notrecommendedforneonates
tastedisturbances,oculardiscomfort
(includingpain,irritationanddryness),hyperaemia;
lesscommonly
vomiting,headache,paraesthesia,
cornealdisorders(includingkeratitis,erosion,and
staining),conjunctivalhaemorrhage,eyeliderythema,
visualdisturbances,nasaldiscomfort,pharyngolar-
yngealpain;
alsoreported
nausea,palpitation,dys-
pnoea,dizziness,raisedintra-ocularpressure,photo-
phobia,rash,pruritus
Indicationanddose
ocaltreatmentofinfections(seealsonotes
hild1monthÐ18years
apply3timesdaily
(continuetreatmentfor2Ð3daysafterinfection
improves;reviewifnoimprovementwithin5days)
(Alcon)
Eyedrops
NEOMYCINSULPHATE
Indicationanddose
Seenotesabove
OFLOXACIN
nottobeusedformorethan10days
manufactureradvisesuseonlyifbeneÞt
outweighsrisk;systemicquinoloneshavecaused
arthropathyin
manufactureradvisesavoid
localirritationincludingphotophobia;
dizziness,numbness,nauseaandheadachereported
Licenseduse
notlicensedforuseinneonates
Indicationanddose
ocaltreatmentofinfections(seealsonotes
ApplyeverytwotofourhoursfortheÞrsttwodays
thenreducefrequencytofourtimesdaily(max.10
daystreatment)
Ophthalmicsolution
(=eyedrops),oßoxacin0.3%.
POLYMYXINBSULPHATE
Indicationanddose
Seenotesabove
Withotherantibacterials
(TEVAUK)
Eyeointment
,polymyxinBsulphate10000units,
TOBRAMYCIN
Indicationanddose
ocaltreatmentofinfections(seealsonotes
hild1Ð18years
applytwicedailyfor6Ð8days;
insevereinfection,apply4timesdailyontheÞrst
day,thentwicedailyfor5Ð7days
Tobravisc
(Alcon)
Eyedrops
Manydifferentfungiarecapableofproducingocular
infection;theycanbeidentiÞedbyappropriatelabora-
toryprocedures.
Antifungalpreparationsfortheeyearenotgenerally
available.Treatmentisnormallycarriedoutatspecialist
centres,butrequestsforinformationaboutsuppliesof
preparationsnotavailablecommerciallyshouldbe
addressedtotheStrategicHealthAuthority(orequiva-
lentinScotlandorNorthernIreland),ortothenearest
hospitalophthalmologyunit,ortoMoorÞeldsEyeHos-
pital,162CityRoad,LondonEC1V2PD(tel.(020)7253
3411)or
www.moorÞelds.nhs.uk
Antivirals
Herpessimplexinfectionsproducing,forexample,
dendriticcornealulcerscanbetreatedwith
aciclovir
Aciclovireyeointmentisusedincombinationwith
systemictreatmentforophthalmiczoster(section
ACICLOVIR
localirritationandinßammation,super-
Þcialpunctatekeratopathy;
rarely
hypersensitivityreactionsincludingangio-
Indicationanddose
ocaltreatmentofherpessimplexinfections
Apply5timesdaily(continueforatleast3days
Withneomycin
Singleuse
Withantibacterials
Eyedrops
PREDNISOLONE
seenotesabove
seenotesabove
Indicationanddose
Localtreatmentofinßammation(short-term)
Applyevery1Ð2hoursuntilcontrolledthenreduce
PredForte
Eyedrops
Singleuse
PrednisoloneSodiumPhosphate
(Bausch
&Lomb)
Eyedrops
Withneomycin
(UCBPharma)
(forearoreye),seesection12.1.1
Otheranti-inßammatory
Eyedropscontaining
,suchas
ANTAZOLINESULPHATE
Indicationanddose
Allergicconjunctivitis
Seepreparationbelow
Otrivine-Antistin
(NovartisConsumerHealth)
Eyedrops
AZELASTINEHYDROCHLORIDE
mildtransientirritation;bittertaste
Indicationanddose
llergicconjunctivitis,seasonalallergiccon-
hild4Ð18years
applytwicedaily,increasedif
necessaryto4timesdaily
erennialconjunctivitis
hild12Ð18years
applytwicedaily,increasedif
necessaryto4timesdaily;max.durationof
treatment6weeks
11.4.2Otheranti-inammatorypreparations
BNFC2011–
Eyedrops
transientburningorstinging;blurred
vision,localoedema,keratitis,irritation,dryeye,
lacrimation,cornealinÞltrates(discontinue)and
staining;photophobia;headache,andrhinitisocca-
sionallyreported
Indicationanddose
easonalallergicconjunctivitis
hild3Ð18years
applytwicedaily
Eyedrops
EPINASTINEHYDROCHLORIDE
burning;
lesscommonly
drymouth,taste
disturbance;nasalirritation,rhinitis;headache,ble-
pharoptosis,conjunctivaloedemaandhyperaemia,
dryeye,localirritation,photophobia,visualdistur-
bance;pruritus
Indicationanddose
easonalallergicconjunctivitis
hild12Ð18years
applytwicedaily;max.dura-
tionoftreatment8weeks
Relestat
Eyedrops
,epinastinehydrochloride500micr-
LODOXAMIDE
burning,stinging,itching,blurredvision,
tearproductiondisturbance,andoculardiscomfort;
lesscommonly
,ßushing,nasaldryness,dizziness,
drowsiness,headache,blepharitis,andkeratitis
Indicationanddose
llergicconjunctivitis
hild4Ð18years
apply4timesdaily
NEDOCROMILSODIUM
transientburningandstinging;distinc-
tivetastereported
Indicationanddose
easonalandperennialallergicconjunctivitis
hild6Ð18years
applytwicedailyincreasedif
necessaryto4timesdaily;max.12weekstreat-
mentforseasonalallergicconjunctivitis
ernalkeratoconjunctivitis
hild6Ð18years
apply4timesdaily
Eyedrops
OLOPATADINE
localirritation;lesscommonlykeratitis,
dryeye,localoedema,photophobia;headache,asth-
enia,dizziness;drynosealsoreported
Indicationanddose
easonalallergicconjunctivitis
hild3Ð18years
applytwicedaily;max.duration
oftreatment4months
Eyedrops
,olopatadine(ashydrochloride)1mg/mL,
SODIUMCROMOGLICATE
(Sodiumcromoglycate)
transientburningandstinging
Indicationanddose
llergicconjunctivitis,vernalkeratoconjuncti-
Applyeyedrops4timesdaily
SodiumCromoglicate
Singleuse
Catacrom
Eyedrops
Mydriaticsand
cycloplegics
Antimuscarinicsdilatethepupilandparalysetheciliary
muscle;theyvaryinpotencyanddurationofaction.
Short-acting,relativelyweakmydriatics,suchas
tropic-
0.5%(actionlastsfor4Ð6hours),facilitatethe
examinationofthefundusoftheeye.
Cyclopentolate
1%(actionupto24hours)or
atropine
(actionupto7
days)arepreferableforproducingcycloplegiafor
refractioninyoungchildren;tropicamidemaybepre-
ferredinneonates.
Phenylephrine
2.5%isusedfor
mydriasisindiagnosticortherapeuticprocedures;
mydriasisoccurswithin60Ð90minutesandlastsupto
5Ð7hours.Phenylephrine10%dropsarecontra-indi-
catedinchildrenowingtotheriskofsystemiceffects.
Mydriaticsandcycloplegicsareusedinthetreatmentof
anterioruveitis,usuallyasanadjuncttocorticosteriods
(section11.4.1).Atropineisusedinanterioruveitis
mainlytopreventposteriorsynechiaeandtorelieve
ciliaryspasm;cyclopentolateor
upto3days)canalsobeusedandmaybepreferred
becausetheyhaveashorterdurationofaction.
Cautionsandcontra-indications
Darklypigmented
iridesaremoreresistanttopupillarydilatationand
cautionshouldbeexercisedtoavoidoverdosage.
Mydriasiscanprecipitateacuteangle-closureglaucoma
intheveryfewchildrenwhoarepredisposedtothe
conditionbecauseofashallowanteriorchamber.Atro-
pine,cyclopentolate,andhomatropineshouldbeused
withcautioninchildrenunder3monthsowingtothe
ATROPINESULPHATE
riskofsystemiceffectswitheyedropsin
infantsunder3months,seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenfor
Indicationanddose
ycloplegia
hild3monthsÐ18years
applydropsoroint-
menttwicedailyfor3daysbeforeprocedure
nterioruveitis
hild2Ð18years
1dropupto4timesdaily
Singleuse
AtropineSulphate
(Bausch&Lomb)
Eyedrops
CYCLOPENTOLATEHYDROCHLORIDE
seenotesabove
seenotesabove
Indicationanddose
Seenotesabove
ycloplegia
hild3monthsÐ12years
1dropof1%eyedrops
30Ð60minutesbeforeexamination
hild12Ð18years
1dropof0.5%eyedrops30Ð
60minutesbeforeexamination
hild3monthsÐ18years
1dropof0.5%eye
drops(1%fordeeplypigmentedeyes)2Ð4times
Eyedrops
Singleuse
CyclopentolateHydrochloride
(Bausch&
Eyedrops
,cyclopentolatehydrochloride0.5%and
HOMATROPINEHYDROBROMIDE
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder3
Indicationanddose
Seenotesabove
hild3monthsÐ2years
(0.5%only)1dropdaily
oronalternatedaysadjustedaccordingto
hild2Ð18years
1droptwicedailyadjusted
accordingtoresponse
seenotesabove
seenotesabove
11.5Mydriaticsandcycloplegics
BNFC2011–
Indicationanddose
Seenotesabove
eonateandchild
apply0.5%eyedrops20
minutesbeforeexamination
Mydriacyl
Eyedrops
Singleuse
Tropicamide
(Bausch&Lomb)
Eyedrops
PHENYLEPHRINEHYDROCHLORIDE
cardiovasculardisease(avoidoruse2.5%
strengthonly);tachycardia;hyperthyroidism;dia-
Singleuse
PhenylephrineHydrochloride
(Bausch&
Eyedrops
CARTEOLOLHYDROCHLORIDE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seenotesabove
Applytwicedaily
Teoptic
(SpectrumThea)
Eyedrops
LEVOBUNOLOLHYDROCHLORIDE
seenotesabove
Contra-indications
seenotesabove
seenotesabove;anterioruveitisocca-
sionallyreported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seenotesabove
Applyonceortwicedaily
TIMOLOLMALEATE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seenotesabove
Applytwicedaily;long-actingpreparations,see
underpreparationsbelow
Once-dailypreparations
Eyegel
Withdorzolamide
SeeunderDorzolamide
Prostaglandinanalogues
Theprostaglandinanalogues
latanoprost
,and
travo-
prost
Bymouthorslowintravenousinjection
initially2.5mg/kg2Ð3timesdaily,fol-
lowedby5Ð7mg/kg2Ð3timesdaily(maintenance
Child1monthÐ12years
initially2.5mg/kg2Ð3
timesdaily,followedby5Ð7mg/kg2Ð3timesdaily,
max.750mgdaily(maintenancedose)
hild12Ð18years
250mg2Ð4timesdaily
aisedintracranialpressure
Bymouthorslowintravenousinjection
Child1monthÐ12years
initially8mg/kg3times
daily,increasedasnecessarytomax.100mg/kg
ModiÞedrelease
Capsules
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
systemicabsorptionfollowstopicalapplica-
tion;neonatesandinfantswithimmaturerenal
systemicabsorptionfollowstopicalapplica-
tion;historyofrenalcalculi;neonatesandinfantswith
Withtimolol
Forprescribinginformationontimolol,seesection
PILOCARPINE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildren
11.6Treatmentofglaucoma
BNFC2011–
Indicationanddose
Seealsonotesabove
aisedintra-ocularpressureinocularhyper-
tensionandopen-angleglaucoma
hild1monthÐ2years
1dropof0.5%or1%
solution3timesdaily
hild2Ð18years
1drop4timesdaily
re-operativelyingoniotomyandtrabeculot-
hild1monthÐ18years
apply1%or2%solution
oncedaily
PilocarpineHydrochloride
Singleuse
PilocarpineNitrate
(Bausch&Lomb)
Eyedrops
LIDOCAINEHYDROCHLORIDE
(Lignocainehydrochloride)
Contra-indications
OXYBUPROCAINEHYDROCHLORIDE
(Benoxinatehydrochloride)
Contra-indications
OxybuprocaineHydrochloride
(Bausch&
Eyedrops
Withßuorescein
(e.g.hourly)foradequaterelief.Ocularsurfacemucinis
oftenabnormalinteardeÞciencyandthecombination
ofhypromellosewithamucolyticsuchas
(Polyacrylicacid)
CARMELLOSESODIUM
Indicationanddose
ryeyeconditions
Applyasrequired
Eyedrops
Singleuse
HYDROXYPROPYLGUAR
Indicationanddose
ryeyeconditions
Applyasrequired
Eyedrops
Singleuse
Eyedrops
HYPROMELLOSE
Indicationanddose
eardeÞciency
Applyasrequired
Artelac
Eyedrops
Singleuse
Artelac
Eyedrops
LIQUIDPARAFFIN
Indicationanddose
ryeyeconditions
Applyasrequired
Eyeointment
,whitesoftparafÞn57.3%,liquidpar-
PARAFFIN,YELLOW,SOFT
Indicationanddose
Seenotesabove
Apply2hourlyasrequired
SimpleEyeOintment
Ointment
,liquidparafÞn10%,woolfat10%,inyellow
POLYVINYLALCOHOL
Indicationanddose
eardeÞciency
Applyasrequired
LiquiÞlmTears
Ophthalmicsolution
(=eyedrops),polyvinylalcohol
SODIUMCHLORIDE
Indicationanddose
rrigation,includingÞrst-aidremovalofharmful
substances
Useasrequired
SodiumChloride0.9%Solutions
Seesection13.11.1
BalancedSaltSolution
(sterile),sodiumchloride0.64%,sodium
Singleuse
(Bausch&Lomb)
Eyedrops
SODIUMHYALURONATE
Indicationanddose
ryeyeconditions
Applyasrequired
(SpectrumThea)
Eyedrops
Singleuse
Eyedrops
Oculardiagnosticand
peri-operative
Oculardiagnosticpreparations
Fluoresceinsodium
isusedindiagnosticprocedures
andforlocatingdamagedareasofthecorneadueto
injuryordisease.
FLUORESCEINSODIUM
Indicationanddose
Withlocalanaesthetic
Section11.7
Ocularperi-operativedrugs
Drugsusedtopreparetheeyeforsurgeryanddrugsthat
areinjectedintotheanteriorchamberatthetimeof
surgeryareincludedhere.
Sodiumhyaluronateisusedduringsurgicalprocedures
ontheeye.
,analpha
-adrenoceptoragonist,
reducesintra-ocularpressurepossiblybyreducingthe
productionofaqueoushumour.Itisusedforshort-term
treatmentonly.
BalancedSaltSolution
isusedroutinelyinintra-ocular
surgery(section11.8.1).
APRACLONIDINE
Apraclonidineisaderivativeofclonidine
historyofangina,severecoronaryinsufÞ-
ciency,recentmyocardialinfarction,heartfailure,
cerebrovasculardisease,vasovagalattack,chronic
renalfailure;depression;pregnancyandbreast-feed-
ing;monitorintra-ocularpressureandvisualÞelds;
lossofeffectmayoccurovertime;suspendtreatment
ifreductioninvisionoccursinend-stageglaucoma;
monitorforexcessivereductioninintra-ocularpres-
surefollowingperi-operativeuse;
Appendix1(alpha
-adrenoceptorstimulants)
Skilledtasks
Drowsinessmayaffectperformanceofskilled
tasks(e.g.driving)
Contra-indications
historyofsevereorunstableand
uncontrolledcardiovasculardisease
drymouth,tastedisturbance;hyperae-
mia,ocularpruritus,discomfortandlacrimation
(withdrawifocularintoleranceincludingoedemaof
lidsandconjunctiva);headache,asthenia,drynose;
DICLOFENACSODIUM
Licenseduse
notlicensedforuseinchildren
Indicationanddose
nhibitionofintra-operativemiosisduringcat-
aractsurgery(butdoesnotpossessintrinsic
mydriaticproperties),postoperativeinßamma-
tionincataractsurgery,strabismussurgery,
argonlasertrabeculoplasty
consultproductliterature
11.8.2Oculardiagnosticandperi-operativepreparations
BNFC2011–
Voltarol
OphthaMultidose
Eyedrops
Singleuse
Voltarol
Eyedrops
FLURBIPROFENSODIUM
Licenseduse
notlicensedforuseinchildren
Indicationanddose
nhibitionofintra-operativemiosis(butdoes
notpossessintrinsicmydriaticproperties),
controlofpostoperativeandpost-lasertrabe-
culoplastyinßammation(ifcorticosteroids
consultproductliterature
Ophthalmicsolution
(=eyedrops),ßurbiprofen
sodium0.03%,polyvinylalcohol(
LiquiÞlm
)1.4%.
Ear,nose,andoropharynx
Drugsactingontheear
Otitisexterna
Otitismedia
Removalofearwax
Drugsactingonthenose
Drugsusedinnasalallergy
Topicalnasaldecongestants
Nasalpreparationsforinfection
Drugsactingontheoro-
pharynx
Drugsfororalulcerationand
inßammation
Oropharyngealanti-infective
Lozengesandsprays
Mouthwashesandgargles
Treatmentofdrymouth
Thischapteralsoincludesadviceonthedrugman-
agementofthefollowing:
allergicrhinitis,p.538
nasalpolyps,p.538
oropharyngealinfections,p.545
periodontitis,p.543
Drugsactingontheear
Otitisexterna
Otitismedia
Removalofearwax
Otitisexterna
Otitisexternaisaninßammatoryreactionofthelining
oftheearcanalusuallyassociatedwithanunderlying
seborrhoeicdermatitisoreczema;itisimportantto
excludeanunderlyingchronicotitismediabeforetreat-
mentiscommenced.Manycasesrecoverafterthorough
cleansingoftheexternalearcanalbysuctionordry
mopping.
AfrequentprobleminresistantcasesisthedifÞcultyin
applyinglotionsandointmentssatisfactorilytothe
relativelyinaccessibleaffectedskin.Themosteffective
Ear,nose,andoropharynx
Withantibacterial
Withantibacterial
(GSKConsumerHealthcare)
Earspray
Ear,nose,andoropharynx
AU
Withantibacterial
Locorten-Vioform
Eardrops
HYDROCORTISONE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforusein
childrenunder3years;
otherpreparations
foruseinchildren(agerangenotspeciÞedby
manufacturers)
Indicationanddose
czematousinßammationinotitisexterna
notesabove);fordose,seeunderpreparations
Withantibacterial
Eardrops
PREDNISOLONESODIUM
PHOSPHATE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturers)
Indicationanddose
czematousinßammationinotitisexterna
notesabove);fordose,seeunderpreparations
section11.4.1
(UCBPharma)
(forearoreye),prednisolonesodiumphos-
Withantibacterial
(UCBPharma)
(forearoreye),prednisolonesodiumphos-
CHLORAMPHENICOL
avoidprolongeduse(seenotesabove)
highincidenceofsensitivityreactionsto
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturers)
Indicationanddose
acterialinfectioninotitisexterna
(butseenotes
above);fordose,seeunderpreparation
Chloramphenicol
CLOTRIMAZOLE
occasionallocalirritationorsensitivity
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturer)
Indicationanddose
ungalinfectioninotitisexterna
(seenotes
above);fordose,seeunderpreparation
(BayerConsumerCare)
Ear,nose,andoropharynx
Withcorticosteroid
GENTAMICIN
avoidprolongeduse(seenotesabove)
Contra-indications
perforatedtympanicmembrane
(butseep.534andsection12.1.2)
localsensitivity
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturer)
Indicationanddose
acterialinfectioninotitisexterna
(seenotes
above);fordose,seeunderpreparations
(forearoreye),gentamicin0.3%(assulphate).
Withcorticosteroid
seeHydrocortisone,p.536
NEOMYCINSULPHATE
avoidprolongeduse(seenotesabove)
Contra-indications
perforatedtympanicmembrane
(seep.534)
localsensitivity
Indicationanddose
acterialinfectioninotitisexterna
(seenotes
Withcorticosteroid
Ear,nose,andoropharynx
Earwaxcausingdiscomfortorimpairedhearingmaybe
softenedwithsimpleremediessuchas
oliveoil
dropsor
almondoil
eardrops;
sodiumbicarbonate
eardropsarealsoeffective,butmaycausedrynessof
theearcanal.Ifthewaxishardandimpacted,thedrops
canbeusedtwicedailyforseveraldaysandthismay
reducetheneedformechanicalremovalofthewax.The
childshouldliewiththeaffectedearuppermostfor5to
10minutesafteragenerousamountofthesoftening
Ear,nose,andoropharynx
AZELASTINEHYDROCHLORIDE
irritationofnasalmucosa;bittertaste(if
appliedincorrectly)
Indicationanddose
reatmentofallergicrhinitis
fordose,seeunder
Nasalspray
,azelastinehydrochloride140micr-
seenotesabove;
Appendix1
(corticosteroids)
seenotesabove
Indicationanddose
Seeunderpreparations
BNFC2011–
12.2.1Drugsusedinnasalallergy
Ear,nose,andoropharynx
seenotesabove
seenotesabove
Indicationanddose
rophylaxisandtreatmentofallergicrhinitis
hild5Ð14years
initially25micrograms(1spray)
intoeachnostrilupto3timesdailythenreduced
formaintenance
hild14Ð18years
50micrograms(2sprays)into
eachnostriltwicedaily,increasedifnecessaryto
max.3timesdailythenreducedformaintenance
(IVAX)
Aqueousnasalspray
,ßunisolide25micrograms/
FLUTICASONEPROPIONATE
seenotesabove;
Appendix1
(corticosteroids)
seenotesabove
Indicationanddose
rophylaxisandtreatmentofallergicrhinitis
hild4Ð12years
50micrograms(1spray)into
eachnostriloncedaily,preferablyinthemorning,
increasedtomax.twicedailyifrequired
hild12Ð18years
100micrograms(2sprays)
intoeachnostriloncedaily,preferablyinthe
morning,increasedtomax.twicedailyifrequired;
whencontrolachievedreduceto50micrograms(1
spray)intoeachnostriloncedaily
asalpolyps
FlixonaseNasule
Aqueousnasalspray
,ßuticasonepropionate
Fluticasonefuroate
Nasalspray
,ßuticasonefuroate27.5micrograms/
Ear,nose,andoropharynx
Indicationanddose
reatmentofallergicrhinitis
hild2Ð6years
55micrograms(1spray)into
eachnostriloncedaily;max.durationoftreatment
3months
hild6Ð12years
55micrograms(1spray)into
eachnostriloncedaily,increasedifnecessaryto
110micrograms(2sprays)intoeachnostrilonce
daily;whencontrolachieved,reduceto55micr-
ograms(1spray)intoeachnostriloncedaily;max.
durationoftreatment3months
hild12Ð18years
110micrograms(2sprays)
intoeachnostriloncedaily;whencontrol
achieved,reduceto55micrograms(1spray)into
eachnostriloncedaily
Nasacort
Aqueousnasalspray
SODIUMCROMOGLICATE
(SodiumCromoglycate)
localirritation;
rarely
transientbroncho-
Licenseduse
licensedforuseinchildren(agerange
notspeciÞedbymanufacturers)
Indicationanddose
rophylaxisofallergicrhinitis
fordose,seeunder
4%aqueousnasalspray
,sodiumcromoglicate4%
EPHEDRINEHYDROCHLORIDE
seenotesabove;alsoavoidexcessiveor
Ear,nose,andoropharynx
IPRATROPIUMBROMIDE
seesection3.1.2;avoidsprayingneareyes
epistaxis,nasaldryness,andirritation;
lessfrequentlynausea,headache,andpharyngitis;
veryrarely
antimuscariniceffectssuchasgastro-
intestinalmotilitydisturbances,palpitations,and
Ear,nose,andoropharynx
Naseptin
,chlorhexidinehydrochloride0.1%,neomycin
BENZYDAMINEHYDROCHLORIDE
occasionalnumbnessorstinging;rarely
hypersensitivityreactions
Licenseduse
licensedforusein
children(agerangenotspeciÞedbymanufacturer)
Indicationanddose
ainfulinßammatoryconditionsoforopharynx
fordose,seeunderpreparations
Oralrinse
,green,benzydaminehydrochloride0.15%,
Ear,nose,andoropharynx
CORTICOSTEROIDS
Contra-indications
untreatedoralinfection
occasionalexacerbationoflocalinfec-
tion;thrushorothercandidalinfections
Licenseduse
Hydrocortisonemucoadhesivebuccal
DOXYCYCLINE
section5.1.3;monitorforsuperÞcialfungal
infection,particularlyifpredispositiontooralcandi-
Contra-indications
section5.1.3
Hepaticimpairment
section5.1.3
Renalimpairment
section5.1.3
section5.1.3
section5.1.3
section5.1.3;fungalsuperinfection
Indicationanddose
Seeunderpreparations
ralherpes
section12.3.2
therindications
section5.1.3
(Alliance)
Localapplication
Forsevererecurrentaphthousulceration,a100mg
section10.1.1
Contra-indications
section10.1.1
Hepaticimpairment
section10.1.1
Renalimpairment
section10.1.1
section10.1.1
section10.1.1
tastedisturbance,mouthulcers(move
lozengearoundmouth);seealsosection10.1.1
Indicationanddose
eliefofsorethroat
fordose,seeunderprepara-
(ReckittBenckiser)
SALICYLATES
frequentapplication,especiallyinchildren,
maygiverisetosalicylatepoisoning
Contra-indications
childrenunder16years
ReyeÕssyndrome
TheCHMhasadvisedthattopicaloral
painreliefproductscontainingsalicylatesaltsshouldnotbe
usedinchildrenunder16years,asacautionarymeasuredue
Cholinesalicylate
CholineSalicylateDentalGel,BP
Oralgel
,cholinesalicylate8.7%inaßavouredgel
Ear,nose,andoropharynx
Salicylicacid
Oralpaint
,brown,rhubarbextract(anthraquinone
MICONAZOLE
avoidinacuteporphyria(section9.8.2);
Appendix1(antifungals,imidazole)
Contra-indications
impairedswallowingreßex
Hepaticimpairment
avoid
manufactureradvisesavoidifpossibleÑ
toxicityathighdosesin
BNFC2011–
12.3.2Oropharyngealanti-infectivedrugs
Ear,nose,andoropharynx
manufactureradvisescautionÑno
informationavailable
nauseaandvomiting,
veryrarely
diarr-
hoea(usuallyonlong-termtreatment),hepatitis,rash,
toxicepidermalnecrolysis,andStevens-Johnson
Licenseduse
notlicensedforuseinchildrenunder4
monthsofageorduringÞrst5Ð6monthsoflifeofan
infantbornpre-term
Indicationanddose
reventionandtreatmentoforalandintestinal
fungalinfections
Bymouth
(oralfungalinfectionsonly)1mL2Ð4
timesdailysmearedaroundthemouthafterfeeds
Child1monthÐ2years
2.5mLtwicedaily
smearedaroundthemouthafterfood
hild2Ð6years
NYSTATIN
oralirritationandsensitisation,nausea
Licenseduse
notlicensedforusein
neonatesforthetreatmentofcandidiasis
Indicationanddose
ralandperioralfungalinfections
100000units4timesdailyafterfeeds
Child1monthÐ18years
100000units4times
dailyafterfood
Treatmentisusuallygivenfor7days,andcontinuedfor
48hoursafterlesionshavehealed.
kininfections
section13.10.2
Oralsuspension
,yellow,nystatin100000units/mL.
Ear,nose,andoropharynx
CHLORHEXIDINEGLUCONATE
mucosalirritation(ifdesquamation
occurs,discontinuetreatmentordilutemouthwash
withanequalvolumeofwater);tastedisturbance;
Withchlorobutanol
Mouthwashorgargle
,chlorhexidinegluconate0.1%,
HYDROGENPEROXIDE
hypertrophyofpapillaeoftongueon
prolongeduse
Indicationanddose
ralhygiene
(seenotesabove);fordose,seeunder
HydrogenPeroxideMouthwash,BP
,consistsofHydrogenPeroxideSolution
6%(=approx.20volume)BP
Rinsethemouthfor2Ð3minuteswith15mLdilutedin
halfatumblerfulofwarmwater2Ð3timesdaily(seenotes
DentalprescribingonNHS
HydrogenPeroxideMouthwash
maybeprescribed
Peroxyl
(Colgate-Palmolive)
Ear,nose,andoropharynx
SODIUMCHLORIDE
Indicationanddose
ralhygiene
(seenotesabove);fordose,seeunder
SodiumChlorideMouthwash,Compound,BP
,sodiumbicarbonate1%,sodiumchlor-
ide1.5%inasuitablevehiclewithapeppermint
ßavour
Extemporaneouspreparationsshouldbeprepared
accordingtothefollowingformula:sodiumchloride1.5g,
sodiumbicarbonate1g,concentratedpeppermintemul-
sion2.5mL,double-strengthchloroformwater50mL,
waterto100mL
Tobedilutedwithanequalvolumeofwarmwater
DentalprescribingonNHS
CompoundSodiumChloride
Mouthwashmaybeprescribed
Indicationanddose
ralhygiene
(seenotesabove);fordose,seeunder
Ear,nose,andoropharynx
Pastilles
,sugar-free,reddish-amber,acacia,malic
Ear,nose,andoropharynx
Managementofskincondi-
Vehicles
Suitablequantitiesforpre-
scribing
Excipientsandsensitisation
Emollientandbarrierprepara-
Emollients
Emollientbathadditivesand
showerpreparations
Barrierpreparations
Topicalantipruritics
Topicalcorticosteroids
Preparationsforeczemaand
Preparationsforeczema
Preparationsforpsoriasis
Drugsaffectingtheimmune
response
Acneandrosacea
Topicalpreparationsforacne
Oralpreparationsforacne
Preparationsforwartsand
Sunscreensandcamoußagers
Sunscreenpreparations
Shampoosandotherprepara-
tionsforscalpconditions
Anti-infectiveskinprepara-
Antibacterialpreparations
13.10.1.1
Antibacterialpreparationsonly
usedtopically
13.10.1.2
Antibacterialpreparationsalso
usedsystemically
Antifungalpreparations
Antiviralpreparations
Parasiticidalpreparations
Preparationsforminorcutsand
Skincleansers,antiseptics,
andpreparationsforpromo-
tionofwoundhealing
Alcoholsandsaline
Chlorhexidinesalts
Cationicsurfactantsandsoaps
Oxidisersanddyes
Preparationsforpromotionof
woundhealing
Antiperspirants
Topicalcirculatoryprepara-
Thischapteralsoincludesadviceonthemanage-
mentofthefollowing:
candidiasis,p.588
dermatophytoses,p.588
headlice,p.592
nappyrash,p.556
pityriasisversicolor,p.588
scabies,p.592
Forinformationonwoundmanagementproductsand
elasticatedgarments,seetherelevantBNFappendix.
TheBritishAssociationofDermatologists’listofpre-
ferredunlicenseddermatologicalpreparations(spe-
cials)isavailableat
www.bad.org.uk/site/495/
Managementofskin
Whenprescribingtopicalpreparationsforthetreatment
ofskinconditionsinchildren,thesiteofapplication,the
conditionbeingtreated,andthechild’s(andcarer’s)
preferenceforaparticularvehicleallneedtobetaken
intoconsideration.
Cautionisrequiredwhenprescribingtopical
preparationsforneonates—theirlargebodysurface
areainrelationtobodymassincreasessusceptibility
totoxicityfromsystemicabsorptionofsubstances
appliedtotheskin.Topicalpreparationscontaining
potentiallysensitisingsubstancessuchascorticoster-
oids,aminoglycosides,iodine,andparasiticidaldrugs
shouldbeavoided.Preparationscontainingalcohol
shouldbeavoidedbecausetheycandehydratethe
skin,causepainifappliedtorawareas,andthealcohol
cancausenecrosis.
menstrualage,mayalsorequirespecialmeasuresto
maintainskinhydration.
Vehicles
Thevehicleintopicalpreparationsfortheskinaffects
thedegreeofhydration,hasamildanti-inammatory
Emollientandbarrier
Emollients
Barrierpreparations
Borderlinesubstances
Thepreparationsmarked
‘ACBS’areregardedasdrugswhenprescribedinaccor-
dancewiththeadviceoftheAdvisoryCommitteeon
BorderlineSubstancesfortheclinicalconditionslisted.
Prescriptionsissuedinaccordancewiththisadviceand
endorsed‘ACBS’willnormallynotbeinvestigated.See
Appendix2forlistingbyclinicalcondition.
Emollients
hydratetheskin,softentheskin,actas
barriertowaterandexternalirritants,andareindicated
foralldryorscalingdisorders.Theireffectsareshort-
livedandtheyshouldbeappliedfrequentlyevenafter
improvementoccurs.Theyareusefulindryandecze-
matousdisorders,andtoalesserextentinpsoriasis
(section13.5.2);theyshouldbeappliedinthedirection
ofhairgrowthimmediatelyafterwashingorbathingto
maximisetheeffectofskinhydration.Thechoiceofan
appropriateemollientwilldependontheseverityofthe
condition,thechild’s(orcarer’s)preference,andthesite
ofapplication.Ointmentsmayexacerbateacneand
folliculitis.Someingredientsrarelycausesensitisation
(section13.1.3)andthisshouldbesuspectedifan
eczematousreactionoccurs.Theuseofaqueous
creamasaleave-onemollientmayincreasetheriskof
skinreactions,particularlyineczema.
FirehazardwithparafÞn-basedemollients
Emulsifyingointment
50%LiquidParafnand
50%WhiteSoftParafnOintmentincontactwith
dressingsandclothingiseasilyignitedbyanaked
ame.Theriskisgreaterwhenthesepreparations
areappliedtolargeareasofthebody,andclothingor
dressingsbecomesoakedwiththeointment.Chil-
drenandtheircarersshouldbetoldtokeepaway
fromreoramesandnottosmokewhenusing
thesepreparations.Theriskofreshouldbecon-
sideredwhenusinglargequantitiesofanyparafn-
basedemollient.
Preparationssuchas
aqueouscream
canbeusedassoapsubstitutes;theprepara-
Preparationscontainingurea
Aquadrate
ItchReliefCream
(ReckittBenckiser)
Withantimicrobials
,benzalkoniumchloride0.1%,chlorhexidine
hydrochloride0.1%,isopropylmyristate10%,liquid
13.2.1.1
Emollientbathadditivesand
showerpreparations
Emollientbathadditivesshouldbeaddedtobathwater;
Thesepreparationsmakeskinandsurfacesslip-
pery—particularcareisneededwhenbathinga
Bathoil
,colloidaloatmeal,whiteoatfractionin
Child1monthÐ12years
add5–10mLtobathwateror
applytowetskinandrinse
Child12Ð18years
add15–20mLtobathwaterorapply
Zerozole
(Thornton&Ross)
Bathoil
,renedsoyabeanoil83.45%,macrogol4-
Withantimicrobials
600bathemollient
,benzalkoniumchloride
0.5%,liquidparafn25%,isopropylmyristate25%,
Withtar
Section13.5.2
Barrierpreparations
Barrierpreparationsoftencontainwater-repellentsub-
stancessuchas
Drapolene
(ChefaroUK)
Indicationanddose
butseenotesabove
CROTAMITON
avoiduseneareyesandbrokenskin;useon
doctor’sadviceforchildrenunder3years
Contra-indications
acuteexudativedermatoses
Indicationanddose
ruritus(includingpruritusafterscabies—sec-
tion13.10.4)
seenotesabove
Apply2–3timesdaily(forpruritusafterscabiesin
childrenunder3yearsapplyoncedailyonly)
(NovartisConsumerHealth)
DOXEPINHYDROCHLORIDE
susceptibilitytoangle-closureglaucoma;
manufactureradvisesuseonlyifpotential
benetoutweighsrisk
manufactureradvisesuseonlyif
potentialbenetoutweighsrisk
drowsiness;localburning,stinging,irri-
tation,tinglingandrash;systemicside-effectssuchas
antimuscarinicaffects,headache,fever,dizziness,
gastro-intestinaldisturbancesalsoreported
Indicationanddose
ruritusineczema
hild12Ð18years
applythinly3–4timesdaily;
usualmax.3gperapplication;usualtotalmax.
12gdaily;coverageshouldbelessthan10%of
bodysurfacearea
epressiveillness
section4.3.1
severeeczemaofthefaceandneck
potentcorticosteroidfor3–5daysonly,ifnotcon-
trolledbyamildcorticosteroid;
severeeczemaonthetrunkandlimbs
potentorpotentcorticosteroidfor1–2weeksonly,
switchingtoalesspotentpreparationasthecon-
ditionimproves;
eczemaaffectingareawiththickenedskin
(e.g.
HYDROCORTISONE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Indicationanddose
ildinammatoryskindisorderssuchas
eczemas(butforover-the-counterprepara-
tions,seebelow);nappyrash
(seealsosection
Applythinly1–2timesdaily
Over-the-counterhydrocortisonepreparations
Skincreamsandointmentscontaininghydrocortisone
(aloneorwithotheringredients)canbesoldtothe
publicforthetreatmentofallergiccontactdermatitis,
irritantdermatitis,insectbitereactionsandmildto
moderateeczemainchildrenover10years,tobe
appliedsparinglyovertheaffectedarea1–2times
dailyformax.1week.Over-the-counterhydrocorti-
sonepreparationsshouldnotbesoldwithoutmedical
adviceforchildrenunder10yearsorforpregnant
women;theyshould
besoldforapplicationtothe
face,anogenitalregion,brokenorinfectedskin
Compoundpreparations
Compoundpreparationswithcoaltarseesection
Alphaderm
(Alliance)
Withantimicrobials
Seenotesaboveforcommentoncompoundpreparations
CanestenHC
(BayerConsumerCare)
Ointment
,hydrocortisone1%,miconazolenitrate2%,
HYDROCORTISONEBUTYRATE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Indicationanddose
evereinammatoryskindisorderssuchas
eczemasunresponsivetolesspotentcorticos-
teroids,psoriasis
seenotesabove
hild1Ð18years
applythinly1–2timesdaily
Withsalicylicacid
Seenotesaboveforcommentoncompoundpreparations
Forprescribinginformationonsalicylicacid,seep.571
Diprosalic
(Schering-Plough)
Ointment
Withantimicrobials
Seenotesaboveforcommentoncompoundpreparations
Indicationanddose
hort-termtreatmentonlyofsevereresistant
inammatoryskindisorderssuchasrecalci-
tranteczemasunresponsivetolesspotent
corticosteroids,psoriasis
seenotesabove
Applythinly1–2timesdailyforupto4weeks
Dermovate
Withantimicrobials
Seenotesaboveforcommentoncompoundpreparations
Dermovate-NN
Withantimicrobials
Seenotesaboveforcommentoncompoundpreparations
Trimovate
DIFLUCORTOLONEVALERATE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
licensedforuseinchildren
(agerangenotspeciedbymanufacturer);
notlicensedforuseinchildrenunder4years
Indicationanddose
evereinammatoryskindisorderssuchas
eczemasunresponsivetolesspotentcorticos-
teroids;highstrength(0.3%),short-term
treatmentofsevereexacerbations,psoriasis
seenotesabove
Applythinly1–2timesdailyforupto4weeks
(0.1%preparations)or2weeks(0.3%prepara-
tions),reducingstrengthasconditionresponds
FLUDROXYCORTIDE
(Flurandrenolone)
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
nammatoryskindisorderssuchaseczemas
Applythinly1–2timesdaily
(Typharm)
Tape
,polytheneadhesivelmimpregnatedwithu-
droxycortide4micrograms/cm
Withantibacterials
Seenotesaboveforcommentoncompoundpreparations
SynalarC
(GPPharma)
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder1
year
Indicationanddose
evereinammatoryskindisorderssuchas
eczemasunresponsivetolesspotentcorticos-
teroids,psoriasis
seenotesabove
Applythinly1–2timesdaily
FLUOCORTOLONE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
evereinammatoryskindisorderssuchas
eczemasunresponsivetolesspotentcorticos-
teroids,psoriasis
seenotesabove
Applythinly1–2timesdaily
UltralanumPlain
,uocortolonecaproate0.25%,uocortolone
FLUTICASONEPROPIONATE
seenotesabove
Contra-indications
seenotesabove
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder3
13.4Topicalcorticosteroids
BNFC2011–
Indicationanddose
nammatoryskindisorderssuchasdermatitis
andeczemasunresponsivetolesspotentcor-
ticosteroids,psoriasis
seenotesabove
Applythinly1–2timesdaily
Withantimicrobials
Seenotesaboveforcommentoncompoundpreparations
Aureocort
Ointment
Preparationsforeczema
andpsoriasis
Preparationsforeczema
Preparationsforpsoriasis
Drugsaffectingtheimmuneresponse
Preparationsforeczema
Themaintypesofeczema(dermatitis)inchildrenare
atopic,irritantandallergiccontact;differenttypesmay
Atopiceczema
isthemostcommontypeandit
usuallyinvolvesdryskinaswellasinfectionandliche-
nicationcausedbyscratchingandrubbing.
Seborr-
hoeicdermatitis
(seebelow)isalsocommonininfants.
Managementofeczemainvolvestheremovalortreat-
mentofcontributoryfactors;knownorsuspectedirri-
tantsandcontactallergensshouldbeavoided.Rarely,
ingredientsintopicalmedicinalproductsmaysensitise
theskin(section13.1.3);
BNFforChildren
listsactive
atelypotentorpotenttopicalcorticosteroidwhichcan
becombinedwithanantimicrobialsuchasclioquinol.
Eczemainvolvingmoderatetosevere,widespread,or
recurrentinfectionrequirestheuseofasystemicanti-
bacterial(section5.1,table1)thatisactiveagainstthe
infectingorganism.Preparationsthatcombineananti-
septicwithanemollientapplication(section13.2.1)and
withabathemollient(section13.2.1.1)canalsobeused;
antisepticshampoos(section13.9)canbeusedonthe
scalp.
Intertriginouseczema
commonlyinvolvescandidaand
bacteria;itisbesttreatedwithamildormoderately
potenttopicalcorticosteroidcombinedwithasuitable
antimicrobialdrug.Forthetreatmentofnappyrash,see
section13.2.2.
herpessimplexinfection
maycomplicate
skinirritation
Licenseduse
noinformationavailable
Indicationanddose
hroniclicheniedeczema
hild1Ð18years
apply1–3timesdaily
IchthammolOintment,BP1980
Ointment
,ichthammol10%,yellowsoftparafn45%,
woolfat45%
ZincandIchthammolCream,BP
bestoppedortheconcentrationreduced;ifitistoler-
ated,itseffectsshouldbeassessedafter4to6weeks
andtreatmentcontinuedifitiseffective.
unstablepsoriasis
oferythrodermicorgen-
eralisedpustulartyperequiresurgentspecialistassess-
ment.Initialtopicaltreatmentshouldbelimitedtousing
emollientsfrequentlyandgenerously.Morelocalised
acuteorsubacute
inßammatorypsoriasis
withhot,
spreadingoritchylesions,shouldbetreatedtopically
withemollientsorwithacorticosteroidofmoderate
potency.
Scalppsoriasis
isusuallyscaly,andthescalemaybe
thickandadherent.Thisrequiressofteningwithan
emollientointment,cream,oroilandusuallycombined
salicylicacid
asakeratolytic.
Somepreparationsforpsoriasisaffectingthescalp
combinesalicylicacidwithcoaltaror
.The
preparationshouldbeappliedgenerouslyandleftonfor
atleastanhour,oftenmoreconvenientlyovernight,
beforewashingitoff.Ifacorticosteroidlotionorgelis
required(e.g.foritch),itcanbeusedinthemorning.
Calcipotriol
areanaloguesofvitaminD
thataffectcelldivisionanddifferentiation.
Calcitriol
anactiveformofvitaminD.VitaminDanditsanalogues
areusedasrst-linetreatmentforplaquepsoriasis;they
donotsmellorstainandtheymaybemoreacceptable
thantarordithranolproducts.OfthevitaminDanalo-
gues,tacalcitolandcalcitriolarelesslikelytoirritate.
Coaltar
hasanti-inammatorypropertiesthatareuse-
fulinchronicplaquepsoriasis;italsohasantiscaling
properties.Contactofcoaltarproductswithnormal
skinisnotnormallyharmfulandpreparationscontain-
ingcoaltarcanbeusedforwidespreadsmalllesions;
however,irritation,contactallergy,andsterilefolliculitis
canoccur.Leave-onpreparationsthatremainincontact
withtheskin,suchascreamsorointments,containing
upto6%coaltarmaybeusedonchildren1monthto2
years;leave-onpreparationscontainingcoaltar10%
maybeusedonchildrenover2yearswithmoresevere
psoriasis.Tarbathsandtarshampoos(seesection13.9)
mayalsobehelpful.
iseffectiveforchronicplaquepsoriasis.Its
majordisadvantagesareirritation(forwhichindividual
susceptibilityvaries)andstainingofskinandofclothing.
Itshouldbeappliedtochronicextensorplaquesonly,
carefullyavoidingnormalskin.Dithranolisnotgener-
allysuitableforwidespreadsmalllesionsnorshouldit
beusedintheexuresorontheface.Treatmentshould
bestartedwithalowconcentrationsuchasdithranol
0.1%,andthestrengthincreasedgraduallyeveryfew
lientsshouldbeencouragedandtopicalcorticosteroids
canbecontinuedifnecessary.
CALCIPOTRIOL
seenotesabove;avoiduseonface;avoid
excessiveexposuretosunlightandsunlamps
Contra-indications
seenotesabove
manufactureradvisesavoidunlessessen-
noinformationavailable
seenotesabove;alsophotosensitivity,
dryskin;
facialorperioraldermatitis
Licenseduse
Calcipotriolointmentandscalpsolu-
(LEO)
CALCITRIOL
(1,25-Dihydroxycholecalciferol)
seenotesabove
Contra-indications
seenotesabove;donotapply
underocclusion
Hepaticimpairment
manufactureradvisesavoid—no
informationavailable
Renalimpairment
manufactureradvisesavoid—no
informationavailable
13.5.2Preparationsforpsoriasis
BNFC2011–
manufactureradvisesuseinrestricted
amountsonlyifclearlynecessaryandtomonitor
urine-andserum-calciumconcentration
manufactureradvisesavoid
seenotesabove
Indicationanddose
ildtomoderateplaquepsoriasis
hild12Ð18years
applytwicedaily;notmore
than35%ofbodysurfacetobetreateddaily,max.
30gdaily
Ointment
TACALCITOL
seenotesabove;avoideyes;monitorserum-
calciumconcentrationifriskofhypercalcaemia;if
usedinconjunctionwithUVtreatment,UVradiation
shouldbegiveninthemorningandtacalcitolapplied
atbedtime
Contra-indications
seenotesabove
Renalimpairment
monitorserum-calciumconcen-
manufactureradvisesavoidunlessnosafer
alternative—noinformationavailable
manufactureradvisesavoidapplica-
tiontobreastarea;noinformationavailableonpre-
senceinmilk
seenotesabove
Indicationanddose
laquepsoriasis
hild12Ð18years
applyoncedailypreferablyat
bedtime;max.10g
ointment
or10mL
TARS
applicationtofaceandskinexures;use
suitablechemicalprotectionglovesforextempora-
neouspreparation
Contra-indications
notforuseinsore,acute,or
pustularpsoriasisorinpresenceofinfection;avoid
eyes,mucosa,genitalorrectalareas;brokenor
inamedskin
skinirritationandacne-likeeruptions,
photosensitivity;stainsskin,hair,andfabric
Indicationanddose
soriasisandoccasionallychronicatopicecz-
Apply1–3timesdailystartingwithlow-strength
Bathpreparations
CoalTarSolution,BP
,coaltar20%,polysorbate‘80’5%,inalcohol
Withcorticosteroids
AlphosylHC
(GSKConsumerHealthcare)
,coaltarextract5%,hydrocortisone0.5%,
(Anthralin)
avoiduseneareyesandsensitiveareasof
skin;seealsonotesabove
Contra-indications
hypersensitivity;acuteandpust-
ularpsoriasis
noadverseeffectsreported
noadverseeffectsreported
localburningsensationandirritation;
stainsskin,hair,andfabrics
Licenseduse
foruseinchildren(agerangenotspeciedby
licensedforusein
children,butnotrecommendedforinfantsoryoung
children(agerangenotspeciedbymanufacturer)
Indicationanddose
ubacuteandchronicpsoriasis
Seenotesaboveandunderpreparations
Someofthesedithranolpreparationsalsocontain
coaltarorsalicylicacid—forprescribinginformationsee
underTarsorunderSalicylicAcid
Scalpgel
,dithranol0.25%,salicylicacid1.6%ingel
SALICYLICACID
Forcoaltarpreparationscontainingsalicylicacid,seeunder
Tarsp.569;fordithranolpreparationscontainingsalicylicacid
seeunderDithranol,above
seenotesabove;avoidbrokenorinamed
Salicylatetoxicity
Salicylatetoxicitymayoccurparticularly
ifappliedonlargeareasofskinoronneonatalskin
sensitivity,excessivedrying,irritation,
systemiceffectsafterwidespreaduse(seeunder
Indicationanddose
yperkeratoticskindisorders
seeunderpre-
section13.6.1
artsandcalluses
section13.7
calpconditions
section13.9
ungalnailinfections
section13.10.2
ZincandSalicylicAcidPaste,BP
,(Lassar’sPaste),zincoxide24%,salicylicacid
Capsules
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Drugsaffectingthe
immuneresponse
Drugsaffectingtheimmuneresponseareusedforecz-
emaorpsoriasis.
Pimecrolimus
bytopicalapplicationislicensedfor
tomoderateatopiceczema
Tacrolimus
islicensedfor
topicalusein
moderatetosevereatopiceczema
.Both
CICLOSPORIN
(Cyclosporin)
section8.2.2
Additionalcautionsinatopicdermatitisandpsoriasis
inabnormalrenalfunction,uncontrolled
hypertension(seealsobelow),infectionsnotundercontrol,
andmalignancy(seealsobelow).Dermatologicalandphy-
sicalexamination,includingbloodpressureandrenalfunc-
tionmeasurementsrequiredatleasttwicebeforestarting.
Duringtreatment,monitorserumcreatinineevery2weeks
forrst3monthstheneverymonth;reducedoseby25–50%
ifserumcreatinineincreasesmorethan30%abovebaseline
(evenifwithinnormalrange)anddiscontinueifreduction
notsuccessfulwithinonemonth.Discontinueifhypertension
developsthatcannotbecontrolledbydosereductionor
antihypertensivetherapy.Avoidexcessiveexposuretosun-
lightandavoiduseofUVBorPUVA.
Inatopicdermatitis
alsoallowherpessimplexinfectionstoclearbeforestarting
(iftheyoccurduringtreatmentwithdrawifsevere);
lococcusaureus
skininfectionsnotabsolutecontra-indica-
tionprovidingcontrolled(butavoiderythromycinunlessno
otheralternative—seealso
:Appendix1
(ciclosporin));investigatelymphadenopathythatpersists
despiteimprovementinatopicdermatitis.
Inpsoriasis
,also
excludemalignancies(includingthoseofskinandcervix)
beforestarting(biopsyanylesionsnottypicalofpsoriasis)
andtreatpatientswithmalignantorpre-malignantcondi-
tionsofskinonlyafterappropriatetreatment(andifnoother
option);discontinueiflymphoproliferativedisorderdevelops
Hepaticimpairment
section8.2.2
Renalimpairment
seeCautionsabove
section8.2.2
section8.2.2
section8.2.2
Licenseduse
notlicensedforuseinchildrenunder
16yearsforatopiceczema(dermatitis)orpsoriasis
Indicationanddose
hort-termtreatment(usuallymax.8weeks
butmaybeusedforlongerunderspecialist
supervision)ofsevereatopicdermatitiswhere
conventionaltherapyineffectiveorinappropri-
Bymouth,administeredinaccordancewith
expertadvice
Child1monthÐ18years
initially1.25mg/kg
twicedaily,ifgoodinitialresponsenotachieved
within2weeks,increaserapidlytomax.2.5mg/kg
twicedaily;initialdoseof2.5mg/kgtwicedailyif
verysevere
Important
Forpreparationsandcounsellingandfor
month(discontinueifresponsestillinsufcient
after6weeks);initialdoseof2.5mg/kgtwicedaily
justiedifconditionrequiresrapidimprovement
Important
Forpreparationsandcounsellingandfor
Section8.2.2
Section10.1.3
UVlight(avoidexcessiveexposuretosun-
lightandsunlamps),avoidothertopicaltreatments
exceptemollientsattreatmentsite;alcoholcon-
sumption(riskoffacialushingandskinirritation)
Contra-indications
contactwitheyesandmucous
membranes,applicationunderocclusion,infectionat
treatmentsite;congenitalepidermalbarrierdefects;
generalisederythroderma;immunodeciency;con-
comitantusewithdrugsthatcauseimmunosuppres-
sion(maybeprescribedinexceptionalcircumstances
byspecialists);applicationtomalignantorpotentially
malignantskinlesions
burningsensation,pruritus,erythema,
skininfections(includingfolliculitisand
lesscom-
TACROLIMUS
infectionattreatmentsite,UVlight(avoid
excessiveexposuretosunlightandsunlamps);alcohol
consumption(riskoffacialushingandskinirritation)
Contra-indications
hypersensitivitytomacrolides;
congenitalepidermalbarrierdefects;generalised
erythroderma;immunodeciency;concomitantuse
withdrugsthatcauseimmunosuppression(maybe
prescribedinexceptionalcircumstancesbyspecia-
lists);applicationtomalignantorpotentiallymalig-
nantskinlesions;applicationunderocclusion;avoid
contactwitheyesandmucousmembranes
manufactureradvisesavoidunlessessen-
tial;toxicityin
studiesfollowingsystemic
manufactureradvisesavoid—present
inmilkfollowingsystemicadministration
application-sitereactionsincludingrash,
irritation,pain,andparaesthesia;herpessimplex
infection,Kaposi’svaricelliformeruption;application-
siteinfections;
lesscommonly
acne;rosacea,andskin
malignancyalsoreported
Indicationanddose
hort-termtreatmentofmoderatetosevere
atopiceczema(includingares)eitherunre-
sponsiveto,orinchildrenintolerantofcon-
ventionaltherapy;seealsonotesabove
hild2Ð16years
initiallyapply0.03%ointment
thinlytwicedailyforupto3weeks(considerother
treatmentifeczemaworsensorifnoimprovement
after2weeks)thenreducetooncedailyuntil
lesionclears
hild16Ð18years
initiallyapply0.1%ointment
thinlytwicedailyuntillesionclears(considerother
BNFC2011–
13.5.3Drugsaffectingtheimmuneresponse
treatmentifeczemaworsensorifnoimprovement
after2weeks);reducetooncedailyorswitchto
0.03%ointmentifclinicalconditionallows
reventionofaresinchildrenwithmoderate
tosevereatopiceczemaand4ormorearesa
year,whohaverespondedtoinitialtreatment
withtopicaltacrolimus
hild2Ð16years
apply0.03%ointmentthinly
Section10.1.3
Acneandrosacea
Topicalpreparationsforacne
Oralpreparationsforacne
Acnevulgaris
Acnevulgariscommonlyaffectschil-
drenaroundpubertyandoccasionallyaffectsinfants.
Treatmentofacneshouldbecommencedearlyto
preventscarring;lesionsmayworsenbeforeimproving.
Thechoiceoftreatmentdependsonage,severity,and
Benzoylperoxideandazelaicacid
Benzoylperoxide
iseffectiveinmildtomoderateacne.
Bothcomedonesandinamedlesionsrespondwellto
benzoylperoxide.Thelowerconcentrationsseemtobe
aseffectiveashigherconcentrationsinreducinginam-
mation.Itisusualtostartwithalowerstrengthandto
increasetheconcentrationofbenzoylperoxidegradu-
ally.Adverseeffectsincludelocalskinirritation,parti-
cularlywhentherapyisinitiated,butthescalingand
rednessoftensubsidewithareductioninbenzoylper-
oxideconcentration,frequency,andareaofapplication.
Iftheacnedoesnotrespondafter2monthsthenuseofa
topicalantibacterialshouldbeconsidered.
Azelaicacid
hasantimicrobialandanticomedonal
properties.Itmaybeusedasanalternativetobenzoyl
BENZOYLPEROXIDE
avoidcontactwitheyes,mouth,andmucous
membranes;maybleachfabricsandhair;avoid
excessiveexposuretosunlight
skinirritation(reducefrequencyorsus-
penduseuntilirritationsubsidesandre-introduceat
reducedfrequency)
Licenseduse
islicensedforusein
allotherpreparations
,notlicensedforuse
intreatmentofinfantileacne
Indicationanddose
cnevulgaris
hild12Ð18years
apply1–2timesdailyprefer-
ablyafterwashingwithsoapandwater,start
treatmentwithlower-strengthpreparations
Maybleachclothing
nfantileacne
hild1monthÐ2years
apply1–2timesdaily;
starttreatmentwithlower-strengthpreparations
Withantimicrobials
OnceDaily
,benzoylperoxide5%,clindamycin1%(asphos-
AZELAICACID
avoidcontactwitheyes,mouth,andmucous
localirritation(reducefrequencyordis-
continuetemporarily);
lesscommonly
skindiscolora-
veryrarely
Indicationanddose
Seeunderpreparations
Antibacterialresistanceof
Propionibacteriumacnes
somemanufacturersadvisepreparations
containingalcoholarenotsuitableforusewith
benzoylperoxide
Indicationanddose
cnevulgaris
fordose,seeunderpreparations
DalacinT
Topicalsolution
,clindamycin1%(asphosphate),in
ADAPALENE
seenotesabove
seenotesabove
amountofdruginmilkprobablytoo
smalltobeharmful;ensureinfantdoesnotcomein
contactwithtreatedareas
seenotesabove
Licenseduse
notlicensedforuseininfantileacne
Indicationanddose
nfantileacne
hild1monthÐ2years
applythinlyoncedailyat
ildtomoderateacnevulgaris
hild12Ð18years
applythinlyoncedailyinthe
evening;reducefrequencyorsuspendtreatmentif
irritationoccurs
Withbenzoylperoxide
Withantibacterial
Acnevulgaris,particularlythatassociatedwithoily
Applythinly1–2timesdaily
Withantibacterial
AknemycinPlus
NICOTINAMIDE
avoidcontactwitheyesandmucousmem-
branes(includingnoseandmouth);reducefrequency
ofapplicationifexcessivedryness,irritationorpeel-
drynessofskin;alsopruritus,erythema,
burningandirritation
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
nammatoryacnevulgaris
seeunderprepara-
tionsbelow
SALICYLICACID
riskofsignicantsystemicabsorptionin
neonates;avoidcontactwithmouth,eyes,mucous
membranes;systemiceffectsafterexcessiveuse
Salicylatetoxicity
Salicylatetoxicitycanoccurparticularly
ifappliedonlargeareasofskinoronneonatalskin
localirritation
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
cnevulgaris
seeunderpreparation
section13.5.2
artsandcalluses
section13.7
ungalnailinfections
section13.10.2
BNFC2011–
13.6.1Topicalpreparationsforacne
(Alliance)
Topicalsolution
Applyupto3timesdaily
Oralpreparationsforacne
Oralantibacterialsforacne
Oralantibacterialsmaybeusedin
moderatetosevere
inßammatoryacne
whentopicaltreatmentisnotade-
quatelyeffectiveorisinappropriate.Concomitantanti-
comedonaltreatmentwithtopicalbenzoylperoxideor
azelaicacidmayalsoberequired(section13.6.1).
CO-CYPRINDIOL
dermatologist.Itisgivenforatleast16weeks;repeat
coursesarenotnormallyrequired.
cappack=£20.02.Label:10,patientinformation
card,11,21
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
Preparationsforwarts
andcalluses
Warts(verrucavulgaris)arecommon,benign,self-limit-
ing,andusuallyasymptomatic.Theyarecausedbya
humanpapillomavirus,whichmostfrequentlyaffects
SALICYLICACID
signicantperipheralneuropathy,patients
seeunderSalicylicAcid
seeunderSalicylicAcid
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
arts,particularlyplantarwarts
fordosesee
preparationbelow
Veracur
(Typharm)
,formaldehyde0.75%inawater-misciblegel
GLUTARALDEHYDE
protectsurroundingskin;notforapplication
toface,mucosa,oranogenitalareas
rashes,skinirritation(discontinueif
severe);stainsskinbrown
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
arts,particularlyplantarwarts
Applytwicedaily
SILVERNITRATE
protectsurroundingskinandavoidbroken
skin;notsuitableforapplicationtoface,ano-genital
region,orlargeareas
chemicalburnsonsurroundingskin;
stainsskinandfabric
Licenseduse
noagerangespeciedbymanufac-
Indicationanddose
ommonwartsandverrucas
Applymoistenedcausticpenciltipfor1–2minutes;
repeatafter24hoursuptomax.3applicationsfor
warts
max.6applicationsforverrucas
avoidnormalorbrokenskinandopen
wounds;notsuitableforinternalgenitalwarts;uncir-
cumcisedmales(riskofphimosisorstrictureoffore-
skin);autoimmunedisease;immunosuppressed
noevidenceofteratogenicityortoxicityin
studies;manufactureradvisescaution
noinformationavailable
localreactions(includingitching,burn-
ingsensation,erythema,erosion,oedema,excoria-
tion,andscabbing);headache;inuenza-likesymp-
toms;myalgia;
lesscommonly
localulcerationand
Stevens-Johnsonsyndromeand
cutaneouslupuserythematosus-likeeffect;
veryrarely
dysuriainfemales;permanenthypopigmentationor
hyperpigmentationreported
Licenseduse
notlicensedforuseinchildren
Indicationanddose
xternalgenitalandperianalwarts
(foruseunder
specialistsupervisiononly)
Applythinly3timesaweekatnightuntillesions
resolve(max.16weeks)
Important
Shouldberubbedinandallowedtostayon
thetreatedareafor6–10hoursthenwashedoffwithmild
soapandwater(uncircumcisedmalestreatingwarts
underforeskinshouldwashtheareadaily).Thecream
shouldbewashedoffbeforesexualcontact
PODOPHYLLOTOXIN
seenotesabove;avoidnormalskinandopen
wounds;keepawayfromface;veryirritanttoeyes
avoid
avoid
localirritation
Licenseduse
notlicensedforuseinchildren
Indicationanddose
Seeunderpreparations(foruseunderspecialist
supervisiononly)
Condyline
(Nycomed)
Sunscreensand
Sunscreenpreparations
Sunscreenpreparations
Foroptimumphotoprotection,sunscreenprepara-
tionsshouldbeapplied
(approximately2hourly).Inphotodermatoses,
theyshouldbeusedfromspringtoautumn.As
maximumprotectionfromsunlightisdesirable,pre-
parationswiththehighestSPFshouldbeprescribed.
Ingredientnomenclatureinsunscreen
rINNINCI
amiloxateisoamyl
(UVAandUVBprotection;UVB-SPF30),avoben-
zone5%,bisoctrizole1.5%,octinoxate7.5%,octocrilene4%,
theproductisincontactwiththescalpandbytheir
irritantnature.
Oilsandointmentsareveryusefulforscaly,dryscalp
Scalyscalpdisordersincludingpsoriasis,seborr-
hoeicdermatitis,anddandruff
Applyatleasttwiceweekly
(Alliance)
Scalyscalpdisordersincludingpsoriasis,seborr-
hoeicdermatitis,anddandruff
Applyatleasttwiceweekly
Psoriderm
Scalplotion
(=shampoo),coaltar2.5%,lecithin
Otherscalppreparations
Cocois
Section13.5.2
,arachis(peanut)oilextractofcoaltar0.3%,
cadeoil0.3%,coaltarsolution0.1%,oleylalcohol1%,
13.10.1.1
Antibacterialpreparationsonly
usedtopically
Renalimpairment
manufactureradvisescaution
ointmentusedinmoderateor
severeimpairmentbecauseitcontainsmacrogols
NEOMYCINSULPHATE
largeareas—iflargeareasofskinarebeing
treatedototoxicitymaybeahazardinchildren,par-
ticularlyinthosewithrenalimpairment
Contra-indications
Renalimpairment
seeCautionsabove
sensitisation(seealsonotesabove)
Licenseduse
NeomycinCreamBPC
—noinforma-
tionavailable
Indicationanddose
acterialskininfections
seeunderpreparation
NeomycinCreamBPC
POLYMYXINS
largeareas—iflargeareasofskinarebeing
treatednephrotoxicityandneurotoxicitymaybea
hazard,particularlyinchildrenwithrenalimpairment
Renalimpairment
seeCautionsabove
sensitisation(seealsonotesabove)
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
acterialskininfections
seeunderpreparation
(TEVAUK)
Ointment
,polymyxinBsulphate10000units,baci-
SILVERSULFADIAZINE
(Silversulphadiazine)
G6PDdeciency;mayinactivateenzymatic
debridingagents—concomitantusemaybeinap-
Appendix1(sulfonamides)
Largeareas
Plasma-sulfadiazineconcentrationsmay
approachtherapeuticlevelswith
asforsulfonamides(seesection5.1.8)iflargeareasofskin
aretreated.Owingtotheassociationofsulfonamideswith
severebloodandskindisorders,treatmentshouldbe
stoppedimmediatelyifblooddisordersorrashesdevelop—
butleucopeniadeveloping2–3daysafterstartingtreatment
ofburnspatientsisreportedusuallytobeself-limitingand
silversulfadiazineneednotusuallybediscontinuedprovided
longeduse;leucopeniareported(monitorblood
Licenseduse
noagerangespeciedbymanufac-
turerbutseecontra-indications,above
Indicationanddose
rophylaxisandtreatmentofinfectioninburn
wounds,forconservativemanagementofn-
ger-tipinjuries
seeunderpreparationbelow
djuncttoshort-termtreatmentofinfectionin
pressuresores,adjuncttoprophylaxisof
infectioninskingraftdonorsitesandextensive
13.10.1.2
Antibacterialpreparationsalso
usedsystemically
Sodiumfusidate
isanarrow-spectrumantibacterial
usedforstaphylococcalinfections.Fortheroleofsod-
FUSIDICACID
seenotesabove;avoidcontactwitheyes
rarelyhypersensitivityreactions
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
taphylococcalskininfections
Apply3–4timesdaily,usuallyfor7days
enicillin-resistantstaphylococcalinfections
section5.1.7
taphylococcaleyeinfections
section11.3.1
A
seenotesabove;alsoavoidcontactwith
ears;usewithcautioninchildlikelytosuckaffected
systemicabsorptionverylow,butmanu-
factureradvisesavoid—noinformationavailable
manufactureradvisesavoid—no
informationavailable
seenotesabove
Licenseduse
notlicensedforuseinchildrenunder
12years
13.10.2Antifungalpreparations
BNFC2011–
Indicationanddose
ungalnailinfections
Applytoinfectednails1–2timesweeklyafterling
andcleansing;allowtodry(approx.3minutes);
treatngernailsfor6months,toenailsfor9–12
months(reviewatintervalsof3months);avoidnail
varnishorarticialnailsduringtreatment
Loceryl
Naillacquer
BENZOICACID
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
ingworm(tinea)
butseenotesabove;doseunder
Withsalicylicacid
Forprescribinginformationonsalicylicacid,see
p.571
BenzoicAcidOintment,Compound,BP
(Whiteld’sointment)
Ointment
,benzoicacid6%,salicylicacid3%,in
emulsifyingointment
CLOTRIMAZOLE
seenotesabove
minimalabsorptionfromskin;notknown
tobeharmful
seenotesabove
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
ungalskininfections
Apply2–3timesdaily
aginalcandidiasis
section7.2.2
titisexterna
section12.1.1
ECONAZOLENITRATE
seenotesabove
minimalabsorptionfromskin;notknown
tobeharmful
seenotesabove
Licenseduse
,noagerangespeciedby
Indicationanddose
ungalskininfections
Applytwicedaily
ungalnailinfections
Applyoncedailyunderocclusivedressing
aginalcandidiasis
section7.2.2
MICONAZOLENITRATE
seenotesabove
seenotesabove
Licenseduse
Licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
ungalskininfections
applytwicedailycontinuingfor10days
afterlesionshavehealed
Child1monthÐ18years
applytwicedailycon-
tinuingfor10daysafterlesionshavehealed
ungalnailinfections
Apply1–2timesdaily
BNFC2011–
13.10.2Antifungalpreparations
ralandintestinalfungalinfections
aginalcandidiasis
section7.2.2
NYSTATIN
seenotesabove
seenotesabove
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
kininfectionsdueto
fordose,see
ralfungalinfections
section12.3.2
Nystaform
(Typharm)
,nystatin100000units/g,chlorhexidine
SALICYLICACID
avoidbrokenorinammedskin
Salicylatetoxicity
Salicylatetoxicitycanoccurparticularly
ifappliedonlargeareasofskin
seenotesabove
Indicationanddose
ungalnailinfections,particularlytinea
hild5Ð18years
applytwicedailyandafter
washing
Usewithcautioninchildlikelytosuckaffected
yperkeratoticskindisorders
section13.5.2
cnevulgaris
section13.6.1
artsandcalluses
section13.7
,salicylicacid1.46%(totalcombined),tannic
acid4.89%andboricacid3.12%(asborotannic
avoidcontactwitheyes
manufactureradvisesuseonlyifpotential
benetoutweighsrisk—
studiessuggestno
adverseeffects
manufactureradvisesavoid—present
inmilk,butlessthan5%ofthedoseisabsorbedafter
topicalapplicationofterbinane;avoidapplicationto
mother’schest
seenotesabove
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ungalskininfections
Applythinly1–2timesdailyforupto1weekin
tineapedis,1–2weeksintineacorporisandtinea
cruris,2weeksincutaneouscandidiasisandpity-
riasisversicolor;reviewafter2weeks
ystemictherapy
section5.2.5
TerbinaÞne
TIOCONAZOLE
seenotesabove;alsousewithcautionif
childlikelytosuckaffecteddigits
manufactureradvisesavoid
seenotesabove;alsolocaloedema,dry
skin,naildiscoloration,periungualinammation,nail
pain,rash,exfoliation
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
ungalnailinfections
Applytonailsandsurroundingskintwicedailyfor
upto6months(maybeextendedto12months)
Trosyl
Cutaneoussolution
UNDECENOATES
seenotesabove
Licenseduse
notlicensedforusein
childrenunder12years;
licensedforuse
inchildren(agerangenotspeciedbymanufac-
Indicationanddose
Seeunderpreparations
13.10.2Antifungalpreparations
BNFC2011–
(Thornton&Ross)
,zincundecenoate20%,undecenoicacid5%,
ACICLOVIR
avoidcontactwitheyesandmucousmem-
notknowntobeharmful—manufacturers
adviseuseonlywhenpotentialbenetoutweighsrisk;
limitedabsorptionfromtopicalaciclovirpreparations
transientstingingorburning;occasion-
allyerythema,itchingordryingoftheskin
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
erpessimplexinfections
Applytolesionsevery4hours(5timesdaily)for5–
10days,startingatrstsignofattack
erpessimplexandvaricella–zosterinfections
section5.3.2.1
yeinfections
section11.3.3
PENCICLOVIR
avoidcontactwitheyesandmucousmem-
transientstinging,burning,numbness;
hypersensitivityreactionsalsoreported
Licenseduse
notlicensedforuseinchildrenunder
12years
Vectavir
(NovartisConsumerHealth)
MALATHION
avoidcontactwitheyes;donotuseon
brokenorsecondarilyinfectedskin;donotuselotion
morethanonceaweekfor3consecutiveweeks;
alcoholiclotions
recommendedforheadlicein
childrenwithsevereeczemaorasthma,orforscabies
orcrablice(seenotesabove)
skinirritationandhypersensitivityreac-
tions;chemicalburnsalsoreported
Licenseduse
notlicensedforuseinchildrenunder6
monthsexceptundermedicalsupervision
Indicationanddose
Seenotesaboveandunderpreparations
eadlice
Rubintodryhairandscalp,allowtodrynaturally,
removebywashingafter12hours;repeatappli-
cationafter7days(seealsonotesabove)
rablice
Applyoverwholebody,allowtodrynaturally,
washoffafter12hoursorovernight;repeat
applicationafter7days
Applyoverwholebody,andwashoffafter24
hours;ifhandsarewashedwithsoapwithin24
Histoacryl
Tissueadhesive
ALCOHOL
ammable;avoidbrokenskin;patientshave
sufferedsevereburnswhendiathermyhasbeenpre-
cededbyapplicationofalcoholicskindisinfectants
Contra-indications
neonates,seesection13.1
Indicationanddose
kinpreparationbeforeinjection
Applytoskinasnecessary
SODIUMCHLORIDE
Indicationanddose
Seenotesabove
ebuliserdiluent
section3.1.5
SodiumChloride
(Medlock)
CHLORHEXIDINE
avoidcontactwitheyes,brain,meningesand
middleear;notforuseinbodycavities;alcoholic
solutionsnotsuitablebeforediathermyorforuseon
neonatalskin
occasionalsensitivity
Indicationanddose
Seeunderpreparations
Ingredientof
Travasept
,seeabove
BNFC2011–
13.11.2Chlorhexidinesalts
13.11.4
brokenskin(seebelow)
Largeopenwounds
Theapplicationofpovidone–iodineto
largewoundsorsevereburnsmayproducesystemicadverse
HYDROGENPEROXIDE
largeordeepwounds;avoidonhealthyskin
andeyes;bleachesfabric;incompatiblewithproducts
containingiodineorpotassiumpermanganate
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
upercialbacterialskininfection
seeunder
preparationbelow
Crystacide
(GPPharma)
POTASSIUMPERMANGANATE
irritanttomucousmembranes
Indicationanddose
leansinganddeodorisingsuppuratingecze-
matousreactions(section13.5.1)andwounds
Forfurtherinformationonwoundmanagementpro-
ductsandelastichosiery,seetherelevantBNFappen-
(Recombinanthumanplatelet-derivedgrowth
avoidonsiteswithinfectionorperipheral
arteriopathy
Contra-indications
malignantdisease
pain;infectionsincludingcellulitisand
osteomyelitis,localreactionsincludingerythema;
bullouseruption,oedema,andhypertrophic
granulation
Licenseduse
notlicensedforuseinchildren
Indicationanddose
ALUMINIUMSALTS
avoidcontactwitheyesormucousmem-
branes;avoiduseonbrokenorirritatedskin;donot
shaveaxillaeorusedepilatorieswithin12hoursof
application;avoidcontactwithclothing
skinirritation
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
GLYCOPYRRONIUMBROMIDE
seesection15.1.3(butpoorlyabsorbedand
systemiceffectsunlikely)
Contra-indications
seesection15.1.3(butpoorly
absorbedandsystemiceffectsunlikely),infections
affectingthetreatmentsite
seesection15.1.3(butpoorlyabsorbed
andsystemiceffectsunlikely),tinglingatadministra-
tionsite
Licenseduse
licensedforuseinchildren(agerange
notspeciedbymanufacturer)
Indicationanddose
,heparinoid0.3%inavanishing-creambasis,
Immunologicalproducts
andvaccines
Activeimmunity
Passiveimmunity
Storageanduse
Vaccinesandantisera
Immunoglobulins
NormalImmunoglobulin
Disease-speciÞcimmunoglobu-
Anti-D(Rh
)immunoglobulin
Internationaltravel
Activeimmunity
Activeimmunitycanbeacquiredbynaturaldiseaseor
byvaccination.
Vaccines
stimulateproductionofanti-
bodiesandothercomponentsoftheimmunemechan-
ism;theyconsistofeither:
1.a
liveattenuated
formofavirus(e.g.measles,
mumps,andrubellavaccine)orbacteria(e.g.BCG
vaccine),or
inactivated
preparationsofavirus(e.g.inßuenza
vaccine)orbacteria,or
Immunologicalproductsandvaccines
suppressivedrugs
,andforchildrenwithmalignant
conditionsundergoingchemotherapyorgeneralised
radiotherapy
.Forspecialreferenceto
HIVinfection
seebelow.
TheRoyalCollegeofPaediatricsandChildHealthhas
producedastatement,
ImmunisationoftheImmuno-
compromisedChild(2002)
(availableat
www.rcpch.ac.uk
Livevaccinesshouldnotbeadministered
thesmallvolumerequired.
Furtherinformationonadverseeffectsassociatedwith
speciÞcvaccinescanbefoundunderindividualvac-
cines.
VaccinesandHIVinfection
HIV-positivechildren
withorwithoutsymptomscanreceivethefollowinglive
vaccines:
MMR(butavoidifimmunitysigniÞcantlyimpaired),
varicella-zoster(butavoidifimmunitysigniÞcantly
impairedÑconsultproductliterature);
andthefollowinginactivatedvaccines:
anthrax,cholera(oral),diphtheria,haemophilus
inßuenzaetypeb,hepatitisA,hepatitisB,human
papillomavirus,inßuenza,meningococcal,per-
tussis,pneumococcal,poliomyelitis
,rabies,
Livevaccinesshouldbepostponeduntilatleast3months
afterstoppinghigh-dosesystemiccorticosteroidsandat
least6monthsafterstoppingotherimmunosuppressive
drugsorgeneralisedradiotherapy(atleast12monthsafter
discontinuingimmunosuppressantsfollowingbone-mar-
rowtransplantation).
Useofnormalimmunoglobulinshouldbeconsideredafter
exposuretomeasles(seep.623)andvaricellaÐzoster
immunoglobulinconsideredafterexposuretochickenpox
orherpeszoster(seep.625).
Inactivatedpoliomyelitisvaccineisnowusedinsteadof
oralpoliomyelitisvaccineforroutineimmunisationof
Ifyellowfeverriskisunavoidable,specialistadviceshould
besought.
14.1Activeimmunity
BNFC2011–
Immunologicalproductsandvaccines
Immunisationschedule
Vaccinesforthechildhoodimmunisationscheduleshouldbeobtainedfrom
localhealthorganisations
orfromImmForm
www.immform.dh.gov.uk
)ÑnottobeprescribedonFP10(HS21inNorthernIreland;GP10inScotland;WP10inWales).
Thetwohumanpapillomavirusvaccinesarenotinterchangeableandonevaccineproductshouldbeusedfortheentire
Immunologicalproductsandvaccines
Vaccinesandasplenia
Thefollowingvaccinesare
recommendedforasplenicchildrenorthosewithsple-
nicdysfunction:
haemophilusinßuenzaetypeb;inßuenza;meningo-
coccalA,C,W135,andYconjugate;pneumo-
Forantibioticprophylaxisinaspleniaseep.255.
Routeofadministration
Vaccinesshouldnotbe
givenintravenously.Mostvaccinesaregivenbythe
intramuscularroute;somevaccinesaregivenbyother
routesÑtheintradermalrouteforBCGvaccine,deep
subcutaneousrouteforJapaneseencephalitisandvari-
cellavaccines,andtheoralrouteforcholera,livepolio-
myelitis,rotavirus,andlivetyphoidvaccines.Theintra-
muscularrouteshouldnotbeusedinchildrenwith
bleedingdisorders
suchashaemophiliaorthrombocy-
topenia;vaccinesusuallygivenbytheintramuscular
routeshouldbegivenbydeepsubcutaneousinjection
TheDepartmentofHealthhasadvised
againsttheuseof
parationsmadefromtheplasmaofimmuneindividuals
withadequatelevelsofantibodytothediseaseforwhich
protectionissought(seeunderImmunoglobulins,sec-
tion14.5).Thedurationofthispassiveimmunityvaries
accordingtothedoseandthetypeofimmunoglobulin.
Passiveimmunitymaylastonlyafewweeks;when
necessary,passiveimmunisationcanberepeated.
Antibodiesofhumanoriginareusuallytermed
immu-
noglobulins
.Theterm
antiserum
isappliedtomaterial
preparedinanimals.Becauseofserumsicknessand
otherallergic-typereactionsthatmayfollowinjections
ofantisera,thistherapyhasbeenreplacedwhenever
possiblebytheuseofimmunoglobulins.Reactionsare
PublicHealth.InWalesenquiriesforvaccinesnot
commerciallyavailableshouldbedirectedto:
WelshMedicinesInformationCentre
UniversityHospitalofWales
Cardiff,CF144XW
Tel:(029)20742979
andinNorthernIreland:
PharmacyandMedicinesManagementCentre
BeechHouse
AntrimHospitalSite
NorthernHealthandSocialCareTrust
BushRoad
Antrim,BT412RL
Immunologicalproductsandvaccines
Anthraxvaccine
Anthraxvaccineisrarelyrequiredforchildren.For
furtherinformationseeBNFsection14.4.
BCGvaccines
Intradermal
Listofcountriesorprimarycaretrustswheretheincidence
oftuberculosisisgreaterthan40casesper100000is
availableat
www.hpa.org.uk
BNFC2011–
14.4Vaccinesandantisera
Immunologicalproductsandvaccines
Twointerferongammareleaseassay(IGRA)testsare
alsoavailableasanaidinthediagnosisoftuberculosis
QuantiFERON
-TBGold
BothtestsmeasureT-cellmediatedimmuneresponseto
Choleravaccine
Choleravaccine
(oral)containsinactivatedInaba
(includingEl-Torbiotype)andOgawastrainsof
subunitofthecholeratoxinproducedinInabastrains
V.cholerae
,serotypeO1.
Oralcholeravaccineislicensedfortravellerstoende-
micorepidemicareasonthebasisofcurrentrecom-
mendations(seealsosection14.6).Immunisation
CHOLERAVACCINE
seesection14.1andnotesabove
Contra-indications
seesection14.1;alsoacutegas-
tro-intestinalillness
seep.600
seep.600
seesection14.1;also
respiratory
symptomssuchasrhinitisandcough;
veryrarely
throat,insomnia
Indicationanddose
Seenotesabove
Bymouth
Child2–6years
3doseseachseparatedbyan
intervalof1Ð6weeks
hild6–18years
2dosesseparatedbyaninterval
of1Ð6weeks
Immunologicalproductsandvaccines
DIPHTHERIA-CONTAININGVACCINES
seesection14.1;seealsoindividualcom-
ponentsofvaccines
Contra-indications
seesection14.1;seealsoindivi-
dualcomponentsofvaccines
seep.600
seep.600
seesection14.1;alsorestlessness,sleep
disturbances,andunusualcryingininfants;
Licenseduse
Infanrix-IPV+Hib
notlicensedfor
useinchildrenover36months;
Pediacel
licensedinchildrenover4yearsbutDepartmentof
Healthrecommendsthatthesebeusedforchildren
upto10years
Indicationanddose
Seenotesaboveandunderpreparations
Diphtheria-containingvaccinesforchildren
under10years
Important
recommendedforchildren
aged10yearsor
(seeDiphtheriavaccinesforchildrenover10)
Immunologicalproductsandvaccines
Diphtheria-containingvaccinesforchildrenover
10years
AlowdoseofdiphtheriatoxoidissufÞcienttorecall
immunityinolderchildrenpreviouslyimmunised
againstdiphtheriabutwhoseimmunitymayhave
diminishedwithtime;itisinsufÞcienttocauseserious
reactionsinachildwhoisalreadyimmune.Prepara-
tionscontaininglowdosediphtheriashouldbeused
forchildren
over10years
,bothforprimaryimmuni-
sationandboosterdoses.
Diphtheriaantitoxin
Diphtheriaantitoxin
isusedforpassiveimmuni-
sationinsuspectedcasesofdiphtheriaonly(without
waitingforbacteriologicalconÞrmation);testsfor
hypersensitivityshouldbeÞrstcarriedout.Itis
derivedfromhorseserum,andreactionsarecommon
afteradministration;resuscitationfacilitiesshouldbe
availableimmediately.
Itisnolongerusedforprophylaxisbecauseoftherisk
ofhypersensitivity;unimmunisedcontactsshouldbe
promptlyinvestigatedandgivenantibacterialprophy-
laxis(Table2,section5.1)andvaccine(seeContacts
above,p.605).
DiphtheriaAntitoxin
Notrecommendedthereforenodosestated(seenotes
Treatment
Consultproductliterature
AvailablefromCentreforInfections(Tel(020)82006868)orin
NorthernIrelandfromPublicHealthLaboratory,BelfastCity
Hospital(Tel(028)90329241).
HaemophilustypeBconjugatevaccine
Haemophilusinßuenzaetypeb(Hib)vaccine
ismade
fromcapsularpolysaccharide;itisconjugatedwitha
HAEMOPHILUSTYPEBCONJUGATE
VACCINE
seesection14.1
Contra-indications
seesection14.1
seep.600
seep.600
seesection14.1;also,atopicdermatitis,
Licenseduse
isnotlicensedforusein
childrenover2years
Indicationanddose
Seenotesaboveandunderpreparation
Primaryimmunisation
,seeunderDiphtheria-
containingvaccines
14.4Vaccinesandantisera
BNFC2011–
Immunologicalproductsandvaccines
Menitorix
,powderforreconstitution,capsularpoly-
saccharideof
Haemophilusinßuenzae
typeband
capsularpolysaccharideof
Neisseriameningitidis
Combinedvaccines
SeealsoDiphtheria-containingvaccines
HepatitisAvaccine
HepatitisAvaccine
ispreparedfromformaldehyde-
inactivatedhepatitisAvirusgrowninhumandiploid
cells.
Immunisationisrecommendedfor:
residentsofhomesforthosewithseverelearning
difÞculties;
childrenwithhaemophiliaorotherconditionstrea-
tedwithplasma-derivedclottingfactors;
childrenwithsevereliverdisease;
childrentravellingtohigh-riskareas(seep.626);
adolescentswhoareatriskduetotheirsexual
behaviour;
parenteraldrugabusers.
Immunisationshouldbeconsideredfor:
childrenwithchronicliverdiseaseincludingchronic
hepatitisBorchronichepatitisC;
preventionofsecondarycasesinclosecontactsof
conÞrmedcasesofhepatitisA,within14daysof
exposuretotheprimarycase(within8weeksof
exposuretotheprimarycasewherethereismore
than1contactinthehousehold).
AboosterdoseofhepatitisAvaccineisusuallygiven6Ð
12monthsaftertheinitialdose.Asecondboosterdose
canbegiven20yearsafterthepreviousboosterdoseto
thosewhocontinuetobeatrisk.Specialistadvice
shouldbesoughtonre-immunisationofimmunocom-
promisedindividuals.
Post-exposureprophylaxisisnotrequiredforhealthy
childrenunder1yearofage,solongasallthose
involvedinnappychangingarevaccinatedagainst
hepatitisA.However,children2Ð12monthsofage
canbegivenadoseofhepatitisAvaccineifitisnot
possibletovaccinatetheircarers,orifthechild
becomesasourceofinfectiontoothers[unlicensed
use];inthesecases,ifthechildgoesontorequire
long-termprotectionagainsthepatitisAaftertheÞrst
birthday,thefullcourseof2dosesshouldbegiven.
Inchildrenunder16years,asingledoseofthecom-
binedvaccine
Ambirix
canbeusedtoproviderapid
protectionagainsthepatitisA.
normalimmunoglobulin
14.5.1)isrecommendedforuseinadditiontoHepatitis
Avaccineforclosecontacts(ofconÞrmedcasesof
hepatitisA)whohavechronicliverdiseaseorHIV
infection,orwhoareimmunosuppressed.
HEPATITISAVACCINE
section14.1
Contra-indications
section14.1
seep.600
seep.600
section14.1;forcombinationvaccines,
seealsoTyphoidvaccines,p.620
Indicationanddose
mmunisationagainsthepatitisAinfection
Fordose,seeunderpreparations
Singlecomponent
(SanoPasteur)
,suspensionofformaldehyde-inactivated
hepatitisAvirus(GBMgrowninhumandiploidcells)
320antigenunits/mLadsorbedontoaluminium
Immunologicalproductsandvaccines
Child16–18years
1mLasasingledose;boosterdose
1mL6Ð12monthsafterinitialdose
Boosterdosemaybedelayedbyupto3yearsifnot
givenafterrecommendedintervalfollowingprimary
dosewith
HavrixMonodose
.Thedeltoidregionisthe
preferredsiteofinjection.Thesubcutaneousroutemay
beusedforchildrenwithbleedingdisorders
Vaqta
(SanoPasteur)
,suspensionofformaldehyde-inactivated
hepatitisAvirus(growninhumandiploidcells)
50antigenunits/mLadsorbedontoaluminium
WithhepatitisBvaccine
,suspensionofinactivatedhepatitisAvirus
(growninhumandiploidcells)720ELISAunits/mL
absorbedontoaluminiumhydroxide,andrecombi-
nant(DNA)hepatitisBsurfaceantigen(growninyeast
cells)20micrograms/mLadsorbedontoaluminium
daysafterÞrstdose,thirddoseafterfurther14daysand
fourthdose12monthsaftertheÞrstdose
Withtyphoidvaccine
,suspensionofinactivatedhepatitisAvirus
(growninhumandiploidcells)1440ELISAunits/mL
adsorbedontoaluminiumhydroxide,combinedwith
typhoidvaccinecontaining25micrograms/mLviru-
lencepolysaccharideantigenof
Salmonellatyphi
Immunologicalproductsandvaccines
closefamilycontactsofanindividualwithchronic
hepatitisBinfection;
babieswhosemothershavehadacutehepatitisB
duringpregnancy
arepositiveforhepatitisB
surfaceantigen(regardlessofe-antigenmarkers);
hepatitisBvaccinationisstartedimmediatelyon
deliveryand
hepatitisBimmunoglobulin
p.624)givenatthesametime(butatadifferent
site).Babieswhosemothersarepositiveforhepat-
itisBsurfaceantigenandfore-antigenantibody
shouldreceivethevaccineonly(butbabiesweigh-
ing1.5kgorlessshouldalsoreceivetheimmuno-
globulinregardlessofthemotherÕse-antigenanti-
bodystatus);
childrenwithhaemophilia,thosereceivingregular
bloodtransfusionsorbloodproducts,andcarers
responsiblefortheadministrationofsuchproducts;
childrenwithchronicrenalfailureincludingthose
onhaemodialysis.Childrenreceivinghaemodialysis
shouldbemonitoredforantibodiesannuallyandre-
immunisedifnecessary.Homecarers(ofdialysis
patients)shouldbevaccinated;
childrenwithchronicliverdisease;
patientsofday-careorresidentialaccommodation
forthosewithseverelearningdifÞculties;
childrenincustodialinstitutions;
childrentravellingtoareasofhighorintermediate
prevalencewhoareatincreasedriskorwhoplanto
remainthereforlengthyperiods(seep.626);
familiesadoptingchildrenfromcountrieswitha
highorintermediateprevalenceofhepatitisB;
fostercarersandtheirfamilies.
DifferentimmunisationschedulesforhepatitisB
vaccinearerecommendedforspeciÞccircumstances
(seeunderindividualpreparations);anÔaccelerated
scheduleÕisrecommendedforpre-exposureprophylaxis
inhighÐriskgroupswhererapidprotectionisrequired,
andforpost-exposureprophylaxis(seebelow).Gener-
ally,threeorfourdosesarerequiredforprimary
immunisation.Immunisationmaytakeupto6months
toconferadequateprotection;thedurationofimmunity
isnotknownprecisely,butasinglebooster5yearsafter
theprimarycoursemaybesufÞcienttomaintainimmu-
nityforthosewhocontinuetobeatrisk.
Immunisationdoesnoteliminatetheneedforcommon-
senseprecautionsforavoidingtheriskofinfectionfrom
knowncarriersbytheroutesofinfectionwhichhave
beenclearlyestablished,consult
GuidanceforClinical
HealthCareWorkers:ProtectionagainstInfectionwith
Blood-borneViruses
(availableat
www.dh.gov.uk
).Acci-
dentalinoculationofhepatitisBvirus-infectedblood
intoawound,incision,needle-prick,orabrasionmay
leadtoinfection,whereasitisunlikelythatindirect
exposuretoacarrierwilldoso.
FollowingsigniÞcantexposuretohepatitsB,anaccel-
eratedschedule,withtheseconddosegiven1month,
andthethirddose2monthsaftertheinitialdose,is
recommended.Forthoseatcontinuedrisk,afourth
doseshouldbegiven12monthsaftertheÞrstdose.
AcombinedhepatitisAandhepatitisBvaccineisalso
available.
HEPATITISBVACCINE
section14.1
Contra-indications
section14.1
seep.600
seep.600
section14.1
Indicationanddose
mmunisationagainsthepatitisBinfection
Fordoseseeunderpreparations
Singlecomponent
EngerixB
,suspensionofhepatitisBsurfaceantigen
(preparedfromyeastcellsbyrecombinantDNA
technique)20micrograms/mLadsorbedontoalu-
Immunologicalproductsandvaccines
andboosterdosesmayneedtobeadjustedinthosewith
lowantibodyconcentration
Child16–18years
4dosesof40micrograms,thesec-
ond1month,thethird2monthsandthefourth6months
aftertheÞrstdose;immunisationscheduleandbooster
dosesmayneedtobeadjustedinthosewithlowantibody
Deltoidmuscleispreferredsiteofinjectioninolder
children;anterolateralthighispreferredsiteinneonates,
infantsandyoungchildren;nottobeinjectedintothe
buttock(vaccineefÞcacyreduced)
,suspensionofhepatitisBsurfaceantigen
(preparedfromyeastcellsbyrecombinantDNA
technique)40micrograms/mLadsorbedontoalu-
WithhepatitisAvaccine
SeeHepatitisAVaccine
Humanpapillomavirusvaccines
Humanpapillomavirusvaccine
isavailableasa
bivalentvaccine(
Cervarix
)oraquadrivalentvaccine
Gardasil
islicensedforuseinfemalesfor
thepreventionofcervicalcancerandotherpre-
cancerouslesionscausedbyhumanpapillomavirus
types16and18.
Gardasil
islicensedforuseinfemales
forthepreventionofcervicalcancer,genitalwartsand
pre-cancerouslesionscausedbyhumanpapillomavirus
types6,11,16and18.Thevaccinesmayalsoprovide
limitedprotectionagainstdiseasecausedbyothertypes
ofhumanpapillomavirus.Thetwovaccinesarenot
interchangeableandonevaccineproductshouldbe
usedforanentirecourse.However,theDepartmentof
Health(November2008)statesforindividualswith
HUMANPAPILLOMAVIRUS
VACCINES
seesection14.1
Contra-indications
seesection14.1
notknowntobeharmful,butvaccination
Immunologicalproductsandvaccines
Indicationanddose
Seenotesaboveandunderpreparations
Toavoidconfusion,prescribersshouldspecifythe
brandtobedispensed
Cervarix
,suspensionofvirus-likeparticlesofhuman
papillomavirustype16(40micrograms/mL),type18
(40micrograms/mL)capsidprotein(preparedby
recombinantDNAtechniqueusingaBaculovirus
expressionsystem)inmonophosphoryllipidAadju-
chronicliverdisease;
chronicrenaldisease;
chronicneurologicaldisease;
INFLUENZAVACCINES
seesection14.1;
Appendix1
(vaccines)
Contra-indications
seesection14.1;avoid
Immunologicalproductsandvaccines
Child3–13years
0.5mL(repeatedafter4Ð6
weeksinchildrenwhohavenotreceivedseasonal
inßuenzavaccinepreviously)
hild13–18years
0.5mLasasingledose
nßuenzaA(HINI)v
Seeunder
Pandemrix
Seasonalinßuenzavaccines
InactivatedInuenzaVaccine(SplitVirion)
,suspensionofformaldehyde-inactivated
inßuenzavirus(splitvirion)growninfertilisedhensÕ
MonovalentinßuenzaA(H1N1)vvaccines
Celvapan
,suspensionofformaldehyde-inactivated
inßuenzaA(H1N1)vvirus(wholevirion,growninvero
cells),15micrograms/mL,5-mLmultidosevialcon-
tains10dosesof0.5mL
PreventionofinßuenzaA(H1N1)v
Byintramuscularinjection
Child6months–18years
2doseseachof0.5mL
separatedbyanintervalofatleast3weeks
isnotinterchangeablewith
,suspensionofinactivatedinßuenza
A(H1N1)vvirus(splitvirion,growninfertilisedhensÕ
eggs)7.5micrograms/mLwhenmixedwithemulsion
ofadjuvant,5mLofmixedmultidosevialcontains10
dosesof0.5mL
includegentamicinandthiomersal
PreventionofinßuenzaA(H1N1)v
Byintramuscularinjection
Child6months–10years
0.25mLasasingledose
Child10–18years
0.5mLasasingledose
isnotinterchangeablewith
Measlesvaccine
Measlesvaccine
hasbeenreplacedbyacombinedlive
measles,mumpsandrubellavaccine(MMRvaccine).
MMRvaccinemaybeusedinthecontrolofoutbreaksof
measles(seeunderMMRVaccine).
Singleantigenvaccine
NolongeravailableintheUK
Combinedvaccines
SeeMMRvaccine,below
Measles,MumpsandRubella(MMR)
Acombinedlive
measles,mumps,andrubella
(MMRvaccine)aimstoeliminatemeasles,
mumpsandrubella(andcongenitalrubellasyndrome).
EverychildshouldreceivetwodosesofMMRvaccine
byentrytoprimaryschool,unlessthereisavalid
contra-indication(seesection14.1).MMRvaccine
shouldbegivenirrespectiveofpreviousmeasles,
mumps,orrubellainfectionorvaccination.
TheÞrstdoseofMMRvaccineisgiventochildrenaged
12Ð13months.Aseconddoseisgivenbeforestarting
14.4Vaccinesandantisera
BNFC2011–
Immunologicalproductsandvaccines
schoolat3Ð5yearsofage(seeImmunisationschedule,
section14.1).
Whenprotectionagainstmeaslesisrequiredurgently
(e.g.duringameaslesoutbreak),theseconddoseof
MMRvaccinecanbegiven1monthaftertheÞrstdose;
iftheseconddoseisgivenbefore18monthsofage,then
childrenshouldstillreceivetheroutinedosebefore
startingschoolat3Ð5yearsofage.
Childrenpresentingforpre-schoolboosterwhohave
notreceivedtheÞrstdoseofMMRvaccineshouldbe
givenadoseofMMRvaccinefollowed3monthslaterby
aseconddose.Atschool-leavingageoratentryinto
furthereducation,MMRimmunisationshouldbe
offeredtoindividualsofbothsexeswhohavenot
received2dosesduringchildhood.Inayoungadult
whohasreceivedonlyasingledoseofMMRinchild-
hood,aseconddoseisrecommendedtoachievefull
protection.If2dosesofMMRvaccinearerequired,the
seconddoseshouldbegivenonemonthaftertheinitial
dose.
MMRvaccineshouldbeusedtoprotectagainstrubella
seronegativefemalesofchild-bearingage
Immunisationschedule,section14.1).MMRvaccine
mayalsobeofferedtopreviously
unimmunisedand
seronegativepost-partum
mothersÑvaccinationafew
daysafterdeliveryisimportantbecauseabout60%of
congenitalabnormalitiesfromrubellainfectionoccurin
babiesofmotherswhohavebornemorethanonechild.
Immigrantsarrivingaftertheageofschoolimmuni-
sationareparticularlylikelytorequireimmunisation.
Contacts
MMRvaccinemayalsobeusedinthe
controlofoutbreaksofmeaslesandshouldbeoffered
tosusceptiblechildrenincludingbabiesagedover6
monthswhoarecontactsofacase,within3daysof
exposuretoinfection;thesechildrenshouldstillreceive
routineMMRvaccinationsattherecommendedages.
Childrenagedunder9monthsforwhomavoidanceof
measlesinfectionisparticularlyimportant(suchas
thosewithhistoryofrecentsevereillness)canbe
givennormalimmunoglobulin(section14.5,p.622)
afterexposuretomeasles;routineMMRimmunisation
shouldthenbegivenafteratleast3monthsatthe
appropriateage.
MMRvaccineis
notsuitable
forprophylaxisfollowing
exposuretomumpsorrubellasincetheantibody
responsetothemumpsandrubellacomponentsistoo
slowforeffectiveprophylaxis.
Childrenwithimpairedimmuneresponseshouldnot
receivelivevaccines(foradviceonHIVseesection
14.1).Iftheyhavebeenexposedtomeaslesinfection
theyshouldbegivennormalimmunoglobulin(section
Travel
Unimmunisedchildrenover6monthsofage
travellingtoareaswheremeaslesisendemicorepi-
demicshouldreceiveMMRvaccine.Childrenimmu-
nisedbefore12monthsofageshouldstillreceivetwo
dosesofMMRattherecommendedages.Ifonedoseof
MMRhasalreadybeengiventoachild,thenthesecond
doseshouldbebroughtforwardtoatleastonemonth
www.dh.gov.uk/immunisation
MEASLES,MUMPSANDRUBELLA
VACCINE,LIVE
seesection14.1;alsoafterimmunoglobulin
administrationorbloodtransfusion,leaveaninterval
ofatleast3monthsbeforeMMRimmunisationas
antibodyresponsetomeaslescomponentmaybe
Appendix1(vaccines)
Hypersensitivitytoegg
Thereisincreasingevidencethat
MMRvaccinecanbegivensafelyevenwhenthechildhas
hadananaphylacticreactiontofoodcontainingegg(dislike
ofeggorrefusaltoeateggisnotacontra-indication).For
childrenwithaconÞrmedanaphylacticreactiontoegg-
containingfood,MMRvaccinemaybeadministeredina
Immunologicalproductsandvaccines
seesection14.1andnotesabove;also
lesscommonly
sleepdisturbance,unusualcryingin
infants,alsoreportedperipheralandopticneuritis.
Licenseduse
notlicensedforuseinchildrenunder9
Indicationanddose
mmunisationagainstmeasles,mumps,and
Byintramuscularordeepsubcutaneousinjec-
CHILD6months–18years
primaryimmuni-
sation,2doseseachof0.5mL,seeImmunisation
schedule,section14.1,p.601;seealsonotesabove
foruseinoutbreaks,forcontactsofcases,andfor
travel
Combinedvaccines
(SanoPasteur)
,powderforreconstitution,liveattenuated,
measlesvirus(EndersÕEdmonstonstrain)andmumps
virus(JerylLynn[LevelB]strain)preparedinchick
embryocells,andrubellavirus(WistarRA27/3
strain);single-dosevial(withsyringecontainingsol-
includegelatinandneomycin
Onlyavailableaspartofchildhoodimmunisationschedulefrom
healthorganisationsorImmForm
,powderforreconstitution,liveattenuated,
measlesvirus(Schwarzstrain)andmumpsvirus(RIT
4385strain)preparedinchickembryocells,andru-
MENINGOCOCCALVACCINES
seesection14.1
Contra-indications
seesection14.1
seep.600
seep.600
seesection14.1;also
symptomsof
meningitisreported(butnoevidencethatvaccine
causesmeningococcalCmeningitis)
Licenseduse
notlicensedforusein
childrenunder11years
Indicationanddose
mmunisationagainst
Neisseriameningitidis
fordose,seeunderpreparations
MeningococcalGroupCconjugatevaccine
Immunologicalproductsandvaccines
MeningococcalGroupCconjugatevaccinewith
HaemophilusInßuenzaetypeBvaccine
HaemophilusInßuenzae
typeBvaccine
MeningococcalA,C,W135,andYconjugate
(NovartisVaccines)
,powderforreconstitution,capsularoligo-
saccharideantigensof
Neisseriameningitidis
A,C,W135,andY(conjugatedto
Corynebacterium
diphtheriae
MeningococcalpolysaccharideA,C,W135andY
ACWYVax
,powderforreconstitution,capsularpoly-
saccharideantigensof
Neisseriameningitidis
Singleantigenvaccine
NolongeravailableintheUK
Combinedvaccines
SeeMMRVaccine,p.612
Pertussisvaccine
Pertussisvaccine
isgivenasacombinationprepara-
tioncontainingothervaccines(seeDiphtheriaVac-
cines).Acellularvaccinesarederivedfromhighlypur-
iÞedcomponentsof
Bordetellapertussis
.Primary
immunisationagainstpertussis(whoopingcough)
requires3dosesofanacellularpertussis-containing
vaccine(seeImmunisationschedule,section14.1,
p.601),givenatintervalsof1monthfromtheageof
2months.
Allchildrenuptotheageof10yearsshouldreceive
Immunologicalproductsandvaccines
Sideeffects
Seealsosection14.1.Theincidenceof
localandsystemiceffectsisgenerallylowerwithvac-
cinescontainingacellularpertussiscomponentsthan
withthewhole-cellpertussisvaccineused.However,
comparedwithprimaryvaccination,boosterdoseswith
vaccinescontainingacellularpertussisarereportedto
increasetheriskofinjection-sitereactions(someof
whichaffecttheentirelimb);localreactionsdonot
contra-indicatefurtherdoses(seebelow).
Thevaccineshouldnotbewithheldfromchildrenwitha
historytoaprecedingdoseof:
fever,irrespectiveofseverity;
persistentcryingorscreamingformorethan3
hours;
severelocalreaction,irrespectiveofextent.
Combinedvaccines
Combinedvaccines,seeunderDiphtheriavaccines
Pneumococcalvaccines
Pneumococcalvaccinesprotectagainstinfectionwith
Streptococcuspneumoniae
(pneumococcus);thevac-
cinescontainpolysaccharidefromcapsularpneumo-
Pneumococcalpolysaccharidevaccine
tainspuriÞedpolysaccharidefrom23capsulartypesof
pneumococci,whereas
pneumococcalpolysaccharide
conjugatevaccine
(adsorbed)containspolysaccharide
fromeither10capsulartypes(
Synßorix
)or13
capsulartypes(
Prevenar
)withthepolysaccharide
beingconjugatedtoprotein.
The13-valentconjugatevaccineisusedforchildhood
immunisation.Therecommendedscheduleconsistsof3
doses,theÞrstat2monthsofage,thesecondat4
months,andthethirdat12Ð13months(seeImmuni-
sationSchedule,section14.1).
Pneumococcalvaccinationisrecommendedforindivi-
dualsatincreasedriskofpneumococcalinfectionas
follows:
childunder5yearswithahistoryofinvasive
pneumococcaldisease;
aspleniaorsplenicdysfunction(includinghomozy-
goussicklecelldiseaseandcoeliacdiseasewhich
couldleadtosplenicdysfunction);
chronicrespiratorydisease(includesasthmatrea-
tedwithcontinuousorfrequentuseofasystemic
corticosteroid);
chronicheartdisease;
chronicrenaldisease;
chronicliverdisease;
discussedwithahaematologist,immunologist,or
microbiologist.
PNEUMOCOCCALVACCINES
seesection14.1
Contra-indications
seesection14.1
seep.600
seep.600
seesection14.1;
Revaccination,
Indicationanddose
mmunisationagainstpneumococcalinfection
Fordoseseeunderpreparations
Pneumococcalpolysaccharidevaccines
(SanoPasteur)
Injection,polysaccharidefromeachof23capsular
Immunologicalproductsandvaccines
Pneumococcalpolysaccharideconjugatevaccine
Prevenar13
www.travax.nhs.uk
orfromtheNational
POLIOMYELITISVACCINES
seesection14.1;
alsoforlivevaccine
:Appendix1(vaccines)
Contra-indications
seenotesaboveandsection14.1
seep.600
seep.600
seenotesaboveandsection14.1
Indicationanddose
Seeunderpreparations
Combinedvaccines
SeeunderDiphtheria-containingVaccines
Inactivated(Salk)Vaccine
SeeunderDiphtheria-containingVaccines
Live(oral)(Sabin)vaccine
PoliomyelitisVaccine,Live(Oral)
Asuspensionofsuitableliveattenuatedstrainsof
poliomyelitisvirus,types1,2,and3.Availablein
single-doseand10-dosecontainers
includeneomycinandpolymyxinB
Controlofoutbreaks
Bymouth
Child1month–18years
3drops;maybegivenona
lumpofsugar;nottobegivenwithfoodswhichcontain
preservatives
Livepoliomyelitisvaccinelosespotencyoncethe
containerhasbeenopenedÑanyvaccineremainingatthe
endofanimmunisationsessionshouldbediscarded;
wheneverpossiblesessionsshouldbearrangedtoavoid
unduewastage.
Rabiesvaccine
Rabiesvaccinecontainsinactivatedrabiesvirusculti-
vatedineitherhumandiploidcellsorpuriÞedchick
embryocells;vaccinesareusedforpre-andpost-
exposureprophylaxis.
Pre-exposureprophylaxis
Immunisationshouldbe
offeredtochildrenathighriskofexposuretorabiesÑ
wherethereislimitedaccesstopromptmedicalcarefor
thoselivinginareaswhererabiesisenzootic,forthose
travellingtosuchareasforlongerthan1month,andfor
thoseonshortervisitswhomaybeexposedtounusual
risk.Transmissionofrabiesbyhumanshasnotbeen
recordedbutitisadvisedthatthosecaringforchildren
withthediseaseshouldbevaccinated.
Immunisationagainstrabiesisindicatedduring
pregnancyifthereissubstantialriskofexposureto
BNFC2011–
14.4Vaccinesandantisera
Immunologicalproductsandvaccines
rabiesandrapidaccesstopost-exposureprophylaxisis
likelytobelimited.
Up-to-datecountry-by-countryinformationontheinci-
denceofrabiescanbeobtainedfromtheNational
VirusReferenceDepartment,Colindale,London(tel.
(020)82004400)ortheCentreforInfections(tel.
(020)82006868),inScotlandfromHealthProtection
Scotland(tel.(0141)3001100),inNorthernIrelandfrom
thePublicHealthLaboratory,BelfastCityHospital(tel.
(028)90329241).
TherearenospeciÞccontra-indicationstotheuseof
rabiesvaccineforpost-exposureprophylaxisanditsuse
shouldbeconsideredwheneverachildhasbeen
attackedbyananimalinacountrywhererabiesis
enzootic,evenifthereisnodirectevidenceofrabies
intheattackinganimal.Becauseofthepotentialcon-
sequencesofuntreatedrabiesexposureandbecause
RABIESVACCINE
seesection14.1
Contra-indications
seesection14.1;butseealsoPost-
exposureManagementinnotesabove
seep.600
seep.600
seesection14.1;alsoreportedparesis
Indicationanddose
re-exposureimmunisationagainstrabies
Byintramuscularinjectionindeltoidregionor
anterolateralthighininfants
Child1month–18years
1mLondays0,7,and
21or28;forthoseatcontinuedriskgiveasingle
reinforcingdose1yearaftertheprimarycourseis
ROTAVIRUSVACCINE
seesection14.1;
diarrhoeaorvomiting
(postponevaccination);immunosuppressedclose
contacts(seenotesabove);
Appendix1
(vaccines)
Contra-indications
seesection14.1;alsopredisposi-
tionto,orhistoryof,intussusception
seesection14.1
Indicationanddose
mmunisationagainstgastro-enteritiscaused
byrotavirusinfection
Bymouth
Childover6weeks
2dosesof1.5mL,separated
byanintervalofatleast4weeks;courseshouldbe
Immunologicalproductsandvaccines
Rubellavaccine
Acombinedmeasles,mumpsandrubellavaccine(MMR
vaccine)aimstoeliminaterubella(Germanmeasles)
andcongenitalrubellasyndrome.MMRvaccineisused
forchildhoodvaccinationaswellasforvaccinating
adults(includingwomenofchild-bearingage)whodo
nothaveimmunityagainstrubellathecombinedlive
measles,mumpsandrubellavaccineisasuitablealter-
native.
Singleantigenvaccine
NolongeravailableintheUK;seeMMRvaccine,
p.612
Combinedvaccines
seeMMRvaccine
Smallpoxvaccine
Limitedsuppliesof
smallpoxvaccine
areheldatthe
SpecialistandReferenceMicrobiologyDivision,Health
ProtectionAgency(Tel.(020)82004400)fortheexclu-
siveuseofworkersinlaboratorieswherepoxviruses
(suchasvaccinia)arehandled.
Ifawideruseofthevaccineisbeingconsidered,
linesforsmallpoxresponseandmanagementinthe
post-eradicationera
shouldbeconsultedat
www.dh.gov.uk
Travelrecommendationsseesection14.6.
Contra-indications
Seesection14.1
seep.600
seep.600
Seesection14.1
Wounds
Combinedvaccines
SeeDiphtheria-containingVaccines
Tick-borneencephalitisvaccine
Tick-borneencephalitisvaccinecontainsinactivated
tick-borneencephalitisviruscultivatedinchickembyro
cells.Itisrecommendedforimmunisationofthose
livinginorvisitinghigh-riskareas(seeInternational
Travel,section14.6).Childrenwalkingorcampingin
warmforestedareasofCentralandEasternEurope,
Scandinavia,NorthernandEasternChina,andsome
partsofJapan,particularlyfromApriltoNovember
whenticksaremostprevalent,areatgreatestriskof
BNFC2011–
14.4Vaccinesandantisera
Immunologicalproductsandvaccines
tick-borneencephalitis.Forfullprotection,3dosesof
thevaccinearerequired;boosterdosesarerequired
every3Ð5yearsforthosestillatrisk.Ideally,immuni-
TICK-BORNEENCEPHALITIS
VACCINE,INACTIVATED
seesection14.1
Contra-indications
seesection14.1
seep.600
seep.600
seesection14.1
Indicationanddose
mmunisationagainsttick-borneencephalitis
Byintramuscularinjectionindeltoidregionor
anterolateralthighininfants
Child1–16years
initialimmunisation,3dosesof
0.25mL,seconddoseafter1Ð3monthsandthird
doseafterafurther5Ð12months
hild16–18years
3doseseachof0.5mL,sec-
onddoseafter1Ð3monthsandthirddoseafter
further5Ð12months
Immunocompromised(includingthosereceiving
immunosuppressants),antibodyconcentration
maybemeasured4weeksafterseconddoseand
doserepeatedifprotectivelevelsnotachieved
Toachievemorerapidprotection,seconddosemay
begiven14daysafterÞrstdose.
Boosterdoses,giveÞrstdosewithin3yearsafter
initialcourse,thenevery3Ð5years
TicoVac
(MASTA)
,suspension,formaldehyde-inactivated
rßtick-borneencephalitisvirusstrain,(culti-
vatedinchickembryocells)adsorbedontohydrated
TYPHOIDVACCINE
section14.1;
:seeaboveand
Appendix1(vaccines)
Contra-indications
section14.1;alsofor
vaccine,
acutegastro-intestinalillness
seep.600
seep.600
section14.1
Indicationanddose
mmunisationagainsttyphoidfever
Fordoseseeunderpreparations
Typhoidpolysaccharidevaccineforinjection
Typherix
,Vicapsularpolysaccharidetyphoid
vaccine,50micrograms/mLvirulencepolysaccharide
antigenof
Salmonellatyphi
PolysaccharidevaccinewithhepatitisAvaccine
SeeHepatitisAVaccine
14.4Vaccinesandantisera
BNFC2011–
Immunologicalproductsandvaccines
Typhoidvaccine,live(oral)
(Crucell)
Capsules
,e/c,liveattenuated
Salmonellatyphi
VARICELLA–ZOSTERVACCINES
seesection14.1;alsopost-vaccinationclose-
contactwithsusceptibleindividuals(seenotesabove):
Appendix1(vaccines)
Contra-indications
seesection14.1
avoidpregnancyfor3monthsafter
vaccination;seealsop.600
seep.600
seesection14.1;
varicella-likerash;
thrombocytopenia
Indicationanddose
mmunisationagainstvaricellainfection
notesabove)
Fordose,seeunderpreparations
Varilrix
,powderforreconstitution,liveattenuated
varicellaÐzostervirus(Okastrain)propagatedin
YELLOWFEVERVACCINE
seesection14.1;alsosee
Appendix1(vaccines)
Contra-indications
seesection14.1andnotesabove;
alsochildrenunder6months;historyofthymus
seenotesabove
seenotesabove
seesection14.1;
reportedneuro-
tropicdisease,andviscerotropicdisease(seenotes
Indicationanddose
mmunisationagainstyellowfever
Bydeepsubcutaneousinjection
Child9months–18years
0.5mL(seealsonotes
BNFC2011–
14.4Vaccinesandantisera
Immunologicalproductsandvaccines
YellowFeverVaccine,Live
Yel(live)
,powderforreconstitution,live,attenuated
17D-204strainofyellowfevervirus,cultivatedin
chickembryos;singledosevialwithsyringecontain-
ing0.5mLdiluent
Available(onlytodesignatedYellowFeverVaccinationcentres)as
Immunoglobulins
NormalImmunoglobulin
Disease-specicimmunoglobulins
Anti-D(Rh
)immunoglobulin
Twotypesofhumanimmunoglobulinpreparationare
available,
normalimmunoglobulin
Þcimmunoglobulins
Humanimmunoglobulinisasterilepreparationofcon-
centratedantibodies(immuneglobulins)recovered
frompooledhumanplasmaorserumobtainedfrom
outsidetheUK,testedandfoundnon-reactiveforhepat-
itisBsurfaceantigenandforantibodiesagainsthepatitis
CvirusandhumanimmunodeÞciencyvirus(types1and
2).Aglobalshortageofhumanimmunoglobulinandthe
rapidlyincreasingrangeofclinicalindicationsfortreat-
mentwithimmunoglobulinshasresultedintheneedfor
aDemandManagementprogrammeintheUK(for
furtherinformationconsult
www.ivig.nhs.uk
icalGuidelinesforImmunoglobulinUse
www.dh.gov.uk
Immunoglobulinsofanimalorigin(antisera)werefre-
quentlyassociatedwithhypersensitivityreactionsand
arenolongerused.
Furtherinformationontheuseofimmunoglobulinsis
includedintheHealthProtectionAgencyÕs
Immuno-
globulinHandbook
www.hpa.org.uk
andintheDepart-
mentofHealthÕspublication,
Immunisationagainst
InfectiousDisease
www.dh.gov.uk
Normalimmunoglobulin
forintramus-
cularadministrationisavailablefromsomeregional
HealthProtectionAgenciesandmicrobiologylabora-
toriesforprotectionofcontactsandthecontrolof
outbreaksofhepatitisA,measles,andrubellaonly.For
otherindications,subcutaneousorintravenousnormal
immunoglobulinshouldbepurchasedfromthemanu-
facturer.
Disease-speciÞcimmunoglobulins
(section14.5.2)
areavailablefromsomeregionalHealthProtection
Agenciesandmicrobiologylaboratorieswiththeexcep-
tionof
InScotlandallimmunoglobulinsareavailablefromthe
ScottishNationalBloodTransfusionService
NormalImmunoglobulin
normalimmunoglobulin
(ÔHNIGÕ)isprepared
frompoolsofatleast1000donationsofhumanplasma;
itcontainsimmunoglobulinG(IgG)andantibodiesto
hepatitisA,measles,mumps,rubella,varicella,and
othervirusesthatarecurrentlyprevalentinthegeneral
Normalimmunoglobulinmay
interferewiththe
immuneresponsetolivevirusvaccines
whichshould
thereforeonlybegiven
atleast3weeksbeforeor3
monthsafter
aninjectionofnormalimmunoglobulin
(thisdoesnotapplytoyellowfevervaccinesince
normalimmunoglobulindoesnotcontainantibodyto
thisvirus).
Normalimmunoglobulin(containing10Ð18%
protein)isadministeredby
intramuscularinjection
theprotectionofsusceptiblecontactsagainst
virus(infectioushepatitis),
and,toalesser
rubella
.Injectionofimmunoglobulinproduces
immediateprotectionlastingforseveralweeks.
Normalimmunoglobulin(containing3Ð12%protein)for
intravenousadministration
isusedas
replacementther-
forchildrenwithcongenitalagammaglobulinaemia
andhypogammaglobulinaemia,andfortheshort-term
treatmentofidiopathicthrombocytopenicpurpuraand
Kawasakisyndrome;itisalsousedfortheprophylaxisof
infectionfollowingbone-marrowtransplantationandin
childrenwithsymptomaticHIVinfectionwhohave
recurrentbacterialinfections.Normalimmunoglobulin
forreplacementtherapymayalsobegivenintramuscu-
larlyorsubcutaneously,butintravenousformulations
arenormallypreferred.Intravenousimmunoglobulinis
alsousedinthetreatmentofGuillain-Barre
syndromeas
analternativetoplasmaexchange.
Thedoseofnormalimmunoglobulinusedasreplace-
menttherapyinpatientswithimmunodeÞcienciesis
thesame
asthedoserequiredfortreatmentofacute
conditions.ForKawasakisyndromeasingledoseof2g/
kgbyintravenousinfusionshouldbegivenwithcon-
Immunologicalproductsandvaccines
pressed;normalimmunoglobulinshouldbegivenas
soonaspossible,preferablywithin14daysofexposure
totheprimarycase.However,normalimmunoglobulin
canstillbegiventocontactsatriskofseverediseaseup
to28daysafterexposuretotheprimarycase.Hepatitis
Avaccinecanbegivenatthesametime,butitshouldbe
givenataseparateinjectionsite.
Intravenousorsubcutaneousnormal
immunoglobulinmaybegiventopreventorattenuate
anattackofmeaslesinchildrenwithcompromised
immunity.Childrenwithcompromisedimmunitywho
havecomeintocontactwithmeaslesshouldreceive
intravenousorsubcutaneousnormalimmunoglobulin
assoonaspossibleafterexposure.Itismosteffectiveif
givenwithin72hoursbutcanbeeffectiveifgivenwithin
6days.
Subcutaneousorintramuscularnormalimmunoglobulin
shouldalsobeconsideredforthefollowingindividualsif
theyhavebeenincontactwithaconÞrmedcaseof
measlesorwithapersonassociatedwithalocalout-
non-immunepregnantwomen
infantsunder9months
FurtheradviceshouldbesoughtfromtheCentrefor
Infections,HealthProtectionAgency(tel.(020)8200
Childrenwithnormalimmunitywhoarenotinthe
abovecategoriesandwhohavenotbeenfullyimmu-
nisedagainstmeasles,canbegivenMMRvaccine
(section14.4)forprophylaxisfollowingexposureto
measles.
Intramuscularimmunoglobulinafterexposure
torubelladoes
preventinfectioninnon-immune
contactsandis
recommendedforprotectionof
pregnantfemalesexposedtorubella.Itmay,however,
reducethelikelihoodofaclinicalattackwhichmay
NORMALIMMUNOGLOBULIN
hypo-oragammaglobulinaemiawithor
withoutIgAdeÞciency;interferencewithlivevirus
vaccinesÑseep.622
Intravenoususe
Thrombophilicdisorders,orriskfactorsfor
arterialorvenousthromboembolicevents;obesity;ensure
adequatehydration,renalinsufÞciency
Contra-indications
patientswithselectiveIgAdeÞ-
ciencywhohaveknownantibodyagainstIgA
Renalimpairment
monitorforacuterenalfailure;
Forintramuscularuse
NormalImmunoglobulin
Normalimmunoglobulininjection.250-mgvial;750-
mgvial
TocontroloutbreaksofhepatitisA
(seenotesabove)
Bydeepintramuscularinjection
Childunder10years
250mg
Child10–18years
500mg
Rubellainpregnancy,preventionofclinicalattack
Bydeepintramuscularinjection
750mg
AvailablefromtheCentreforInfectionsandotherregionalHealth
ProtectionAgencyofÞces(forcontactsandcontrolofoutbreaks
only,seeabove)
Forsubcutaneoususe
Preparationsforsubcutaneoususemaybeadminis-
teredbyintramuscularinjectionifsubcutaneousroutenot
possible;intramuscularroutenotrecommendedforpatients
withthrombocytopeniaorotherbleedingdisorders
Gammanorm
Normalimmunoglobulin(protein16.5%)injection,
Immunologicalproductsandvaccines
Normalimmunoglobulin(protein14Ð18%)injection,
HealthProtectionAgencyrecommendsintramuscularusefor
prophylaxisagainstHepatitisA,orrubella
(CSLBehring)
Forintravenoususe
DoserecommendationforKawasakiSydrome,see
section14.5.1;otherindicationsÑconsultproductliterature
fordosageregimens
Flebogamma
Intravenousinfusion
,humannormalimmunoglobu-
HEPATITISBIMMUNOGLOBULIN
IgAdeÞciency;interferencewithlivevirus
vaccinesÑseeunderNormalImmunoglobulin,p.622
injectionsiteswellingandpain,arthr-
rarely
anaphylaxischesttightness,dyspnoea;
alsoreportedtremor,dizziness,facialoedema,glos-
sitis,andbuccalulceration;forside-effectsassociated
intravenous
immunoglobulins,seesection14.5.1
Indicationanddose
Seeunderpreparationsandseealsonotesabove
HepatitisBImmunoglobulin
,hepatitisB-speciÞcimmunoglobulin,
100units/mL.Vialscontaining200unitsor500units,
availablefromselectedHealthProtectionAgencyand
14.5.2Disease-specicimmunoglobulins
BNFC2011–
Immunologicalproductsandvaccines
NHSlaboratories(exceptforTransplantCentres,see
p.622),alsoavailablefromBPL
ProphylaxisagainsthepatitisBinfection
Byintramuscularinjection
(assoonaspossibleafterexposure;ideallywithin48
hours,butnolaterthan7daysafterexposure)
Child1month–5years
200units
Child5–10years
300units
Child10–18years
500units
Preventionoftransmittedinfectionatbirth
Byintramuscularinjection
200unitsassoonaspossibleafterbirth;forfull
RABIESIMMUNOGLOBULIN
IgAdeÞciency;interferencewithlivevirus
vaccinesÑseep.622underNormalImmunoglobulin
injectionsiteswellingandpain;
anaphylaxis;buccalulceration,glossitis,chesttight-
ness,dyspnoea,tremor,dizziness,arthralgia,and
facialoedemaalsoreported
Indicationanddose
ost-exposureprophylaxisagainstrabies
Byintramuscularinjection
20units/kg,
byinÞltration
inandaroundthe
cleansedwound;ifthewoundnotvisibleorhealed
orifinÞltrationofwholevolumenotpossible,give
byintramuscularinjection
intoantero-
lateralthigh(remotefromvaccinationsite)
Thepotencyofindividualbatchesofrabiesimmuno-
globulinfromthemanufacturermayvary;potencymayalso
bedescribeddifferentlybydifferentmanufacturers.Itis
thereforecriticaltoknowthepotencyofthebatchtobeused
andtheweightofthepatientinordertocalculatethespeciÞc
volumerequiredtoprovidethenecessarydose
RabiesImmunoglobulin
(AntirabiesImmunoglobulinInjection)
Seenotesabove
AvailablefromSpecialistandReferenceMicrobiologyDivision,
HealthProtectionAgency(seesection14.5underAvailability)
(alsofromBPL)
Varicella–zoster
VaricellaÐzosterimmunoglobulin
(VZIG)isrecom-
mendedforindividualswhoareatincreasedriskof
severevaricella
whohavenoantibodiestovari-
cellaÐzostervirus
whohavesigniÞcantexposureto
chickenpoxorherpeszoster.Thoseatincreasedrisk
neonateswhosemothersdevelopchickenpoxinthe
period7daysbeforeto7daysafterdelivery;
susceptibleneonatesexposedintheÞrst7daysof
susceptibleneonatesorinfantsexposedwhilst
requiringintensiveorprolongedspecialcarenur-
susceptiblewomenexposedatanystageof
pregnancy(butwhensuppliesofVZIGareshort,
mayonlybeissuedtothoseexposedintheÞrst20
weeksÕgestationortothosenearterm)providing
VZIGisgivenwithin10daysofcontact;
BNFC2011–
14.5.2Disease-specicimmunoglobulins
Immunologicalproductsandvaccines
immunocompromisedindividualsincludingthose
whohavereceivedcorticosteroidsintheprevious
3monthsatthefollowingdoseequivalentsofpred-
children
2mg/kgdaily(ormorethan
40mg)foratleast1weekor1mg/kgdailyfor1
Important:
VARICELLA–ZOSTER
IMMUNOGLOBULIN
IgAdeÞciency;interferencewithlivevirus
vaccinesÑseep.622underNormalImmunoglobulins
injectionsiteswellingandpain;
anaphylaxis
Indicationanddose
rophylaxisagainstvaricellainfection(assoon
aspossibleÑnotlaterthan10daysafter
exposure)
Bydeepintramuscularinjection
250mg
Child1month–6years
250mg
hild6–11years
500mg
hild11–15years
750mg
hild15–18years
Giveseconddoseiffurtherexposureoccursmore
than3weeksafterÞrstdose
Noevidencethateffectiveintreatmentofsevere
disease.
Normalimmunoglobulinforintravenoususe(section14.5.1)
maybeusedinthoseunabletoreceiveintramuscular
Varicella–ZosterImmunoglobulin
(AntivaricellaÐzosterImmunoglobulin)
AvailablefromselectedHealthProtectionAgencyandNHS
laboratories(seesection14.5underAvailability)(alsofrom
Anti-D(Rh
immunoglobulin
Thissectionisnotincludedin
BNFforChildren
.See
BNFforuseofAnti-D(Rh
)immunoglobulin
Internationaltravel
Foradviceon
malariachemoprophylaxis
,seesection
Nospecialimmunisationisrequiredfortravellerstothe
UnitedStates,Europe,Australia,orNewZealand
Listofcountrieswheretheincidenceoftuberculosisis
greaterthan40casesper100000isavailableat
www.hpa.org.uk
14.5.3Anti-D(Rh
)immunoglobulin
BNFC2011–
Immunologicalproductsandvaccines
riskisgreatest(e.g.refugeecamps).Regardlessof
vaccination,travellerstoareaswherecholeraisende-
micshouldtakespecialcarewithfoodhygiene(see
Adviceon
diphtheria
,on
Japaneseencephalitis
(vaccineavailableonnamed-patientbasisfrom
MASTA)andon
tick-borneencephalitis
isincluded
HealthInformationforOverseasTravel
,seebelow.
Foodhygiene
Inareaswheresanitationispoor,good
foodhygieneisimportanttohelppreventhepatitisA,
typhoid,cholera,andotherdiarrhoealdiseases(includ-
ingtravellersÕdiarrhoea).Foodshouldbefreshlypre-
Immunisationrequirementschangefromtimetotime,
andinformationonthecurrentrequirementsforany
particularcountrymaybeobtainedfromtheembassyor
legationoftheappropriatecountryorfrom:
Tel:(028)90522118
(weekdays)
Japaneseencephalitisvaccinenotprescribableonthe
NHS;healthauthoritiesmayinvestigatecircumstances
underwhichvaccineprescribed
BNFC2011–
14.6Internationaltravel
Immunologicalproductsandvaccines
Generalanaesthesia
Anaesthesia
tousfallinbloodpressureunlesscorticosteroidcoveris
providedduringanaesthesiaandintheimmediatepost-
Anaesthesia,sedation,and
resuscitationindentalpractice
Drugsusedforintravenousanaesthesia
seenotesabove;alsonausea,vomiting,
hypotension,apnoea,hyperventilation,stridor,rash;
lesscommonly
hypersalivation,bradycardia,arrhyth-
mias,hypertension,hiccups,cough,phlebitis;AV
block,cardiacarrest,respiratorydepression,seizures,
shivering,andStevens-Johnsonsyndromealso
Indicationanddose
Seeunderpreparations
Anaesthesia
Child1month–12years
1Ð2mg/kgproduces5Ð
10minutesofsurgicalanaesthesia,adjusted
accordingtoresponse
hild12–18years
1Ð4.5mg/kgadjusted
accordingtoresponse(2mg/kgusuallyproduces
5Ð10minutesofsurgicalanaesthesia)
Byintramuscularinjection
4mg/kgusuallyproduces15minutesof
surgicalanaesthesia,adjustedaccordingto
Child1month–18years
4Ð13mg/kg(4mg/kg
sufÞcientforsomediagnosticprocedures),
adjustedaccordingtoresponse;10mg/kgusually
produces12Ð25minutesofsurgicalanaesthesia
nductionandmaintenanceofanaesthesia
(longerprocedures)
Byintravenousadministration
initially0.5Ð2mg/kgby
intravenous
injection
,followedbya
continuousintravenous
of8micrograms/kg/minuteadjusted
accordingtoresponse;upto30micrograms/kg/
minutemaybeusedtoproducedeepanaesthesia
Child1month–18years
initially0.5Ð2mg/kgby
intravenousinjection
followedbya
intravenousinfusion
of10Ð45micrograms/kg/
minuteadjustedaccordingtoresponse
continuousintravenousinfusion
dilutetoaconcentrationof1mg/mLwithGlucose5%
SodiumChloride0.9%;usemicrodripinfusionfor
maintenanceofanaesthesia
For
intravenousinjection
,dilute100mg/mLstrength
toaconcentrationofnotmorethan50mg/mLwith
Glucose5%
SodiumChloride0.9%
seenotesabove;cardiacimpairment;resp-
iratoryimpairment;hypovolaemia;epilepsy;hypo-
tension;raisedintracranialpressure;monitorblood-
lipidconcentrationifriskoffatoverloadorifsedation
longerthan3days;
Appendix1
aintenanceofsedationforsurgicalanddiag-
nosticproceduresusing1%injection
Byintravenousinfusion
Child1month–18years
doseandrateof
administrationadjustedaccordingtodesiredlevel
ofsedationandresponse;usualdoseinchild
1monthÐ17years1.5Ð9mg/kg/hour(additionally,
ifrapidincreaseinsedationrequired,
byslow
intravenousinjection
,max.1mg/kg);usualdose
inchild17Ð18years1.5Ð4.5mg/kg/hour(addi-
tionally,ifrapidincreaseinsedationrequired,
slowintravenousinjection
,10Ð20mg)
aintenanceofsedationforsurgicalanddiag-
nosticproceduresusing2%injection
Byintravenousinfusion
Child3–18years
doseandrateofadministration
adjustedaccordingtodesiredlevelofsedationand
response;usualdoseinchild3Ð17years1.5Ð9mg/
kg/hour;usualdoseinchild17Ð18years1.5Ð
4.5mg/kg/hour(additionally,ifrapidincreasein
sedationrequired,
byslowintravenousinjection
using0.5%or1%injection,10Ð20mg)
continuousintravenousinfusion
microbiologicalÞlternotrecommended;
maybeinfusedundilutedusingasuitable
infusionpump;mayalsobeadministeredviaaY-
piececlosetoinjectionsiteco-administeredwith
Glucose5%
SodiumChloride0.9%;
alternatively
dilutetoaconcentrationnotlessthan2mg/mL
(1mg/mLfor0.5%injection)withGlucose5%(
SodiumChloride0.9%for
Propofol-Lipuro
Propoven
,Braun,andFreseniusKabibrands);use
glassorPVCcontainers(ifPVCbagused,itshouldbe
fullÑwithdrawvolumeofinfusionßuidequaltothat
ofpropofoltobeadded);givewithin6hoursof
2%emulsion
donotdilute;maybeadministeredviaa
Y-piececlosetoinjectionsiteco-administeredwith
Glucose5%
SodiumChloride0.9%
THIOPENTALSODIUM
(Thiopentonesodium)
seenotesabove;cardiovasculardisease;
reconstitutedsolutionishighlyalkalineÑextravasa-
tioncausestissuenecrosisandseverepain;avoid
intra-arterialinjection;
Appendix1
Anaesthesia
gas.Topreventhypoxia,theinspiredgasmixtureshould
containaminimumof25%oxygenatalltimes.Higher
concentrationsofoxygen(greaterthan30%)areusually
requiredduringinhalationalanaesthesiawithnitrous
oxide,seeNitrousOxide,p.634.
Anaesthesiaandskilledtasks
Seesection15.1.
seenotesabove;
Appendix1
HALOTHANE
seenotesabove(
important:
seeHalothane
Hepatoxicityabove);avoidfordentalproceduresin
thoseunder18yearsunlesstreatedinhospital(high
riskofarrhythmia);avoidinacuteporphyria(section
breast-feedingcanberesumedas
soonasmotherhasrecoveredsufÞcientlyfrom
seenotesabove
Indicationanddose
nductionofanaesthesia
ByinhalationthroughspeciÞcallycalibrated
Child1month–18years
initially0.5%then
increasedgraduallyaccordingtoresponseto2Ð5%
inoxygenornitrousoxide-oxygen
aintenanceofanaesthesia
ByinhalationthroughspeciÞcallycalibrated
Child1month–18years
0.5Ð2%inoxygen,or
oxygen-air,ornitrousoxide-oxygen
ISOFLURANE
seenotesabove;
Appendix1
SEVOFLURANE
seenotesabove;susceptibilitytoQT-inter-
valprolongation;
Appendix1(anaes-
leucopenia,agitation;cardiacarrest,torsadede
pointes,dystonia,andseizuresalsoreported
Indicationanddose
nductionofanaesthesia
ByinhalationthroughspeciÞcallycalibrated
upto4%inoxygenornitrousoxide-
oxygen,accordingtoresponse
Child1month–18years
initially0.5Ð1%then
increasedgraduallyupto8%inoxygenornitrous
oxide-oxygen,accordingtoresponse
aintenanceofanaesthesia
ByinhalationthroughspeciÞcallycalibrated
0.5Ð2%inoxygenornitrousoxide-oxy-
gen,accordingtoresponse
Child1month–18years
0.5Ð3%inoxygenor
nitrousoxide-oxygen,accordingtoresponse
Nitrousoxide
Nitrousoxide
isusedformaintenanceofanaesthesia
Anaesthesia
NITROUSOXIDE
seenotesabove;
Appendix1
orhypersalivationinpalliativecareandinchildren
unabletocontrolpostureorwithabnormalswallowing
reßex;effectivedosevariesandtolerancemaydevelop.
Theintramuscularrouteshouldbeavoidedifpossible.
Hyoscinetransdermalpatchesmayalsobeused(sec-
tion4.6).
ATROPINESULPHATE
seenotesinsection1.2
Durationofaction
Sinceatropinehasashorterdurationof
actionthanneostigmine,lateunopposedbradycardiamay
result;closemonitoringofthepatientisnecessary
Contra-indications
seenotesinsection1.2
notknowntobeharmful;usewithcaution
smallamountpresentinmilkÑuse
withcaution
seenotesinsection1.2
Licenseduse
notlicensedforusebyoralroute;not
licensedforuseinchildrenunder12yearsforintra-
operativebradycardia;notlicensedforuseinchil-
drenunder12yearsbyintravenousrouteforpre-
medication;notlicensedforthecontrolofmus-
carinicside-effectsofedrophoniuminreversalof
ontrolofmuscarinicside-effectsofedro-
GLYCOPYRRONIUMBROMIDE
section1.2
Contra-indications
section1.2
section1.2
Licenseduse
notlicensedforuseincontrolofupper
Child1month–12years
10micrograms/kg
(max.500micrograms)
hild12–18years
200microgramsper1mgof
neostigmine,
10Ð15micrograms/kg
HYOSCINEHYDROBROMIDE
(Scopolaminehydrobromide)
seenotesinsection1.2andnotesabove;
alsoepilepsy
Contra-indications
seenotesinsection1.2
Hepaticimpairment
seeHyoscineHydrobromide,
section4.6
Renalimpairment
seeHyoscineHydrobromide,sec-
tion4.6
seeHyoscineHydrobromide,section4.6
seeHyoscineHydrobromide,section
seenotesinsection1.2
Indicationanddose
Bysubcutaneousorintramuscularinjection
30Ð60minutesbeforeinduction
Child1–12years
15micrograms/kg(max.
600micrograms)
hild12–18years
200Ð600micrograms
Samedosemaybegivenbyintravenousinjection
immediatelybeforeinduction
15.1.3Antimuscarinicdrugs
BNFC2011–
Anaesthesia
otionsickness,excessiverespiratorysecre-
tions,hypersalivationassociatedwithcloz-
apinetherapy
section4.6
Fortransdermalandoralpreparationsseesection4.6
Sedativeandanalgesic
peri-operativedrugs
Anxiolytics
Non-opioidanalgesics
Opioidanalgesics
Important
Thedrugsinthissectionshouldbeusedbyexperi-
encedpersonnelonly.
15.1.4.1
Anxiolytics
Benzodiazepines
Benzodiazepinespossessusefulpropertiesforpremedi-
lyticandsedativeeffectslastabout90minutes,although
theremayberesidualdrowsiness.Temazepamisrarely
usedfordentalproceduresinchildren.
producesmoreprolongedsedationthan
temazepamandithasmarkedamnesiceffects.
Peri-operativeuseof
diazepam
isnotrecommendedin
LORAZEPAM
seenotesaboveandsection4.8.2;
Appendix1(anxiolyticsandhypnotics)
Contra-indications
seeDiazepam,section4.8.2
Hepaticimpairment
seeBenzodiazepines,section
Renalimpairment
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seenotesaboveandDiazepam,section
Licenseduse
notlicensedforuseinchildrenunder5
yearsbymouth;notlicensedforuseinchildren
under12yearsbyintravenousinjection
Indicationanddose
Bymouth
Child1month–12years
50Ð100micrograms/kg
(max.4mg)atleast1hourbeforeprocedure
hild12–18years
1Ð4mgatleast1hourbefore
procedure
Samedosemaybegiventhenightbeforeprocedure
inadditionto,ortoreplace,dosebeforeprocedure
Byintravenousinjection
Child1month–18years
50Ð100micrograms/kg
(max.4mg)
Giveintravenousinjection30Ð45minutesbefore
procedure
tatusepilepticus
section4.8.2
intravenousinjection
,dilute
injectionsolutionwithanequalvolumeofSodium
Chloride0.9%;giveover3Ð5minutes;max.rate
50micrograms/kgover3minutes
Extemporaneousformulationsavailablesee
ExtemporaneousPreparations,p.6
seenotesabove;cardiacdisease;respiratory
disease;myastheniagravis;neonates;historyofdrug
oralcoholabuse;reducedoseifdebilitated;riskof
severehypotensioninchildrenwithhypovolaemia,
vasoconstriction,hypothermia;avoidprolonged
use(andabruptwithdrawalthereafter);
Appendix1(anxiolyticsandhypnotics)
Contra-indications
markedneuromuscularrespir-
atoryweaknessincludingunstablemyastheniagravis;
severerespiratorydepression;acutepulmonary
insufÞciency
Hepaticimpairment
usewithcaution;canprecipitate
Renalimpairment
startwithsmalldosesinsevere
impairment;increasedcerebralsensitivity
avoidregularuse(riskofneonatalwith-
drawalsymptoms);useonlyifclearindicationsuchas
seizurecontrol(highdosesduringlatepregnancyor
labourmaycauseneonatalhypothermia,hypotonia,
andrespiratorydepression)
presentinmilkÑavoidbreast-feeding
for24hoursafteradministration
seenotesabove;gastro-intestinaldistur-
Anaesthesia
(butseenotesabove)
Bymouth
Child1month–18years
500micrograms/kg
(max.20mg)15Ð30minutesbeforetheprocedure
Byrectum
Child6months–12years
300Ð500micrograms/
kg15Ð30minutesbeforeinduction
nductionofanaesthesia
(butrarelyused)
Byslowintravenousinjection
Child7–18years
initially150micrograms/kg
(max.7.5mg)giveninstepsof50micrograms/kg
(max.2.5mg)over2Ð5minutes;waitfor2Ð5
minutesthengiveadditionaldosesof50micr-
ograms/kg(max.2.5mg)every2minutesif
necessary;max.totaldose500micrograms/kg
(notexceeding25mg)
edationinintensivecare
Byintravenousinjectionandcontinuousintra-
venousinfusion
eonatelessthan32weeksgestationalage
60micrograms/kg/hour
bycontinuousintra-
venousinfusion
,reducedafter24hoursto
30micrograms/kg/hour;adjustedaccordingto
response;max.treatmentduration4days
eonateover32weeksgestationalage
60micrograms/kg/hour
bycontinuousintra-
venousinfusion
adjustedaccordingtoresponse;
max.treatmentduration4days
Child1–6months
60micrograms/kg/hour
continuousintravenousinfusion
adjustedaccord-
ingtoresponse
hild6months–12years
initially50Ð200micr-
byslowintravenousinjection
overat
least3minutesfollowedby30Ð120micrograms/
bycontinuousintravenousinfusion
adjustedaccordingtoresponse
hild12–18years
initially30Ð300micrograms/
byslowintravenousinjection
giveninstepsof
1Ð2.5mgevery2minutesfollowedby30Ð
200micrograms/kg/hour
bycontinuousintra-
venousinfusion
adjustedaccordingtoresponse
Initialdosemaynotberequiredandlowermain-
tenancedosesneededifopioidanalgesicsalsoused;
reducedose(orreduceoromitinitialdose)inhypovol-
aemia,vasoconstriction,orhypothermia
tatusepilepticus
section4.8.2
foradministration
bymouth
,injection
solutionmaybedilutedwithappleorblackcurrant
juice,chocolatesauce,orcola
For
buccaladministration
,administerhalfofthedose
thevolumetobegivenrectallyistoosmall,dilutewith
WaterforInjections
Midazolam
TEMAZEPAM
seenotesaboveandDiazepam,section
Appendix1(anxiolyticsandhyp-
Contra-indications
seeDiazepam,section4.8.2
Hepaticimpairment
seeBenzodiazepines,section
Renalimpairment
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seeBenzodiazepines,section4.8.1
seenotesaboveandDiazepam,section
Licenseduse
15.1.4.2
Non-opioidanalgesics
Sincenon-steroidalanti-inßammatorydrugs(NSAIDs)
donotdepressrespiration,donotimpairgastro-intes-
tinalmotility,anddonotcausedependence,theymay
beusefulalternativesoradjunctstoopioidsfortherelief
ofpostoperativepain.NSAIDsmaybeinadequatefor
thereliefofseverepain.
BNFC2011–
15.1.4Sedativeandanalgesicperi-operativedrugs
(section10.1.1),
Toradol
(Roche)
15.1.4.3
Opioidanalgesics
Opioidanalgesicsarenowrarelyusedaspremedicants;
theyaremorelikelytobeadministeredatinduction.
Pre-operativeuseofopioidanalgesicsisgenerallylim-
itedtochildrenwhorequirecontrolofexistingpain.The
mainside-effectsofopioidanalgesicsarerespiratory
depression,cardiovasculardepression,nausea,and
vomiting;forgeneralnotesonopioidanalgesicsand
theiruseinpostoperativepain,seesection4.7.2.
Forthemanagementofopioid-inducedrespiratory
depression,seesection15.1.7.
Intra-operativeanalgesia
Opioidanalgesicsgivenin
smalldosesbeforeorwithinductionreducethedose
requirementofsomedrugsusedduringanaesthesia.
,and
remifentanil
areparticularly
usefulbecausetheyactwithin1Ð2minutesandhave
shortdurationsofaction.Theinitialdosesofalfentanil
orfentanylarefollowedeitherbysuccessiveintra-
venousinjectionsorbyanintravenousinfusion;pro-
longedinfusionsincreasethedurationofeffect.
Repeatedintra-operativedosesofalfentanilorfentanyl
shouldbegivenwithcaresincetheresultingrespiratory
depressioncanpersistpostoperativelyandoccasionally
itmaybecomeapparentfortheÞrsttimepostopera-
tivelywhenmonitoringofthechildmightbelessinten-
sive.Alfentanil,fentanyl,andremifentanilcancause
musclerigidity,particularlyofthechestwallmuscleor
jawmuscle,whichcanbemanagedbytheuseofneuro-
muscularblockingdrugs.
ALFENTANIL
section4.7.2andnotesabove
Contra-indications
section4.7.2
Hepaticimpairment
section4.7.2
Renalimpairment
section4.7.2
section4.7.2
presentinmilkÑwithholdbreast-
feedingfor24hours
15.1.4Sedativeandanalgesicperi-operativedrugs
BNFC2011–
Anaesthesia
section4.7.2andnotesabove;also
hypertension,myoclonicmovements;
lesscommonly
arrhythmias,hiccup,laryngospasm;
alsoreportedcardiacarrest,cough,convulsions,and
pyrexia
Indicationanddose
Toavoidexcessivedosageinobesechildren,dosemay
needtobecalculatedonthebasisofidealweightfor
nalgesiaespeciallyduringshortprocedures;
enhancementofanaesthesia
Byintravenousinjectionover30seconds(with
assistedventilation)
initially5Ð20micrograms/kg;supple-
mentaldosesupto10micrograms/kg
Child1month–18years
initially10Ð20micr-
ograms/kg;supplementaldosesupto10micr-
Byintravenousinfusion(withassistedventila-
initially10Ð50micrograms/kgover10
minutesfollowedby0.5Ð1micrograms/kg/minute
Child1month–18years
initially50Ð100micr-
ograms/kgover10minutesfollowedby0.5Ð
1micrograms/kg/minute
continuousorintermittentintra-
venousinfusion
diluteinGlucose5%
Chloride0.9%
Alfentanil
FENTANYL
seeFentanyl,section4.7.2andnotesabove
Contra-indications
seenotesinsection4.7.2
Hepaticimpairment
seenotesinsection4.7.2
Renalimpairment
seenotesinsection4.7.2
seenotesinsection4.7.2
seeFentanyl,section4.7.2
seeFentanyl,section4.7.2andnotes
above;alsomyoclonicmovements;
lesscommonly
laryngospasm;
asystole,insomnia
Licenseduse
notlicensedforuseinchildrenunder2
years;infusionnotlicensedforuseinchildrenunder
12years
Indicationanddose
Toavoidexcessivedosageinobesechildren,dosemay
needtobecalculatedonthebasisofidealweightfor
pontaneousrespiration:analgesiaduring
operation,enhancementofanaesthesia
Byintravenousinjectionoveratleast30sec-
Child1month–12years
initially1Ð3micr-
ograms/kg,then1microgram/kgasrequired
hild12–18years
initially50Ð100micrograms
(max.200microgramsonspecialistadvice),then
25Ð50microgramsasrequired
ssistedventilation:analgesiaduringopera-
tion,enhancementofanaesthesia
Byintravenousinjectionoveratleast30sec-
initially1Ð5micrograms/kg,then1Ð
3micrograms/kgasrequired
Child1month–12years
initially1Ð5micr-
ograms/kg,then1Ð3micrograms/kgasrequired
hild12–18years
initially1Ð5micrograms/kg,
then50Ð200microgramsasrequired
ssistedventilation:analgesiaandrespiratory
depressioninintensivecare
Byintravenousadministration
initiallyby
intravenousinjection
5micrograms/kg,thenby
intravenousinfusion
1.5micrograms/kg/houradjustedaccordingto
Child1month–18years
initiallyby
intravenous
injection
1Ð5micrograms/kg,thenby
intravenous
,1Ð6micrograms/kg/houradjusted
accordingtoresponse
nalgesiainothersituations
section4.7.2
intravenousinfusion
,injection
solutionmaybedilutedinGlucose5%
Chloride0.9%
REMIFENTANIL
section4.7.2andnotesabove
Contra-indications
section4.7.2andnotesabove;left
ventriculardysfunction;analgesiainconscious
Hepaticimpairment
section4.7.2
noinformationavailable;seealsosection
avoidbreast-feedingfor24hoursafter
administrationÑpresentinmilkin
animal
section4.7.2andnotesabove;also
lesscommonly
hypoxia;
AVblockandconvulsionsalsoreported
BNFC2011–
15.1.4Sedativeandanalgesicperi-operativedrugs
Licenseduse
notlicensedforuseinchildrenunder1
year
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
nhancementandmaintenanceofanaesthesia
inventilatedpatients
Byintravenousadministration
intravenousinfusion
0.4Ð1micr-
ograms/kg/minute;additionaldosesof1micr-
ogram/kgcanbegivenby
intravenousinjection
duringtheintravenousinfusion
Child1month–12years
initiallyby
intravenous
injection
0.1Ð1micrograms/kgoveratleast30
seconds(omittedifnotrequired)thenby
intra-
venousinfusion
0.05Ð1.3micrograms/kg/minute
Anaesthesia
Benzylisoquinoliniumnon-depolarising
neuromuscularblockingdrugs(exceptcisatracurium)
areassociatedwithhistaminerelease,whichcan
causeskinßushing,hypotension,tachycardia,broncho-
spasm,andveryrarely,anaphylactoidreactions.Most
aminosteroidneuromuscularblockingdrugsproduce
minimalhistaminerelease.Drugswithvagolyticactivity
cancounteractanybradycardiathatoccursduring
surgery.Acutemyopathyhasalsobeenreportedafter
prolongeduseinintensivecare.
Atracurium
,amixtureof10isomers,isabenzylisoqui-
noliniumneuromuscularblockingdrugwithaninter-
mediatedurationofaction.Itundergoesnon-enzymatic
ATRACURIUMBESILATE
(Atracuriumbesylate)
seenotesabove
seenotesabove
seenotesabove
seenotesabove;seizuresalsoreported
Licenseduse
notlicensedforuseinneonates
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
euromuscularblockade(shorttointermediate
duration)forsurgery
Byintravenousadministration
initiallyby
intravenousinjection
500micrograms/kgfollowed
intravenous
injection
,100Ð200micrograms/kgrepeatedas
necessary
intravenousinfusion
,300Ð
400micrograms/kg/houradjustedaccordingto
Child1month–18years
initiallyby
intravenous
injection
300Ð600micrograms/kgthen100Ð
200micrograms/kgrepeatedasnecessary
initiallyby
intravenousinjection
200Ð600micr-
ograms/kgfollowedby
intravenousinfusion
,300Ð
600micrograms/kg/houradjustedaccordingto
euromuscularblockadeduringintensivecare
Byintravenousadministration
initiallyby
intravenousinjection
500micrograms/kgfollowed
intravenous
injection
,100Ð200micrograms/kgrepeatedas
necessary
intravenousinfusion
,300Ð
400micrograms/kg/houradjustedaccordingto
response;higherdosesmaybenecessary
Child1month–18years
initiallyby
intravenous
injection
300Ð600micrograms/kg(optional)then
intravenousinfusion
,270Ð1770micrograms/
kg/hour(usualdose650Ð780micrograms/kg/
continuousintravenousinfusion
dilutetoaconcentrationof0.5Ð5mg/mLwithGlu-
cose5%
SodiumChloride0.9%;stabilityvaries
withdiluent.
Neonatalintensivecare
,dilute60mg/kgbody-weight
toaÞnalvolumeof50mLwithGlucose5%orSodium
Chloride0.9%;minimumconcentrationof500micr-
ograms/mL,max.concentrationof5mg/mL;an
intravenousinfusionrateof0.1mL/hourprovidesa
doseof120micrograms/kg/hour
Atracurium
CISATRACURIUM
seenotesabove
seenotesabove
seenotesabove
seenotesabove;alsobradycardia
BNFC2011–
15.1.5Neuromuscularblockingdrugs
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
euromuscularblockade(intermediatedura-
tion)duringsurgery
Byintravenousinjection
Child1month–2years
initially150micrograms/
kg,then30micrograms/kgrepeatedapprox.every
20minutesasnecessary
hild2–12years
initially150micrograms/kg
(80Ð100micrograms/kgifnotforintubation),then
20micrograms/kgrepeatedapprox.every10
minutesasnecessary
hild12–18years
initially150micrograms/kg,
then30micrograms/kgrepeatedapprox.every20
minutesasnecessary
Byintravenousadministration
Child2–18years
initially150micrograms/kgby
intravenousinjection
,thenby
intravenousinfu-
180micrograms/kg/hour,reducedto60Ð
120micrograms/kg/houraccordingtoresponse
continuousintravenousinfusion
dilutetoaconcentrationof0.1Ð2mg/mLwithGlu-
cose5%
SodiumChloride0.9%;solutionsof2mg/
mLand5mg/mLmaybeinfusedundiluted
MIVACURIUM
seenotesabove;lowplasmacholinesterase
Hepaticimpairment
reducedoseinsevereimpair-
Renalimpairment
clinicaleffectprolongedinrenal
failureÑreducedoseaccordingtoresponse
seenotesabove
seenotesabove
seenotesabove
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
euromuscularblockade(shortduration)dur-
ingsurgery
Byintravenousadministration
Child2–6months
intravenousinjection
ally150micrograms/kg,then
venousinjection
100micrograms/kgrepeated
every6Ð9minutesasnecessary
intravenous
,8Ð10micrograms/kg/minute,adjustedif
necessaryevery3minutesby1microgram/kg/
minutetousualdose11Ð14micrograms/kg/min-
hild6months–12years
intravenousinjec-
initially200micrograms/kg,then
intravenousinjection
100micrograms/kg
repeatedevery6Ð9minutesasnecessary
intravenousinfusion
,8Ð10micrograms/kg/min-
ute,adjustedifnecessaryevery3minutesby
1microgram/kg/minutetousualdose11Ð
14micrograms/kg/minute
hild12–18years
intravenousinjection
ally70Ð250micrograms/kg,then
venousinjection
100micrograms/kgrepeated
every15minutesasnecessary
intravenous
,8Ð10micrograms/kg/minute,adjustedif
necessaryevery3minutesby1microgram/kg/
minutetousualdoseof6Ð7micrograms/kg/min-
intravenousinjection
,giveundi-
lutedordiluteinGlucose5%
SodiumChloride
0.9%.Dosesupto150micrograms/kgmaybegiven
over5Ð15seconds,higherdosesshouldbegivenover
30seconds.Inasthma,cardiovasculardiseaseorin
thosesensitivetoreducedarterialbloodpressure,
giveover60seconds.
PANCURONIUMBROMIDE
seenotesabove
Hepaticimpairment
ROCURONIUMBROMIDE
seenotesabove
Hepaticimpairment
reducedose
Renalimpairment
reducemaintenancedose;pro-
longedparalysis
seenotesabove
seenotesabove
15.1.5Neuromuscularblockingdrugs
BNFC2011–
Anaesthesia
seenotesabove
Licenseduse
notlicensedforuseinchildrenfor
assistedventilationinintensivecare
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
euromuscularblockade(intermediatedura-
tion)duringsurgery
Byintravenousadministration
Child1month–18years
initiallyby
intravenous
injection
600micrograms/kg,then
intravenousinjection
,150micrograms/kg
repeatedasrequired
intravenousinfusion
300Ð600micrograms/kg/houradjustedaccording
toresponse
ssistedventilationinintensivecare
Byintravenousadministration
Child1month–18years
initiallyby
intravenous
injection
600micrograms/kg(optional),thenby
intravenousinfusion
,300Ð600micrograms/kg/
hourforÞrsthour,thenadjustedaccordingto
continuousintravenousinfusion
orviadriptubing,maybedilutedwithGlucose5%
SodiumChloride0.9%
VECURONIUMBROMIDE
seenotesabove
Hepaticimpairment
cautioninsigniÞcantimpair-
Renalimpairment
cautioninrenalfailure
seenotesabove
seenotesabove
seenotesabove
Licenseduse
notlicensedforassistedventilationin
intensivecare
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
euromuscularblockade(intermediatedura-
tion)duringsurgery
Byintravenousadministration
intravenousinjection
initially
80micrograms/kg,then30Ð50micrograms/kg
adjustedaccordingtoresponse
Child1month–18years
intravenousinjection
initially80Ð100micrograms/kg,then
intravenousinjection
,20Ð30micrograms/kg
repeatedasrequired
intravenousinfusion
0.8Ð1.4micrograms/kg/minute,adjustedaccord-
ingtoresponse
ssistedventilationinintensivecare
Byintravenousinjection
initially80micrograms/kg,then30Ð
50micrograms/kgadjustedaccordingtoresponse
Byintravenousadministration
intravenousinjection
80micrograms/
kg,thenby
intravenousinfusion
,0.8Ð1.4micr-
ograms/kg/minute,adjustedaccordingto
response(riskofaccumulationÑconsiderinter-
ruptionofinfusion)
Child1month–18years
initiallyby
intravenous
injection
80Ð100micrograms/kg(optional),then
intravenousinfusion
0.8Ð1.4micrograms/kg/
minute,adjustedaccordingtoresponse;upto
3micrograms/kg/minutemayberequired
reconstituteeachvialwith5mL
WaterforInjectionstogive2mg/mLsolution;
reconstitutewithupto10mLGlucose5%
SodiumChloride0.9%
WaterforInjectionsÑ
unsuitableforfurtherdilutionifnotreconstitutedwith
WaterforInjections.
For
continuousintravenousinfusion
,dilutereconsti-
tutedsolutiontoaconcentrationupto40micr-
ograms/mLwithGlucose5%
SodiumChloride
0.9%;reconstitutedsolutioncanalsobegivenviadrip
tubing.
Neonatalintensivecare
,reconstituteeachvialwith
5mLWaterforInjectionstogivea2mg/mLsolution.
Dilute5mg/kgbody-weighttoaÞnalvolumeof
50mLwithGlucose5%orSodiumChloride0.9%;an
intravenousinfusionrateof0.5mL/hourprovidesa
doseof50micrograms/kg/hour;minimumconcen-
trationof40micrograms/mL
Norcuron
,powderforreconstitution,vecuronium
andiscausedbythedevelopmentofanon-depolarising
blockfollowingtheinitialdepolarisingblock;edrophon-
ium(section15.1.6)maybeusedtoconÞrmthediag-
nosisofdualblock.Childrenwithmyastheniagravisare
EDROPHONIUMCHLORIDE
section10.2.1;atropineshouldalsobegiven
Contra-indications
section10.2.1
section10.2.1
section10.2.1
section10.2.1
Indicationanddose
riefreversalofnon-depolarisingneuro-
muscularblockade
Byintravenousinjectionoverseveralminutes
Child1month–18years
500Ð700micrograms/
kg(afterorwithatropine)
yastheniagravis
section10.2.1
Anaesthesia
section10.2.1
section10.2.1
Indicationanddose
eversalofnon-depolarisingmuscleblock
Byintravenousinjectionover1minute
50micrograms/kg,afterorwithglyco-
pyrroniumoratropine;afurtherdoseof25micr-
ograms/kgmayberequired
Child1month–12years
50micrograms/kg
(max.2.5mg)afterorwithglycopyrroniumor
atropine;afurtherdoseof25micrograms/kgmay
berequired
hild12–18years
50micrograms/kg(max.
2.5mg)afterorwithglycopyrroniumoratropine;a
furtherdoseof25micrograms/kg(max.2.5mg)
mayberequired
yastheniagravis
section10.2.1
intravenousinjection
,giveundi-
dilutewithGlucose5%
SodiumChloride
Neostigmine
Withglycopyrronium
Glycopyrronium-Neostigmine
recurrenceofneuromuscularblockadeÑ
monitorrespiratoryfunctionuntilfullyrecovered;
recoverymaybedelayedincardiovasculardisease;
pre-existingcoagulationdisordersoruseofanticoa-
gulants(unrelatedtosurgery);wait24hoursbefore
re-administeringrocuronium;
Appendix
1(sugammadex)
Renalimpairment
avoidifestimatedglomerularÞl-
trationratelessthen30mL/minute/1.73m
usewithcautionÑnoinformationavail-
tastedisturbances;
lesscommonly
gicreactions;bronchospasmalsoreported
Indicationanddose
outinereversalofneuromuscularblockade
inducedbyrocuronium
Byintravenousinjection
Child2–18years
2mg/kg(consultproductlit-
intravenousinjection
dosemaybe
dilutedtoaconcentrationof10mg/mLwithSodium
Chloride0.9%
(Schering-Plough)
,sugammadex(assodiumsalt)100mg/mL,
short-acting(repeatdosesmaybeneces-
saryÑbenzodiazepineeffectsmaypersistforatleast
24hours);benzodiazepinedependence(mayprecipi-
tatewithdrawalsymptoms);prolongedbenzodiaze-
pinetherapyforepilepsy(riskofconvulsions);history
ofpanicdisorders(riskofrecurrence);ensureneuro-
muscularblockadeclearedbeforegiving;avoidrapid
injectioninhigh-riskoranxiouschildrenandfollowing
BNFC2011–
201215.1.7Antagonistsforcentralandrespiratorydepression
majorsurgery;headinjury(rapidreversalofbenzo-
diazepinesedationmaycauseconvulsions)
Contra-indications
life-threateningcondition(e.g.
raisedintracranialpressure,statusepilepticus)con-
trolledbybenzodiazepines
Hepaticimpairment
carefullytitratedose
notknowntobeharmful
avoidbreast-feedingfor24hours
nauseaandvomiting;
lesscommonly
NALOXONEHYDROCHLORIDE
cardiovasculardiseaseorthosereceiving
cardiotoxicdrugs(seriousadversecardiovascular
effectsreported);maternalphysicaldependenceon
opioids(mayprecipitatewithdrawalinnewborn);pain
(seealsounderTitrationofDose,below);hasshort
durationofaction(seenotesabove)
Titrationofdose
Inpostoperativeuse,thedoseshouldbe
titratedforeachchildinordertoobtainsufÞcientrespiratory
response;however,naloxoneantagonisesanalgesia
useonlyifpotentialbeneÞtoutweighsrisk
notorallybioavailable
nausea,vomiting;hypotension,hyper-
tension,ventriculartachycardiaandÞbrilation,car-
diacarrest;hyperventilation,dyspnoea,pulmonary
oedema;headache,dizziness;
lesscommonly
diarr-
hoea,drymouth,agitation,excitement,paraesthesia,
tremor,sweating;
veryrarely
seizuresanderythema
multiforme
Indicationanddose
eversalofrespiratoryandCNSdepressionin
neonatefollowingmaternalopioiduseduring
Byintramuscularinjection
200micrograms(60micrograms/kg)asa
singledoseatbirth
Byintravenousorsubcutaneousinjection
10micrograms/kg,repeatedevery2Ð3
minutesifrequired
eversalofpostoperativerespiratorydepres-
Byintravenousinjection
1microgram/kg,repeatedevery2Ð3
minutesifrequired
Child1month–12years
1microgram/kg,
repeatedevery2Ð3minutesifrequired
hild12–18years
1.5Ð3micrograms/kg;if
responseinadequate,givesubsequentdosesof
100microgramsevery2minutes
verdosagewithopioids
seeEmergencyTreat-
mentofPoisoning,p.28
SeeEmergencyTreatmentofPoisoning,p.29
Drugsformalignant
hyperthermia
Important
Thedrugsinthissectionshouldbeusedbyexperi-
encedpersonnelonly.
DANTROLENESODIUM
avoidextravasation(riskoftissuenecrosis);
Appendix1(musclerelaxants)
useonlyifpotentialbeneÞtoutweighsrisk
presentinmilkÑuseonlyifpotential
beneÞtoutweighsrisk
15.1.8Drugsformalignanthyperthermia
BNFC2011–
Anaesthesia
hepatotoxicity,pulmonaryoedema,diz-
ziness,weakness,andinjection-sitereactionsinclud-
ingerythema,rash,swelling,andthrombophlebitis
Licenseduse
notlicensedforuseinchildren
Indicationanddose
alignanthyperthermia
Byrapidintravenousinjection
Child1month–18years
initially2Ð3mg/kg,then
1mg/kgrepeatedasrequired(totalmax.dose
10mg/kg)
hronicseverespasticityofvoluntarymuscle
seesection10.2.2
DantriumIntravenous
,powderforreconstitution,dantrolenesod-
ARTICAINEHYDROCHLORIDEWITH
(Carticainehydrochloridewithadrenaline)
BUPIVACAINEHYDROCHLORIDE
Anaesthesia
Infusion
,anhydrousbupivacainehydrochloride
Withadrenaline
Forprescribinginformationonadrenaline,seesection
2.7.2;seealsoUseofVasoconstrictors,p.649
BupivacaineandAdrenaline
LEVOBUPIVACAINE
Levobupivacaineisanisomerofbupivacaine
LIDOCAINEHYDROCHLORIDE
(Lignocainehydrochloride)
Child12–18years
accordingtoweightofchild
andnatureofprocedure,max.200mg,repeated
notmoreoftenthanevery4hours
urfaceanaesthesia
seepreparationsbelow
entriculararrhythmias,neonatalseizures
tion2.3.2
ntravenousregionalanaesthesiaandnerve
blocks
seekexpertadvice
entalanaesthesia
seekexpertadvice
Important
Thelicenseddosesstatedabovemaynotbeappro-
Lidocainehydrochlorideinjections
Withadrenaline
Forprescribinginformationonadrenalineseesection
2.7.2;seealsoUseofVasoconstrictors,p.649.
Xylocaine
(AstraZeneca)
,anhydrouslidocainehydrochloride10mg/
mL(1%),adrenaline1in200000(5micrograms/mL),
Lidocaineinjectionsfordentaluse
Lidocaineforsurfaceanaesthesia
(CliniMed)
,lidocainehydrochloride2%,chlorhexidine
gluconatesolution0.25%,inasterilelubricantbasisin
reducedoseaccordingtosize,age,andconditionofchild,
max.5mL(200mg)
LMX4
Withprilocaine
Forprescribinginformationonprilocaine,seep.653.
(AstraZeneca)
Lidocaineforear,nose,andoropharyngealuse
Forprescribinginformationonphenylephrine,see
section2.7.2.
LidocainewithPhenylephrine
Anaesthesia
Mepivacaine
Mepivacaine
MEPIVACAINEHYDROCHLORIDE
Withadrenaline
Forprescribinginformationonadrenaline,seesection
2.7.2;seeUseofVasoconstrictors,p.649.
2%Special
,mepivacainehydrochloride20mg/mL,
PRILOCAINEHYDROCHLORIDE
Withlidocaine
SeeLidocaine,p.652
Fordentaluse
ConsultexpertdentalsourcesforspeciÞcadvicein
relationtodoseofprilocainefordentalanaesthesia
Citanest3%withOctapressin
,prilocainehydrochloride30mg/mL,fely-
ROPIVACAINEHYDROCHLORIDE
Licenseduse
2mg/mLstrengthnotlicensedforuse
inchildrenunder12yearsexceptforacutepain
managementbycaudalepiduralblockandcontin-
uousepiduralinfusion;7.5mg/mLand10mg/mL
strengthsnotlicensedforuseinchildrenunder12
years
Indicationanddose
Toavoidexcessivedosageinobesechildren,dose
shouldbecalculatedonthebasisofidealweightfor
AdjustaccordingtochildÕsphysicalstatusand
natureofprocedure,seekexpertadviceÑ
:seealsounderAdministration,p.649
Anaesthesia
Interactions
Twoormoredrugsgivenatthesametimemayexert
theireffectsindependentlyormayinteract.Theinter-
actionmaybepotentiationorantagonismofonedrug
byanother,oroccasionallysomeothereffect.Adverse
druginteractionsshouldbereportedtotheMedicines
andHealthcareproductsRegulatoryAgency(MHRA),
throughtheYellowCardScheme(seeAdverseReac-
tionstoDrugs,p.12),asforotheradversedrug
Druginteractionsmaybe
pharmacodynamic
Appendix1:Interactions
shouldbe
avoided
(oronlyundertakenwithcautionand
appropriatemonitoring).
Interactionsthathavenosymboldonotusuallyhave
seriousconsequences.
Listofdruginteractions
Appendix1:Interactions
Acrivastine
Adalimumab
Abatacept:
increasedriskofside-effectswhenadali-
mumabgivenwith
abatacept
avoidconcomitantuseofadalimumabwith
Vaccines:
avoidconcomitantuseofadalimumabwith
(seep.599)
Adefovir
avoidanceofadefoviradvisedbymanufac-
turerof
Adenosine
Possibilityofinteractionwithdrugstendingtoimpair
myocardialconduction
Appendix1:Interactions
Appendix1:Interactions
-adrenoceptorStimulants
Apraclonidine,
Appendix1:Interactions
(continued)
MuscleRelaxants:
aminoglycosidesenhanceeffectsof
non-depolarisingmusclerelaxants
Appendix1:Interactions
Amphotericin
CardiacGlycosides:
hypokalaemiacausedby
amphotericinincreasescardiactoxicitywith
glycosides
Ciclosporin:
increasedriskofnephrotoxicitywhen
amphotericingivenwith
Corticosteroids:
increasedriskofhypokalaemiawhen
amphotericingivenwith
corticosteroids
Ñavoid
concomitantuseunlesscorticosteroidsneededto
controlreactions
Cytotoxics:
increasedriskofventriculararrhythmias
whenamphotericingivenwith
arsenictrioxide
Appendix1:Interactions
Angiotensin-IIReceptorAntagonists
Alpha-blockers:
enhancedhypotensiveeffectwhen
angiotensin-IIreceptorantagonistsgivenwith
Appendix1:Interactions
Appendix1:Interactions
Antidepressants,SSRI
Appendix1:Interactions
Antidepressants,Tricyclic
Appendix1:Interactions
Appendix1:Interactions
Antifungals,Imidazole
Clopidogrel:
Appendix1:Interactions
Antifungals,Triazole
increasesplasmaconcentrationof
(considerreducingdoseofphenytoin);voricona-
zoleincreasesplasmaconcentrationof
,alsophenytoinreducesplasmacon-
centrationofvoriconazole(increasedoseof
voriconazoleandalsomonitorforphenytoin
toxicity);plasmaconcentrationofposaconazole
reducedby
;plasmaconcentrationof
itraconazolereducedby
Ñavoidcon-
comitantuse
triazolespossiblyantagoniseeffectsof
;plasmaconcentrationofitraconazole
increasedby
(considerreducingdoseof
Appendix1:Interactions
Antifungals,Triazole
Tacrolimus
concentrationof
tacrolimus
(considerreducing
doseoftacrolimus)
Tadalal:
itraconazolepossiblyincreasesplasmacon-
centrationof
tadalaÞl
ßuconazolepossiblyincreasesplasma
concentrationof
Ulcer-healingDrugs:
plasmaconcentrationofposaco-
nazolereducedby
Appendix1:Interactions
(continued)
indinavir
lopinavir
nelÞnavir
ritonavir
saquinavir
tipranavir
;manufactureroffeso-
terodineadvisesdosereductionwhenfesoter-
odinegivenwith
indinavir
nelÞnavir
ritonavir
saquinavir
Ñconsultfesoterodine
productliterature;manufactureroftolterodine
advisesavoidconcomitantusewith
indinavir
lopinavir
nelÞnavir
ritonavir
saquinavir
;plasmaconcentrationofsolifenacin
increasedby
nelÞnavir
ritonavir
Appendix1:Interactions
Antipsychotics
Antidepressants
(continued)
arrhythmias;increasedriskofantimuscarinic
side-effectswhenphenothiazinesgivenwith
tricyclics
;increasedriskofventriculararrhyth-
miaswhenpimozidegivenwith
tricyclics
avoidconcomitantuse;possibleincreasedanti-
muscarinicside-effectswhenclozapinegiven
tricyclics
Appendix1:Interactions
Antipsychotics
Appendix1:Interactions
AnxiolyticsandHypnotics
increasedsedativeeffectwhen
anxiolyticsandhypnoticsgivenwith
antihistamines
Antipsychotics:
increasedsedativeeffectwhenanxio-
lyticsandhypnoticsgivenwith
antipsychotics
buspironeincreasesplasmaconcentrationof
;seriousadverseeventsreportedwithcon-
comitantuseoflorazepamand
notestablished);increasedriskofhypotension,
bradycardiaandrespiratorydepressionwhen
benzodiazepinesgivenwith
plasmaconcentrationofmidazolampossibly
increasedby
atazanavir
Ñavoidconcomitantuseof
midazolam;increasedriskofprolongedsedation
whenmidazolamgivenwith
efavirenz
Ñavoidcon-
comitantuse;plasmaconcentrationofmidazolam
possiblyincreasedby
fosamprenavir
indinavir
ritonavir
(riskofprolongedseda-
tionÑavoidconcomitantuseof
increasedriskofprolongedsedationwhenalprazo-
lamgivenwith
indinavir
Ñavoidconcomitantuse;
plasmaconcentrationofalprazolam,diazepam,
ßurazepamandzolpidempossiblyincreasedby
(riskofextremesedationandrespiratory
depressionÑavoidconcomitantuse);plasmacon-
centrationofanxiolyticsandhypnoticspossibly
increasedby
ritonavir
;plasmaconcentrationof
buspironeincreasedby
ritonavir
(increasedriskof
toxicity);plasmaconcentrationofmidazolam
increasedby
saquinavir
(riskofprolongedseda-
tionÑavoidconcomitantuseof
plasmaconcentrationofmidazolam
increasedby
(riskofprolongedsedation)
Appendix1:Interactions
ArsenicTrioxide
increasedriskofventriculararrhy-
thmiaswhenarsenictrioxidegivenwith
increasedriskofventriculararrhyth-
miaswhenarsenictrioxidegivenwith
erythromycin
levoßoxacin
moxißoxacin
Antidepressants:
increasedriskofventriculararrhy-
thmiaswhenarsenictrioxidegivenwith
amitriptyline
clomipramine
increasedriskofventriculararrhythmias
whenarsenictrioxidegivenwith
Antipsychotics:
increasedriskofventriculararrhyth-
miaswhenarsenictrioxidegivenwith
antipsychotics
thatprolongtheQTinterval;
increasedriskofventriculararrhythmiaswhen
arsenictrioxidegivenwith
;avoidcon-
comitantuseofcytotoxicswith
riskofagranulocytosis)
Appendix1:Interactions
Calcium-channelBlockers:
atazanavirincreases
plasmaconcentrationof
(reducedoseof
diltiazem);atazanavirpossiblyincreasesplasma
concentrationof
Ciclosporin:
atazanavirpossiblyincreasesplasma
concentrationof
ciclosporin
Colchicine:
atazanavirpossiblyincreasesriskof
colchicine
toxicityÑsuspendorreducedoseof
colchicine(avoidconcomitantuseinhepaticorrenal
impairment)
Cytotoxics:
atazanavirpossiblyincreasesplasmacon-
centrationof
everolimus
Ñmanufacturerofever-
olimusadvisesavoidconcomitantuse;avoidanceof
atazanaviradvisedbymanufacturerof
pazopanib
Appendix1:Interactions
Appendix1:Interactions
Appendix1:Interactions
plasmaconcentrationofbusulfan
increasedby
Appendix1:Interactions
Calcium-channelBlockers
diltiazem);plasmaconcentrationofdiltiazem
reducedby
efavirenz
;plasmaconcentrationof
calcium-channelblockerspossiblyincreasedby
;manufactureroflercanidipineadvises
avoidconcomitantusewith
AnxiolyticsandHypnotics:
enhancedhypotensive
effectwhencalcium-channelblockersgivenwith
anxiolyticsandhypnotics
;diltiazemandverapamil
Appendix1:Interactions
ototoxicitywhencapreomycingivenwith
aminoglycosides
vancomycin
Cytotoxics:
increasedriskofnephrotoxicityandoto-
toxicitywhencapreomycingivenwith
platinum
compounds
Vaccines:
antibacterialsinactivate
oraltyphoid
Ñseep.620
ACEInhibitors
Alcohol:
CNSside-effectsofcarbamazepinepossibly
increasedby
effectsofcarbamazepineenhancedby
dextropropoxyphene
;carbamazepinereduces
plasmaconcentrationof
Appendix1:Interactions
Lipid-regulatingDrugs:
carbamazepinereduces
plasmaconcentrationof
increasingdoseofsimvastatin
neurotoxicitymayoccurwhencarbamazepine
givenwith
withoutincreasedplasmacon-
centrationoflithium
MuscleRelaxants:
carbamazepineantagonisesmuscle
relaxanteffectof
non-depolarisingmusclerelaxants
(acceleratedrecoveryfromneuromuscularblockade)
Appendix1:Interactions
Ciclosporin:
plasmaconcentrationofcaspofungin
increasedby
(manufacturerofcaspo-
funginrecommendsmonitoringliverenzymes)
Corticosteroids:
plasmaconcentrationofcaspofungin
possiblyreducedby
dexamethasone
increasingdoseofcaspofungin
Tacrolimus:
caspofunginreducesplasmaconcentration
Cefaclor
Cefadroxil
Cefalexin
CeÞxime
Cefotaxime
Cefpodoxime
Cefradine
see
Ceftazidime
Ceftriaxone
Cefuroxime
Celecoxib
Celiprolol
Appendix1:Interactions
Antibacterials
givenwith
Appendix1:Interactions
Ulcer-healingDrugs:
plasmaconcentrationofcilosta-
zolincreasedby
(considerreducingdose
ofcilostazol)
Appendix1:Interactions
Colchicine
colchicine(avoidconcomitantuseinhepaticor
renalimpairment)
possibleincreasedriskofcolchicinetoxicity
whengivenwith
atazanavir
indinavir
Ñsuspendorreducedoseofcolchicine
(avoidconcomitantuseinhepaticorrenalimpair-
Calcium-channelBlockers:
possibleincreasedriskof
colchicinetoxicitywhengivenwith
verapamil
Ñsuspendorreducedoseofcolchicine
(avoidconcomitantuseinhepaticorrenalimpair-
CardiacGlycosides:
possibleincreasedriskofmyo-
pathywhencolchicinegivenwith
Ciclosporin:
possibleincreasedriskofnephrotoxicity
andmyotoxicitywhencolchicinegivenwith
ciclosporin
Ñsuspendorreducedoseofcolchicine
(avoidconcomitantuseinhepaticorrenalimpair-
GrapefruitJuice:
possibleincreasedriskofcolchicine
toxicitywhengivenwith
grapefruitjuice
Lipid-regulatingDrugs:
possibleincreasedriskof
myopathywhencolchicinegivenwith
Þbrates
Colesevelam
Otherdrugsshouldbetakenatleast4hoursbeforeor
aftercolesevelamtoreducepossibleinterferencewith
absorption
Appendix1:Interactions
Corticosteroids
Appendix1:Interactions
Coumarins
(continued)
anticoagulanteffectofwarfarinpossibly
reducedby
aprepitant
Azathioprine:
anticoagulanteffectofcoumarinspossi-
blyreducedby
azathioprine
monitoringanticoagulanteffectofcoum-
arinsrecommendedbymanufacturerof
Clopidogrel:
anticoagulanteffectofcoumarins
Appendix1:Interactions
avoidanceofdacarbazineadvisedby
manufacturerof
Antipsychotics:
avoidconcomitantuseofcytotoxics
(increasedriskofagranulocytosis)
DairyProducts
dairyproductsreduceabsorptionof
ciproßoxacin
norßoxacin
;dairyproductsreduce
absorptionof
Appendix1:Interactions
(continued)
Antidepressants:
enhancedhypotensiveeffectwhen
diazoxidegivenwith
MAOIs
tricyclic-related
Appendix1:Interactions
Disopyramide
(continued)
Appendix1:Interactions
Appendix1:Interactions
Appendix1:Interactions
Antipsychotics
concentrationof
(increasedriskof
ventriculararrhythmiasÑavoidconcomitantuse)
avoidanceofefavirenzadvisedbymanu-
facturerof
atazanavir
(plasmaconcentrationof
atazanavirreduced);efavirenzreducesplasmacon-
centrationof
darunavir
fosamprenavir
indinavir
efavirenzpossiblyreducesplasmaconcentrationof
Appendix1:Interactions
Erlotinib
plasmaconcentrationoferlotinibpossibly
reducedby
Ñgiveantacidsatleast4hours
beforeor2hoursaftererlotinib
plasmaconcentrationoferlotinib
increasedby
ciproßoxacin
Appendix1:Interactions
Appendix1:Interactions
CalciumSalts:
absorptionofßuoridesreducedby
calciumsalts
Fluorouracil
Capecitabineisaprodrugofßuorouracil
Tegafurisaprodrugofßuorouracil
manufacturerofcapecitabineadvises
avoidconcomitantusewith
Appendix1:Interactions
Gabapentin
Antidepressants:
anticonvulsanteffectofantiepileptics
possiblyantagonisedby
MAOIs
tricyclic-related
(convulsivethresholdlowered);anti-
convulsanteffectofantiepilepticsantagonisedby
and
tricyclics
(convulsivethreshold
lowered);avoidconcomitantuseofantiepileptics
StJohnÕswort
possibleincreasedriskofconvulsions
whenantiepilepticsgivenwith
chloroquineand
hydroxychloroquine
;anticonvulsanteffectofanti-
epilepticsantagonisedby
meßoquine
Antipsychotics:
anticonvulsanteffectofantiepileptics
antagonisedby
antipsychotics
(convulsivethreshold
lowered)
possibleincreasedriskofconvulsionswhen
antiepilepticsgivenwith
orlistat
Galantamine
Appendix1:Interactions
Heparins
possibleincreasedriskofbleedingwhen
heparinsgivenwith
;increasedriskof
haemorrhagewhenanticoagulantsgivenwith
(avoidconcomitantuse,including
low-doseheparins);increasedriskofhaemorrhage
whenanticoagulantsgivenwith
Appendix1:Interactions
Homatropine
see
HormoneAntagonists
see
Bicalutamide,Danazol,
Dutasteride,Exemestane,Flutamide,Lanreotide,
Octreotide,Tamoxifen,Toremifene,andTrilostane
Agonists
Appendix1:Interactions
Indinavir
indinavirpossiblyincreasesplasma
concentrationof
Ñavoidconcomitant
use;indinavirpossiblyincreasesplasmaconcentra-
tionof
ßecainide
(increasedriskofventricular
arrhythmiasÑavoidconcomitantuse)
indinavirincreasesplasmaconcentra-
tionof
Appendix1:Interactions
(continued)
Appendix1:Interactions
Lanreotide
Appendix1:Interactions
Levodopa
(continued)
Clonidine:
enhancedhypotensiveeffectwhenlevo-
dopagivenwith
clonidine
Diazoxide:
enhancedhypotensiveeffectwhenlevo-
dopagivenwith
Appendix1:Interactions
Lopinavir
Incombinationwithritonaviras
Appendix1:Interactions
Macrolides
trationofazithromycinincreasedby
nelÞnavir
(increasedriskoftoxicity);plasmaconcentration
ofclarithromycinreducedby
Appendix1:Interactions
ForinteractionsofreversibleMAO-Ainhibitors
(RIMAs)seeMoclobemide,andforinteractionsofMAO-B
inhibitorsseeRasagilineandSelegiline;theantibacterial
Linezolidisareversible,non-selectiveMAOinhibitor
ACEInhibitors:
MAOIspossiblyenhancehypotensive
effectof
ACEinhibitors
AdrenergicNeuroneBlockers:
enhancedhypotensive
effectwhenMAOIsgivenwith
adrenergicneurone
MAOIsinteractwithtyraminefoundinsome
beveragescontaining
andsomedealcoho-
lisedbeverages(hypertensivecrisis)Ñifnotyramine,
enhancedhypotensiveeffect
-adrenoceptorStimulants:
avoidanceof
MAOIsadvisedbymanufacturerof
apraclonidine
brimonidine
Alpha-blockers:
avoidanceofMAOIsadvisedby
manufacturerof
;enhancedhypotensive
effectwhenMAOIsgivenwith
alpha-blockers
CNSexcitationordepression(hyper-
tensionorhypotension)whenMAOIsgivenwith
Appendix1:Interactions
Appendix1:Interactions
Appendix1:Interactions
Appendix1:Interactions
(continued)
Appendix1:Interactions
MuscleRelaxants
Antidepressants
(continued)
Appendix1:Interactions
NelÞnavir
odineproductliterature;nelÞnavirincreases
plasmaconcentrationof
Antipsychotics:
Appendix1:Interactions
Nimodipine
Calcium-channelBlockers
ACEInhibitors:
enhancedhypotensiveeffectwhen
nitratesgivenwith
ACEinhibitors
AdrenergicNeuroneBlockers:
enhancedhypotensive
effectwhennitratesgivenwith
adrenergicneurone
Alcohol:
enhancedhypotensiveeffectwhennitrates
givenwith
enhancedhypotensiveeffectwhen
nitratesgivenwith
Alpha-blockers:
enhancedhypotensiveeffectwhen
nitratesgivenwith
Appendix1:Interactions
haematologicaltoxicitywhenNSAIDsgivenwith
Appendix1:Interactions
Oestrogens
Appendix1:Interactions
OpioidAnalgesics
mitantuse);plasmaconcentrationofmorphine
possiblyreducedby
ritonavir
;increasedriskof
ventriculararrhythmiaswhenalfentanil,
Appendix1:Interactions
Paraldehyde
riskoftoxicitywhenparaldehydegiven
Appendix1:Interactions
Perindopril
ACEInhibitors
Perphenazine
Antipsychotics
Appendix1:Interactions
Phenobarbital
Calcium-channelBlockers
manufacturerof
nimodipine
(plasmaconcentra-
tionofnimodipinereduced)
Ciclosporin:
Appendix1:Interactions
Phenytoin
Antipsychotics
possiblyincreasedordecreasedby
chlorprom-
;phenytoinpossiblyreducesplasmacon-
centrationof
Ñincreasedoseof
Appendix1:Interactions
PlatinumCompounds
cisplatinpossiblyreducesplasmacon-
centrationof
Antipsychotics:
avoidconcomitantuseofcytotoxics
(increasedriskofagranulocytosis)
Cytotoxics:
increasedriskofotoxicitywhencisplatin
givenwith
;increasedpulmonarytoxicity
whencisplatingivenwith
bleomycin
Appendix1:Interactions
Progesterone
Progestogens
Progestogens
Interactionsofcombinedoralcontraceptivesmayalso
applytocombinedcontraceptivepatchesandvaginalrings,
seep.398.Forfurtherinformationoninteractionsoforal
progestogen-onlycontraceptives,seealsop.403;parenteral
progestogen-onlycontraceptives,seealsop.404;theintra-
uterineprogestogen-onlydevice,seealsop.405;hormonal
emergencycontraception,seealsop.408
plasmaconcentrationofdienogest
increasedby
erythromycin
Appendix1:Interactions
Prostaglandins
Appendix1:Interactions
quininegivenwith
saquinavir
Ñavoidconcomi-
tantuse
CardiacGlycosides:
quinineincreasesplasmacon-
centrationof
quininepossiblyincreasesplasma
concentrationof
avoidanceofantimalarialsadvisedby
manufacturerof
MuscleRelaxants:
quininepossiblyenhanceseffectsof
Appendix1:Interactions
Ranolazine
plasmaconcentrationofranolazine
possiblyincreasedby
clarithromycin
telithromycin
Ñmanufacturerofranolazineadvises
avoidconcomitantuse;plasmaconcentrationof
ranolazinereducedby
Ñmanufacturerof
ranolazineadvisesavoidconcomitantuse
Antidepressants:
plasmaconcentrationofranolazine
increasedby
Appendix1:Interactions
Appendix1:Interactions
Progestogens:
Appendix1:Interactions
Corticosteroids:
ritonavirpossiblyincreasesplasma
concentrationof
corticosteroids
Appendix1:Interactions
StJohnÕsWort
StJohnÕswortpossiblyreducesplasma
concentrationof
Appendix1:Interactions
Saquinavir
Appendix1:Interactions
Sirolimus
cautionwithsirolimusadvisedby
manufacturerof
dronedarone
plasmaconcentrationofsirolimus
increasedby
clarithromycin
telithromycin
avoidconcomitantuse;plasmaconcentrationofboth
drugsincreasedwhensirolimusgivenwith
erythromycin
;plasmaconcentrationofsirolimus
reducedby
Ñavoidcon-
comitantuse
plasmaconcentrationofsirolimus
increasedby
Appendix1:Interactions
possibleincreasedriskofmyopathywhen
atorvastatingivenwith
atazanavir
fosamprenavir
indinavir
nelÞnavir
ritonavir
saquinavir
possibleincreasedriskofmyopathywhenrosuvas-
tatingivenwith
atazanavir
darunavir
fosamprenavir
indinavir
lopinavir
Ñmanufacturerofrosu-
vastatinadvisesavoidconcomitantuse;increased
riskofmyopathywhensimvastatingivenwith
indinavir
nelÞnavir
ritonavir
saquinavir
(avoidconcomitantuse);plasmacon-
centrationofpravastatinpossiblyincreasedby
darunavir
;plasmaconcentrationofatorvastatin,
pravastatinandsimvastatinreducedby
efavirenz
plasmaconcentrationofatorvastatinpossibly
reducedby
Appendix1:Interactions
SulÞnpyrazone
(continued)
Ciclosporin:
sulÞnpyrazonereducesplasmaconcen-
trationof
sulÞnpyrazonereducesplasmaconcen-
trationof
Sulfonamides
Appendix1:Interactions
Appendix1:Interactions
Telithromycin
Antimuscarinics:
manufactureroffesoterodineadvises
dosereductionwhentelithromycingivenwith
Ñconsultfesoterodineproductliterature
Antipsychotics:
increasedriskofventriculararrhyth-
miaswhentelithromycingivenwith
avoidconcomitantuse
manufactureroftelithromycinadvisesavoid
concomitantusewith
atazanavir
fosamprenavir
lopinavir
nelÞnavir
ritonavir
saquinavir
tipranavir
insevererenaland
hepaticimpairment;telithromycinpossiblyincreases
plasmaconcentrationof
maraviroc
(considerredu-
cingdoseofmaraviroc)
AnxiolyticsandHypnotics:
telithromycininhibits
Appendix1:Interactions
Appendix1:Interactions
ThyroidHormones
Lipid-regulatingDrugs:
absorptionoflevothyroxine
reducedby
colesevelam
;absorptionofthyroid
hormonesreducedby
colestyramine
requirementsforthyroidhormonesin
hypothyroidismmaybeincreasedby
oestrogens
possibleincreasedriskofhypothyroidism
whenlevothyroxinegivenwith
orlistat
PolystyreneSulphonateResins:
absorptionof
levothyroxinereducedby
polystyrenesulphonate
absorptionoflevothyroxinepossibly
reducedby
Ulcer-healingDrugs:
absorptionoflevothyroxine
reducedby
Appendix1:Interactions
Topiramate
Antidepressants
(continued)
lowered);avoidconcomitantuseofantiepileptics
StJohnÕswort
Appendix1:Interactions
Ulipristal
ulipristalpossiblyreducescontraceptive
effectof
progestogens
Ulcer-healingDrugs:
manufacturerofulipristaladvises
avoidconcomitantusewith
histamineH
protonpumpinhibitors
concentrationofulipristalpossiblyreduced)
UrsodeoxycholicAcid
BileAcids
Ustekinumab
Vaccines:
avoidconcomitantuseofustekinumabwith
(seep.599)
Vaccines
Forageneralwarningonlivevaccinesandhighdoses
ofcorticosteroidsorotherimmunosuppressivedrugs,see
p.599;foradviceonlivevaccinesandimmunoglobulins,see
underNormalImmunoglobulin,p.622
avoidconcomitantuseoflivevaccineswith
abatacept
(seep.599)
avoidconcomitantuseoflivevaccines
(seep.599)
avoidconcomitantuseoflivevaccineswith
(seep.599)
oraltyphoidvaccineinactivatedby
Ñseep.620
Anticoagulants:
inßuenzavaccinepossiblyenhances
anticoagulanteffectof
inßuenzavaccineenhanceseffectsof
oraltyphoidvaccineinactivatedby
Ñseep.620
Certolizumabpegol:
avoidconcomitantuseoflive
vaccineswith
certolizumabpegol
(seep.599)
Corticosteroids:
immuneresponsetovaccines
impairedbyhighdosesof
corticosteroids
,avoid
concomitantusewithlivevaccines(seep.599)
Appendix1:Interactions
VardenaÞl
plasmaconcentrationofvardenaÞl
increasedby
Appendix1:Interactions
Vigabatrin
(continued)
possibleincreasedriskofconvulsions
whenantiepilepticsgivenwith
chloroquineand
hydroxychloroquine
;anticonvulsanteffectofanti-
epilepticsantagonisedby
meßoquine
Antipsychotics:
anticonvulsanteffectofantiepileptics
antagonisedby
antipsychotics
(convulsivethreshold
lowered)
possibleincreasedriskofconvulsionswhen
antiepilepticsgivenwith
orlistat
Vildagliptin
Appendix1:Interactions
Zonisamide
Antidepressants
(continued)
lowered);avoidconcomitantuseofantiepileptics
StJohnÕswort
plasmaconcentrationofzonisamide
reducedby
carbamazepine
phenobarbital
possibleincreasedriskofconvulsions
whenantiepilepticsgivenwith
chloroquineand
hydroxychloroquine
;anticonvulsanteffectofanti-
epilepticsantagonisedby
meßoquine
Antipsychotics:
anticonvulsanteffectofantiepileptics
antagonisedby
antipsychotics
(convulsivethreshold
lowered)
possibleincreasedriskofconvulsionswhen
antiepilepticsgivenwith
orlistat
Zopiclone
AnxiolyticsandHypnotics
Zuclopenthixol
Antipsychotics
Appendix1:
BNFC2011–
Appendix1:Interactions
Borderlinesubstances
Enteralfeeds(non-disease
Enteralfeeds(non-disease
speciÞc):lessthan5gprotein/
100mL
Enteralfeeds(non-disease
speciÞc):5g(ormore)protein/
100mL
Enteralfeeds(non-disease
speciÞc):Childunder12years
Nutritionalsupplements(non-
diseasespeciÞc)
Nutritionalsupplements:less
than5gprotein/100mL
Nutritionalsupplements:5g
(ormore)protein/100mL
Specialisedformulas
Specialisedformulas:Infant
andchild
Specialisedformulasforspeci-
Þcclinicalconditions
Feedsupplements
High-energysupplements
Fibre,vitamin,andmineral
supplements
Feedadditives
Specialadditivesforconditions
ofintolerance
Feedthickenersandpre-thick-
eneddrinks
Flavouringpreparations
Appendix2:Borderlinesubstances
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1Enteralfeeds(non-diseasespeciÞc)
A2.1.1Enteralfeeds(non-diseasespeciÞc):lessthan5gprotein/100mL
A2.1.1.1Enteralfeeds:1kcal/mLandlessthan5gprotein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(FreseniusKabi)
Liquid(sipor
tubefeed)
per100mL
420kJ
(100kcal)
3.8g
cows’milk
13.8g
(sugars3.5g
3.4gNilGluten-free
Residuallactose
Containsshgelatin
Feedinexiblepackcon-
tainsshoilandshgel-
Standard,p.743
Bottle:200mL=£1.78
Blackcurrant,chocolate,mocha,
nut,peach,vanilla
Flexiblepack:
500mL=£3.45
1000mL=£6.81
1500mL=£10.23
(FreseniusKabi)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
3.8g
cows’milk
13.8g
(sugars1g)
3.4g2gGluten-free
Residuallactose
Containsshoilandsh
Standard,p.743exceptbowels-
Notsuitableforchildunder2years
Flexiblepack:
500mL=£3.90
1000mL=£7.78
1500mL=£10.69
Isosource
Liquid(tubefeed)
per100mL
422kJ
(100kcal)
3.8g
cows’milk
13.6g3.4g1.4gGluten-free
Residuallactose
Standard,p.743
Notsuitableforchildunder2years
Flexiblepack:
500mL=£3.49
1000mL=£6.97
Isosource
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
cows’milk
13.6g3.3gNilGluten-free
Residuallactose
Standard,p.743
Flexiblepack:
500mL=£3.07
1000mL=£6.13
Liquid(tubefeed)
per100mL
441kJ
(106kcal)
caseinates
14.1g
(sugars
470mg)
3.47g1.76gGluten-free
Residuallactose
Standard,p.743exceptbowels-
Notsuitableforchildunder2years
Flexiblepack:
500mL=£4.16
1000mL=£7.81
1500mL=£11.73
Novasource
Control
Liquid(tubefeed)
per100mL
444kJ
(106kcal)
4.1g
cows’milk
14.4g
(sugars
500mg)
3.5g
40%)
2.2gGluten-free
Residuallactose
Standard,p.743
Flexiblepack:
500mL=£4.78
Sugarcontentvarieswithavour
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
cows’milk
12.3g
(sugars1g)
3.9gNilGluten-free
Residuallactose
Standard,p.743
500mL=£3.76
Flexiblepack:
500mL=£4.17
1000mL=£7.32
1500mL=£10.97
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
cows’milk
12.3g
(sugars1g)
3.9g1.5gGluten-free
Residuallactose
Standard,p.743exceptbowels-
500mL=£4.09
Flexiblepack:
500mL=£4.51
1000mL=£8.16
1500mL=£12.25
Liquid(tubefeed)
per100mL
424kJ
(100kcal)
caseinates
soyisolate
13.6g
(sugars
630mg)
3.4gNilGluten-free
Residuallactose
Standard,p.743
Can:250mL=£1.88
500mL=£3.57
1000mL=£6.81
1500mL=£10.22
Soyaproteinformula
(seealsosectionA2.3.1)
(FreseniusKabi)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
3.8g
soyaprotein
13.3g
(sugars4.1g)
3.6g2gGluten-free
Containsshoil
Standard,p.743;
cows’milk
proteinintolerance,lactoseintoler-
ance
Flexiblepack:500mL=£4.03
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
soyisolate
12.3g
(sugars1g)
3.9gNilGluten-free
Residuallactose
Milkprotein-free
Standard,p.743;
cows’milk
proteinandlactoseintolerance
500mL=£4.34
Flexiblepack:
1000mL=£8.69
MultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
soyisolate
12.3g
(sugars
700mg)
3.9g1.5gGluten-free
Residuallactose
Milkprotein-free
Standard,p.743exceptbowels-
cows’milkproteinand
lactoseintolerance
Flexiblepack:
1500mL=£14.46
Peptide-basedformula
Liquid(sipor
tubefeed)
per100mL
420kJ
(100kcal)
wheypep-
12.7g
(sugars
480mg
3.7g
70%)
NilGluten-free
Residuallactose
Shortbowelsyndrome,intractable
malabsorption,proveninamm-
atoryboweldisease,bowelstula
200mL=£2.83
Vanilla
Flexiblepack:
500mL=£5.86
1000mL=£11.00
Sugarcontentvarieswithavour
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.1.1Enteralfeeds:1kcal/mLandlessthan5gprotein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(NutriciaClinical)
Liquid(tubefeed)
per100mL
425kJ
(100kcal)
wheyprotein
hydrolysate
17.6g
(sugars1.7g)
1.7g
47%)
NilGluten-free
Residuallactose
Shortbowelsyndrome,intractable
malabsorption,proveninamm-
atoryboweldisease,bowelstula
500mL=£5.76
Flexiblepack:
500mL=£6.31
1000mL=£11.41
(FreseniusKabi)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
4.5g
lactalbumin
hydrolysate
15g
(sugars
300mg)
2.4g
54%)
NilGluten-free
Residuallactose
Containsshoilandsh
Standard,p.743;
growthfail-
Flexiblepack:
500mL=£5.75
A2.1.1.2Enteralfeeds:Lessthan1kcal/mLandlessthan5gprotein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Aminoacidformula(essentialandnon-essentialaminoacids)
Elemental028
Liquid(sipfeed)
per100mL
360kJ
(86kcal)
2.5g
11g
(sugars4.7g)
3.5g
35%)
Shortbowelsyndrome,intractable
malabsorption,proveninamm-
atoryboweldisease,bowelstula
Carton:
250mL=£3.19
Grapefruit,orangeandpineapple,
summerfruits
Standarddilution
(20%)ofpowder
(siportubefeed)
per100mL
374kJ
(89kcal)
2.5g
11.8g
(sugars1.8g)
3.5g
35%)
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
A2.1.2Enteralfeeds(non-diseasespeciÞc):5g(ormore)protein/100mL
A2.1.2.1Enteralfeeds:1.5kcal/mLand5g(ormore)protein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.2.1Enteralfeeds:1.5kcal/mLand5g(ormore)protein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
1.5kcal
Liquid(tubefeed)
per100mL
640kJ
(152kcal)
6.38g
caseinates
andsoyiso-
20.1g
(sugars1.47g)
4.9g2.2gGluten-free
Residuallactose
Standard,p.743
Notsuitableforchildunder2years;
notrecommendedforchild2–10
Flexiblepack:
500mL=£4.92
1000mL=£9.40
1500mL=£14.67
Novasource
Liquid(tubefeed)
per100mL
631kJ
(150kcal)
cows’milk
18.3g
(sugars1.8g)
5.9g2.2gGluten-free
Residuallactose
Standard,p.743
Flexiblepack:
500mL=£4.75
1000mL=£9.50
(NutriciaClinical)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
cows’milk
18.5g
(sugars1.5g)
5.8gNilGluten-free
Residuallactose
Standard,p.743
500mL=£4.38
Flexiblepack:
500mL=£4.86
1000mL=£8.81
1500mL=£13.18
MultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
cows’milk
18.5g
(sugars1.5g)
5.8g1.5gGluten-free
Residuallactose
Standard,p.743
500mL=£4.90
Flexiblepack:
500mL=£5.39
1000mL=£9.77
1500mL=£15.66
1.5kcal
Liquid(tubefeed)
per100mL
632kJ
(150kcal)
6.25g
cows’milk
soyaprotein
20g
(sugars4.9g)
5gNilGluten-free
Residuallactose
Standard,p.743
Flexiblepack:
500mL=£4.37
1000mL=£8.54
1500mL=£12.79
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
5.6g
cows’milk
21g
(sugars5.2g
5glessthan
500mg
Residuallactose
Standard,p.743
Notsuitableforuseinchildunder3
200mL=£6.97
Apricot,banana,chocolate,cof-
fee,strawberry-raspberry,vanilla
Sugarcontentvarieswithavour
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
A2.1.2.2Enteralfeeds:Lessthan1.5kcal/mLand5g(ormore)protein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.2.2Enteralfeeds:Lessthan1.5kcal/mLand5g(ormore)protein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1yearunlessotherwisestated;notrecommendedforchild1–6years
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
A2.1.3Enteralfeeds(non-diseasespeciÞc):Childunder12years
A2.1.3.1Enteralfeeds,Child:Lessthan1kcal/mLandlessthan4gprotein/100mL
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
EnergyMultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
315kJ
(75kcal)
2.1g
wheyprotein
andcasei-
9.3g
(sugars
600mg)
3.3g800mgGluten-free
Residuallactose
Containsshoil
Paediatric,p.743exceptbowels-
tula,inchild1–6years,body-weight
8–20kg
Bottle:200mL=£2.16
Flexiblepack:
500mL=£5.47
(Cow&Gate)
Liquid(sipfeed)
per100mL
335kJ
(80kcal)
2.5g
wheyprotein
andcasein
7.6g
(lactose6.3g)
4.4g800mgContainssoya,shoiland
egglipid
Lowbirth-weightformula
Bottle:60mL
Hospitalsupplyonly
(Cow&Gate)
Liquid(sipfeed)
per100mL
310kJ
(75kcal)
wheyprotein
andcasein
7.4g
(lactose5.8g)
4g600mgContainssoya,shoiland
egglipid
Catch-upgrowthinpre-terminfants
(lessthan35weeksatbirth)and
smallforgestational-ageinfantsup
to6monthscorrectedage
Carton:200mL=£1.59
(Bottle:100mLHospitalsupply
Standarddilution
(15.3%)ofpow-
der(sipfeed)
per100mL
315kJ
(75kcal)
wheyprotein
andcasein
7.4g
(lactose5.9g)
ingMCT
600mg
Can:900g=£10.64
(5.1-gmeasuringscoopprovided)
Powderprovides:protein13g,carbohydrate48.3g,fat26.7g,bre5.2g,energy2030kJ(485kcal)/100g
GoldPrem2
(SMANutrition)
Standarddilution
(14%)ofpowder
(sipfeed)
per100mL
305kJ
(73kcal)
1.9g
cows’milk
7.5g
sugars6.4g
3.9gNilContainslactose
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.3.1Enteralfeeds,Child:Lessthan1kcal/mLandlessthan4gprotein/100mL
(productlistcontinued)
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Aminoacidformula(essentialandnon-essentialaminoacids)
Standarddilution
(20%)ofpowder
(siportubefeed)
per100mL
368kJ
(88kcal)
2.5g
andnon-
aminoacids)
12g
(sugars1.6g)
3.3g
83%)
NilLactose-free
Short-bowelsyndrome,intractable
malabsorption,proveninamm-
atoryboweldisease,bowelstula
Notsuitableforchildunder1yearor
assolesourceofnutritioninchild
1–5years
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
Infatrini
(NutriciaClinical)
Liquid(sipor
tubefeed)
per100mL
415kJ
(100kcal)
2.6g
cows’milk
10.3g
(lactose5.2g)
5.4g800mgGluten-free
Containsshoil
Failuretothrive,disease-related
malnutritionandmalabsorption,in
childfrombirthuptobody-weight
8kg
100mL=£1.03
200mL=£1.94
Flexiblepack:
500mL=£5.25
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
2.8g
cows’milk
12.3g
(sugars1g)
4.4gNilGluten-free
Residuallactose
Standard,p.743,andgrowthfailure
inchild1–6years,body-weight8–
20kg
Bottle:200mL=£2.58
Flexiblepack:
500mL=£5.80
MultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
2.8g
wheyprotein
andcasei-
12.3g
(sugars
800mg)
4.4g800mgGluten-free
Residuallactose
Containsshoil
Standard,p.743,andgrowthfailure
inchild1–6years,body-weight8–
20kg
200mL=£2.58
Flexiblepack:
500mL=£6.45
Liquid(sipor
tubefeed)
per100mL
422kJ
(100kcal)
2.8g
cows’milk
11.2g
(sugars3.92g)
4.98gNilGluten-free
Residuallactose
Paediatric,p.743inchild1–10
years,body-weight8–30kg
Bottle:200mL=£2.10
Banana,chocolate,strawberry,
Flexiblepack:500mL=£5.24
Vanilla
Liquid(sipor
tubefeed)
per100mL
420kJ
(100kcal)
2.8g
caseinates
andwhey
10.9g
(sugars3.84g)
4.98g730mgGluten-free
Residuallactose
Paediatric,p.743inchild1–10
years,body-weight8–30kg
Bottle:200mL=£2.30
Banana,strawberry,vanilla
Flexiblepack:
500mL=£5.82
Vanilla
Liquid(sipor
tubefeed)
per100mL
420kJ
(100kcal)
wheyprotein
andcasei-
13g
(sugars2.98g)
NilGluten-free
Residuallactose
Standard,p.743,andgrowthfailure
inchild1–10years,body-weight8–
30kg
Bottle:200mL=£3.56
Vanilla
Flexiblepack:500mL=£8.89
Vanilla
Liquid(sipor
tubefeed)
per100mL
419kJ
(100kcal)
2.6g
cows’milk
andwhey
10.1g
(sugars5.6g)
5.2g400mgGluten-free
Containslactose
andsoyoil
Increasedenergyrequirements,fal-
teringgrowth,and/orneedforuid
restriction,inchildbody-weightup
to8kg
120mL=£1.23
200mL=£2.06
Tentrini
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
3.3g
wheyprotein
andcasei-
12.3g
(sugars
800mg)
4.2gNilGluten-free
Residuallactose
Containsshoil
Standard,p.743,andgrowthfailure
inchild7–12years,body-weight
21–45kg
BottleorFlexiblepack:
500mL=£4.92
Nutritionalvaluesvarywithavour—consultproductliterature
Nutritionalvaluesvarywithpacksize—consultproductliterature
A2.1Enteralfeeds(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.3.2Enteralfeeds,Child:1kcal/mLandlessthan4gprotein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1yearunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Tentrini
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
3.3g
wheyprotein
andcasei-
12.3g
(sugars
800mg)
4.2g1.1gGluten-free
Residuallactose
Containsshoil
Standard,p.743,exceptbowels-
tula,andgrowthfailureinchild7–
12yearsbody-weight21–45kg
BottleorFlexiblepack:
500mL=£5.40
HydrolysateFormula
SeealsoInfantFormula(Hydrolysate),section2.3.1
(NutriciaClinical)
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
2.8g
wheyprotein
hydrolysate
13.7g
(sugars
800mg)
3.9g
46%)
NilGluten-free
Residuallactose
Standard,p.743,andgrowthfailure
inchild1–6years,body-weight8–
20kg
Flexiblepack:
500mL=£8.71
Liquid(tubefeed)
per100mL
420kJ
(100kcal)
wheyprotein
hydrolysate
13.2g4g
60%)
NilGluten-free
Residuallactose
Hydrolysedwithporktryp-
Shortbowelsyndrome,intractable
malabsorption,proveninamm-
atoryboweldisease,bowelstula,
inchild1–10years
Flexiblepack:
500mL=£5.86
Standarddilution
(22%)ofpowder
(siportubefeed)
per100mL
420kJ
(100kcal)
wheyprotein
hydrolysate
13.8g3.85g
60%)
NilGluten-free
Residuallactose
Hydrolysedwithbacterial
Can:400g=£15.36
Vanilla
(7.86-gmeasuringscooppro-
Powderprovides:protein13.7g,carbohydrate62.9g,fat17.5g,energy1910kJ(457kcal)/100g
A2.1.3.3Enteralfeeds,Child:Morethan1kcal/mLandlessthan4gprotein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(NutriciaClinical)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
3.4g
cows’milk
18.8g
(sugars7.4g)
6.8gNilGluten-free
Residuallactose
Disease-relatedmalnutritionand
growthfailureinchild1–6years,
body-weight8–20kg
Bottle:200mL=£2.77
Strawberry,vanilla
(NutriciaClinical)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
3.4g
cows’milk
18.8g
(sugars7.4g)
6.8g1.5gGluten-free
Residuallactose
Disease-relatedmalnutritionand
growthfailureinchild1–6years,
body-weight8–20kg
Bottle:200mL=£2.91
Banana,chocolate,strawberry,
vanilla,andunavoured
(NutriciaClinical)
Liquid(sipfeed)
per100mL
625kJ
(150kcal)
3.4g
cows’milk
19g
(sugars11.5g)
6.4g1.4gGluten-free
Residuallactose
Disease-relatedmalnutritionand
growthfailureinchild1–6years,
body-weight8–20kg
Bottle:200mL=£2.91
Berryfruit,summerfruit
BNFC2011–
A2.1Enteralfeeds(non-diseasespecic)
Appendix2:Borderlinesubstances
(FreseniusKabi)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
3.8g
cows’milk
18.7g
(sugars4.5g)
6.7gNilGluten-free
Residuallactose
Disease-relatedmalnutritionand
growthfailureinchild1–10years,
body-weight8–30kg
Bottle:200mL=£2.42
Banana,strawberry
(FreseniusKabi)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
3.75g
cows’milk
18.75g
(sugars
830mg)
6.7gNilGluten-free
Residuallactose
Containsshoilandsh
Standard,p.743,andfailurein
child1–10years,body-weight8–
30kg
Flexiblepack:
500mL=£6.21
FibreDrink
(FreseniusKabi)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
3.8g
cows’milk
18.75g
(sugars4.5g
6.7g1.1gGluten-free
Residuallactose
Disease-relatedmalnutritionand
growthfailureinchild1–10years,
body-weight8–30kg
Bottle:200mL=£2.47
Chocolate,vanilla
(FreseniusKabi)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
3.75g
cows’milk
18.75g
(sugars
830mg)
6.7g1.13gGluten-free
Residuallactose
Containsshoilsandsh
Standard,p.743,andgrowthfailure
inchild1–10years,body-weight8–
30kg
Flexiblepack:
500mL=£6.82
Isosource
Liquid(tubefeed)
per100mL
512kJ
(122kcal)
2.7g
cows’milk
17g
4.7gNilGluten-free
Residuallactose
Standard,p.743,andgrowthfailure
inchild1–6years,body-weight8–
20kg
Flexiblepack:
500mL=£4.99
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
cows’milk
20.6g
(sugars4.9g)
6.2gNilGluten-free
Residuallactose
Standard,p.743inchild1–10
Bottle:200mL=£1.84
Chocolate,strawberry,vanilla
Sugarcontentvarieswithavour
Nutritionalvaluesvarywithavour—consultproductliterature
A2.1.3.4Enteralfeeds,Child:1.5kcal/mLandmorethan4gprotein/100mL
Notsuitableforuseinchildunder1yearunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(NutriciaClinical)
Liquid(tube
per100mL
630kJ
(150kcal)
4.1g
caseinate
wheyprotein
18.5g
(sugars1.1g)
6.7gNilGluten-free
Residuallactose
Containsshoil
Standard,p.743,andgrowthfailure
inchild1–6years,body-weight8–
20kg
Bottle:200mL=£2.84
Flexiblepack:
500mL=£7.28
MultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
4.1g
caseinate
wheyprotein
18.5g
(sugars1.1g)
6.7g800mgGluten-free
Residuallactose
Containsshoil
Paediatric,p.743exceptbowels-
totalgastrectomy,inchild
1–6years,body-weight8–20kg
Bottle:200mL=£3.01
Flexiblepack:
500mL=£7.50
A2.2Nutritionalsupplements(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.1.3.4Enteralfeeds,Child:1.5kcal/mLandmorethan4gprotein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1yearunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Liquid(sipor
tubefeed)
per100mL
632kJ
(151kcal)
4.2g
caseinates
wheyprotein
16.7g
7.47gNilGluten-free
Residuallactose
Paediatric,p.743inchild1–10
years,body-weight8–30kg
Bottle:200mL=£2.56
Banana,strawberry,vanilla,
unavoured
Flexiblepack:
500mL=£6.57
Vanilla
Liquid(sipor
tubefeed)
per100mL
626kJ
(150kcal)
4.2g
caseinates
wheyprotein
16.4g
7.47g1.1gGluten-free
Residuallactose
Paediatric,p.743inchild1–10
years,body-weight8–30kg
Bottle:200mL=£2.79
Vanilla
Flexiblepack:
500mL=£7.00
Vanilla
Tentrini
(NutriciaClinical)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
4.9g
wheyprotein
andcasei-
18.5g
(sugars1.1g)
6.3gNilGluten-free
Residuallactose
Containsshoil
Standard,p.743,andgrowthfail-
ure,inchild7–12years,body-
weight21–45kg
BottleorFlexiblepack:
500mL=£6.07
Tentrini
MultiFibre
(NutriciaClinical)
Liquid(tubefeed)
per100mL
630kJ
(150kcal)
4.9g
wheyprotein
andcasei-
18.5g
(sugars1.1g)
6.3g1.1gGluten-free
Residuallactose
Containsshoil
Paediatric,p.743,andproven
inammatoryboweldisease,in
child7–12years,body-weight21–
45kg
BottleorFlexiblepack:
500mL=£6.70
Sugarcontentvarieswithpresentation
A2.2Nutritionalsupplements(non-diseasespeciÞc)
A2.2.1Nutritionalsupplements:lessthan5gprotein/100mL
A2.2.1.1Nutritionalsupplements:1kcal/mLandlessthan5gprotein/100mL
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Liquid(sipor
tubefeed)
per100mL
423kJ
(100kcal)
caseinates
soyisolate
13.6g
(sugars3.93g)
3.36gNilGluten-free
Residuallactose
Standard,p.743
Can:250mL=£2.07
Chocolate,coffee,vanilla
Nutritionalvaluesvarywithavour—consultproductliterature
BNFC2011–
A2.2Nutritionalsupplements(non-diseasespecic)
Appendix2:Borderlinesubstances
A2.2.1.2Nutritionalsupplements:Morethan1kcal/mLandlessthan5gprotein/100mL
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
PlusJuce
Liquid(sipfeed)
per100mL
638kJ
(150kcal)
4.8g
wheyprotein
32.7g
(sugars9.4g
NilNilGluten-free
Residuallactose
Non-milktaste
Standard,p.743
Bottle:220mL=£1.80
Apple,fruitpunch,lemon-lime,
orange,peach,strawberry
(NutriciaClinical)
Liquid(sipfeed)
per100mL
640kJ
(150kcal)
4.0g
cows’milk
33.5g
(sugars
13.1g
NilNilGluten-free
Residuallactose
Non-milktaste
Standard,p.743
Notsuitableforchildunder3years
Bottle:200mL=£1.85
Apple,blackcurrant,forestfruits,
lemon,orange,strawberry,
tropical
Starterpack(mixed)
200mL=£7.40
Juce
Liquid(sipfeed)
per100mL
638kJ
(150kcal)
4.2g
cows’milk
33.3g
(sugars9.4g)
NilNilGluten-free
Residuallactose
Non-milktaste
Nutritionalsupplementinchild1–
10years,body-weight8–30kgwith
disease-relatedmalnutritionand,or
growthfailure
Bottle:200mL=£2.77
Apple,veryberry
ProvideXtra
Juice
(FreseniusKabi)
Liquid(sipfeed)
per100mL
525kJ
(125kcal)
3.75g
peaandsoya
hydrolysates
27.5g
NilNil
Non-milktaste
A2.2Nutritionalsupplements(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.2.2Nutritionalsupplements:5g(ormore)protein/100mL
A2.2.2.1Nutritionalsupplements:1.5kcal/mLand5g(ormore)protein/100mL
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
PlusFibre
Liquid(sipor
tubefeed)
per100mL
642kJ
(153kcal)
6.25g
cows’milk
soyaprotein
20.2g
(sugars5.5g)
4.92g2.5gGluten-free
Residuallactose
Standard,p.743;
CAPD,haemodialysis
Bottle:200mL=£1.85
Banana,chocolate,fruitsofthe
forest,raspberry,strawberry,
Milkshakestyle
Liquid(sipor
tubefeed)
per100mL
632kJ
(150kcal)
6.25g
cows’milk
soyaprotein
20.2g
(sugars5.6g
incl.sucrose)
4.92gNilGluten-free
Residuallactose
Standard,p.743;
CAPD,
haemodialysis
Can:250mL=£2.35
Chicken,mushroom
Bottle:220mL=£1.85
Banana,blackcurrant,caramel,
chocolate,coffee,fruitsofthe
forest,orange,peach,raspberry,
strawberry,vanilla,neutral
Yoghurtstyle
Liquid(sipfeed)
per100mL
632kJ
(150kcal)
6.25g
cows’milk
20.2g
(sugars11.7g)
4.92gNilGluten-free
Residuallactose
Standard,p.743;
CAPD,
haemodialysis
Bottle:220mL=£1.85
Orange,peach,pineapple,straw-
Commence
Starterpack(5–10day’ssupply),contains:
PlusMilkshakeStyle
(variousavours),1pack(10
220-mL)=£18.52.
(NutriciaClinical)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
cows’milk
18.4g
5.8gNilGluten-free
Residuallactose
Standard,p.743
Notsuitableforchildunder3years
Bottle:200mL=£1.85
Banana,chocolate,neutral,
orange,strawberry,toffee,
tropicalfruits,vanilla
(NutriciaClinical)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
cows’milk
18.4g
(sugars7.0g)
5.8g2.3gGluten-free
Residuallactose
Standard,p.743
Notsuitableforchildunder3years
Bottle:200mL=£1.91
Banana,chocolate,orange,
strawberry,vanilla
Yoghurt
(NutriciaClinical)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
cows’milk
18.7g
(sugars10.8g)
5.8g200mgGluten-free
Containslactose
Standard,p.743
Notsuitableforchildunder3years
Bottle:200mL=£1.85
Peach-orange,raspberry,vanilla-
Nutritionalvaluesvarywithavour—consultproductliterature
Sugarcontentvarieswithavour
BNFC2011–
A2.2Nutritionalsupplements(non-diseasespecic)
Appendix2:Borderlinesubstances
(NutriciaClinical)
Starterpackcontains4
Fortisip
Bottle,4
,2
YogurtStyle,1pack(10
200mL)=£18.50.
EnergyDrink
(FreseniusKabi)
Liquid(sipfeed)
per100mL
630kJ
(150kcal)
10g
cows’milk
12.4g
(sugars6.4g
6.7gNil
Residuallactose
Containsshgelatin
Standard,p.743;
CAPD,haemodialysis
Bottle:200mL=£1.82
Cappuccino,chocolate,straw-
berry,tropicalfruits,vanilla
Thickened
(FreseniusKabi)
Liquid(sip
per100mL
630kJ
(150kcal)
10g
cows’milk
12.2g
(sugars7.1g
6.7g480mg
Residuallactose
Dysphagiaordisease-relatedmal-
nutrition
Notsuitableforchildunder3years.
Bottle:200mL=£2.10
Syrup(Stage1)andcustard
(Stage2)consistencies
Strawberry,vanilla
Sugarcontentvarieswithavour
Fibrecontentvarieswithavour
Sugarcontentvarieswithconsistency
Fibrecontentvarieswithconsistency
A2.2.2.2Nutritionalsupplements:Lessthan1.5kcal/mLand5g(ormore)protein/100mL
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Clinutren
per100g
520kJ
(125kcal)
9.5g
cows’milk
15.5g
(sugars14g
2.6g500mg
Containslactose
Standard,p.743;
CAPD,haemodialysis
Notsuitableforchildunder3years
Pot:4
125g=£5.88
Caramel,chocolate,peach,vanil-
Cre
per100g
574kJ
(137kcal)
5.68g
cow’smilk
soyprotein
18.4g
(sugars12.4g)
4.47gNilGluten-free
Residuallactose
Containssoya
Standard,p.743;
CAPD,haemodialysis
Notsuitableforchildunder3years
Pot:125g=£1.72
Banana,chocolate,neutral,
Regular
(NutriciaClinical)
Liquid(sipfeed)
per100mL
420kJ
(100kcal)
10g
cows’milk
10.3g
(sugars8.1g
2.1gNilGluten-free
Containslactose
Standard,p.743
Notsuitableforchildunder3years
Bottle:200mL=£1.57
Chocolate,forestfruits,straw-
berry,vanilla
(NutriciaClinical)
Semi-Solid
per100g
560kJ
(133kcal)
wheyisolate
16.7g
(sugars11.3g)
4g2.6gResiduallactose
Standard,p.743
exceptbowelstula;
CAPD,
haemodialysis
Notsuitableforchildunder3years
Pot:3
150g=£6.49
Apple,strawberry
Sugarcontentvarieswithavour
Fibrecontentvarieswithavour
Nutritionalvaluesvarywithavour—consultproductliterature
A2.2Nutritionalsupplements(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.2.2.2Nutritionalsupplements:Lessthan1.5kcal/mLand5g(ormore)protein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
OralImpact
Standarddilution
ofpowder(74g
in250mLwater)
(sipfeed)
per100mL
425kJ
(101kcal)
5.6g
cows’milk
13.4g
(sugars7.4g)
2.8g1gResiduallactose
Containsshoil
Pre-operativenutritionalsupple-
mentformalnourishedpatientsor
patientsatriskofmalnourishment
Notsuitableforchildunder3years
BNFC2011–
A2.2Nutritionalsupplements(non-diseasespecic)
Appendix2:Borderlinesubstances
A2.2Nutritionalsupplements(non-diseasespecic)
BNFC2011–
Appendix2:Borderlinesubstances
A2.2.2.3Nutritionalsupplements:Morethan1.5kcal/mLand5g(ormore)protein/100mL
(productlistcontinued)
Notsuitableforuseinchildunder1year;usewithcautioninchild1–5yearsunlessotherwisestated
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Vegenat-med
BalancedProtein
(Vegenat)
per110gserving
1924kJ
(458kcal)
18g
cows’milk
62g
15.35g5.8gGluten-free
Residuallactose
Standard,p.743exceptbowels-
Notsuitableforchildunder14years
BNFC2011–
A2.3Specialisedformulas
Appendix2:Borderlinesubstances
A2.3Specialisedformulas
A2.3.1Specialisedformulas:Infantandchild
Specialisedformulasaresuitableforinfantsfrombirthunlessotherwiseindicated(
seealso
A2.1.3.1Enteralfeeds(non-diseasespecic):Childunder12years)
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Specialisedformulas:Infantandchild:Aminoacid-basedformula
ACBSIndications
:Provenwholeproteinintolerance,shortbowelsyndrome,intractablemalabsorption,orothergastro-intestinaldisorderswhereanelementaldietisindicated
Neocate
Standarddilution
(21%)ofpowder
per300mLser-
A2.3Specialisedformulas
BNFC2011–
Appendix2:Borderlinesubstances
A2.3.1Specialisedformulas:Infantandchild
(productlistcontinued)
Specialisedformulasaresuitableforinfantsfrombirthunlessotherwiseindicated(
seealso
A2.1.3.1Enteralfeeds(non-diseasespecic):Childunder12years)
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(MeadJohnson)
Standarddilution
(13.6%)ofpow-
per100mL
286kJ
(68kcal)
1.89g
essentialand
aminoacids
7g
3.6gNilGluten-free
Severecows’milkproteinintoler-
ance,ormultiplefoodintolerance,
andothergastro-intestinaldisor-
BNFC2011–
A2.3Specialisedformulas
Appendix2:Borderlinesubstances
Lipil2
(MeadJohnson)
Standarddilution
(14.6%)ofpow-
per100mL
285kJ
(68kcal)
1.7g
caseinhydro-
8.6g
2.9gNilGluten-free
Establisheddisaccharideand/or
wholeproteinintolerance(where
additionalchaintriglyceridesarenot
indicated)
Notsuitableforchildunder6
Can:
400g=£8.95
(4.9-gmeasuringscoopprovided)
Powderprovides:protein11.6g,carbohydrate59g,fat20g,energy1950kJ(466kcal)/100g
Standarddilution
(15%)ofpowder
per100mL
297kJ
(71kcal)
2.1g
hydrolysate)
7.8g
(sugars
700mg)
3.5gNilLactose-free
Containsmeat(pork)and
soyaderivatives
Disaccharideand/orwholeprotein
intolerance
Can:
400g=£15.05
(5-gmeasuringscoopprovided)
Powderprovides:proteinequivalent13.8g,carbohydrate52g,fat23.2g,energy1977kJ(472kcal)/100g
Standarddilution
(22.8%)ofpow-
per100mL
423kJ
(100kcal)
3.1g
hydrolysate,
aminoacids)
13g
(sugars1.2g)
3.9g
35%)
NilLactose-free
Containsmeat(pork)and
soyaderivatives
Disaccharideand/orwholeprotein
intolerance,orwhereaminoacidsor
peptidesareindicatedinconjunc-
tionwithmediumchaintriglycerides
Notsuitableforchildunder1year
Can:
400g=£15.81
Unavoured
Powderprovides:proteinequivalent13.8g,carbohydrate57g,fat17.3g,energy1844kJ(439kcal)/100g
(MeadJohnson)
Standarddilution
(13.5%)ofpow-
per100mL
280kJ
(68kcal)
1.89g
caseinhydro-
6.9g
3.8g
54%)
NilGluten-free
Disaccharideand/orwholeprotein
intolerance,orwhereaminoacidsor
peptidesareindicatedinconjunc-
tionwithmediumchaintriglycerides
Can:
400g=£10.18
(4.5-gmeasuringscoopprovided)
Powderprovides:protein14g,carbohydrate51g,fat28g,energy2100kJ(500kcal)/100g
Specialisedformulas:Infantandchild:Residuallactoseformula
Enfamil
(MeadJohnson)
Standarddilution
(13%)ofpowder
per100mL
280kJ
(68kcal)
1.42g
cows’milk
7.2g
3.7gNilGluten-free
Residuallactose
Provenlactoseintolerance
Can:
400g=£4.16
(4.3-gmeasuringscoopprovided)
Powderprovides:protein10.9g,carbohydrate55g,fat28g,energy2200kJ(524kcal)/100g
Galactomin17
Standarddilution
(13.6%)ofpow-
per100mL
295kJ
(70kcal)
1.7g
(cows’milk)
7.5g
(sugars1.4g)
3.7gNilResiduallactose
Provenlactoseintoleranceinpre-
schoolchildren,galactosaemia,and
galactokinasedeciency
Can:
400g=£14.13
Unavoured
(4.3-gmeasuringscoopprovided)
Powderprovides:proteinequivalent12.3g,carbohydrate55.3g,fat27.2g,energy2155kJ(515kcal)/100g
Flavouring:see
FlavourSystem,p.777
A2.3Specialisedformulas
BNFC2011–
Appendix2:Borderlinesubstances
A2.3.1Specialisedformulas:Infantandchild
(productlistcontinued)
Specialisedformulasaresuitableforinfantsfrombirthunlessotherwiseindicated(
seealso
A2.1.3.1Enteralfeeds(non-diseasespecic):Childunder12years)
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(SMANutrition)
Standarddilution
(13%)ofpowder
per100mL
281kJ
(67kcal)
1.5g
casein,whey
7.2g
(sugars2.6g)
3.6gNilResiduallactose
Provenlactoseintolerance
Can:
430g=£4.60.
Powderprovides:protein12g,carbohydrate55.6g,fat28g,energy2185kJ(522kcal)/100g
Specialisedformulas:Infantandchild:MCT-enhancedformula
Caprilon
Standarddilution
(12.7%)ofpow-
per100mL
277kJ
(66kcal)
1.5g
cows’milk
(sugars1.3g)
3.6g
75%)
NilContainslactose
Disordersinwhichahighintakeof
MCTisbenecial
Can:
420g=£14.62
(4.2-gmeasuringscoopprovided)
Powderprovides:protein11.8g,carbohydrate55.1g,fat28.3g,energy2184kJ(522kcal)/100g
MCTPepdite
Standarddilution
(15%)ofpowder
per100mL
286kJ
(68kcal)
aminoacids)
8.8g
(sugars1.2g)
2.7g
75%)
NilGluten-free
Containsmeat(pork)and
soyaderivatives
Disordersinwhichahighintakeof
MCTisbenecial
Can:
400g=£16.39
(5-gmeasuringscoopprovided)
Powderprovides:proteinequivalent13.8g,carbohydrate59g,fat18g,energy1903kJ(453kcal)/100g
MCTPepdite
Standarddilution
(20%)ofpowder
per100mL
381kJ
(91kcal)
2.8g
aminoacids)
11.8g
(sugars1.6g)
3.6g
75%)
NilGluten-free
Containsmeat(pork)and
soyaderivatives
Disordersinwhichahighintakeof
MCTisbenecial
Notsuitableforchildunder1year
Can:
400g=£16.39
Unavoured
Powderprovides:proteinequivalent13.8g,carbohydrate59g,fat18g,energy1903kJ(453kcal)/100g
Standarddilution
(17.5%)ofpow-
per100mL
313kJ
(74kcal)
12g
(sugars1.2g)
2.1g
90%)
NilResiduallactose
Supplementationwith
essentialfattyacidsmay
beneeded
Long-chainacyl-CoAdehydrogenase
deciency(LCAD),carnitinepalmi-
toyltransferasedeciency(CPTD),
primaryandsecondarylipoprotein
lipasedeciency
Can:
400g=£17.07
Unavoured
(5-gmeasuringscoopprovided)
Powderprovides:proteinequivalent11.4g,carbohydrate68g,fat11.8g,energy1786kJ(424kcal)/100g
Flavouring:see
FlavourSystem,p.777
BNFC2011–
A2.3Specialisedformulas
Appendix2:Borderlinesubstances
Specialisedformulas:Infantandchild:Soya-basedformula
InfaSoy
(Cow&Gate)
Standarddilution
(12.8%)ofpow-
per100mL
275kJ
(66kcal)
1.6g
(sugars1g)
3.5gNilLactose-free
Provenlactoseandassociatedsuc-
roseintoleranceinpre-schoolchil-
dren,galactokinasedeciency,
galactosaemia,andprovenwhole
cows’milksensitivity
Can:
900g=£7.47
(4.3-gmeasuringscoopprovided)
Powderprovides:protein12.8g,carbohydrate54.5g,fat27.3g,energy2150kJ(514kcal)/100g
A2.3Specialisedformulas
BNFC2011–
Appendix2:Borderlinesubstances
A2.3.2SpecialisedformulasforspeciÞcclinicalconditions
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Alicalm
Standarddilution
(30%)ofpowder
per100mL
567kJ
(135kcal)
4.5g
caseinate
17.4g
(sugars3.2g)
5.3gNilResiduallactose
Crohn’sdisease
Notsuitableforchildunder1year;
useasnutritionalsupplementonly
inchildren1–6years.
Powder:
400g=£18.08
Vanilla
Powderprovides:protein15g,carbohydrate58g,fat17.5g,energy1889kJ(450kcal)/100g
(NutriciaClinical)
Liquid(sipfeed)
per100mL
675kJ
(160kcal)
cows’milk
19.1g
(sugars13.6g)
5.3g2.1gGluten-free
Residuallactose
Containsshoil
Nutritionalsupplementinpatients
withlungcancerundergoing
chemotherapy,orwithpancreatic
cancer
Notsuitableinchildunder3years
Carton:
125mL=£2.02
Cappuccino,orange-lemon,
peach-ginger.
per100g
1586kJ
(374kcal)
76g
(wheypro-
tein,plus
branched
chainamino
(sugars5g)
5.5gNilElectrolytes/100g:
6.1mmol
10.8mmol
6.5mmol
6.45mmol
Nutritionalsupplementforusein
chronicliverdiseaseand/orporto-
hepaticencephalopathy
Tub:
400g=£51.46
Unavoured
Standarddilution
(22%)ofpowder
per100mL
428kJ
(102kcal)
2.4g
(wheypro-
branched
chainamino
13.6g
(sugars1.4g)
4.2g
32%)
NilElectrolytes/100mL:
0.7mmol
2.7mmol
1.72mmol
1.67mmol
Enteralfeedornutritionalsupple-
mentinchildrenover1yearwith
hepaticdisorders
Can:
400g=£18.40
Unavoured
(5-gmeasuringscoopprovided)
Powderprovides:proteinequivalent11g,carbohydrate62g,fat19g,energy1944kJ(463kcal)/100g
Standarddilution
(18%)ofpowder
per100mL
363kJ
(86kcal)
cows’milk
11.6g
(sugars2.9g)
3.6gNilContainslactose
Electrolytes/100mL:
0.56mmol
1.9mmol
2.3mmol
1.6mmol
Enteralfeedornutritionalsupple-
mentforchildrenwithacuteor
chronicliverfailure
Can:400g=£18.20
(4.5-gmeasuringscoopprovided)
Powderprovides:protein11.1g,carbohydrate64.2g,fat19.9g,energy2016kJ(480kcal)/100g
Flavouring:see
FlavourSystem,p.777
BNFC2011–
A2.3Specialisedformulas
Appendix2:Borderlinesubstances
A2.3Specialisedformulas
BNFC2011–
Appendix2:Borderlinesubstances
A2.3.2SpecialisedformulasforspeciÞcclinicalconditions
(productlistcontinued)
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
(KoRa)
Powder(sipor
tubefeedwhen
reconstituted)
per100g
2003kJ
(477kcal)
4.6g
cows’milk
70.8g19.3gNilContainslactose
Electrolytes/100g:
1.04mmol
0.13mmol
10.22mmol
1.06mmol
ContainsnovitaminAor
vitaminD
Enteralfeedornutritionalsupple-
mentforadultsandchildrenover1
yearwithchronicrenalfailure
BNFC2011–
A2.4Feedsupplements
Appendix2:Borderlinesubstances
A2.4Feedsupplements
A2.4.1High-energysupplements
A2.4.1.1High-energysupplements:carbohydrate
Flavouredcarbohydratesupplementsarenotsuitableforchildunder1year;liquidsupplementsshouldbedilutedbeforeuseinchildunder5years
ACBSIndications
:disease-relatedmalnutrition,malabsorptionstates,orotherconditionsrequiringforticationwithahighorreadilyavailablecarbohydratesupplement
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Caloreen
per100g
1640kJ
(390kcal)
96g
Maltodextrin
NilNilGluten-free
Seeabove
Notsuitableforchildunder3years
Powder:500g=£3.52
Unavoured
(10-gmeasuringscoopprovided)
per100g
1615kJ
(380kcal)
95g
Glucosepoly-
(sugars8.6g)
NilNilGluten-free
Seeabove
A2.4Feedsupplements
BNFC2011–
Appendix2:Borderlinesubstances
A2.4.1.1High-energysupplements:carbohydrate
(productlistcontinued)
Flavouredcarbohydratesupplementsarenotsuitableforchildunder1year;liquidsupplementsshouldbedilutedbeforeuseinchildunder5years
ACBSIndications
:disease-relatedmalnutrition,malabsorptionstates,orotherconditionsrequiringforticationwithahighorreadilyavailablecarbohydratesupplement
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
per100g
1610kJ
(380kcal)
96g
Driedglucose
NilNilGluten-free
Seeabove
Can:
500g=£3.66
2.5kg=£17.83
25kg=£107.39
(10-gmeasuringscoopprovided)
A2.4.1.2High-energysupplements:fat
Liquidsupplementsshouldbedilutedbeforeuseinchildunder5years
ACBSindications
:disease-relatedmalnutrition,malabsorptionstates,orotherconditionsrequiringforticationwithahighfat(orfatandcarbohydrate)supplement
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Calogen
(NutriciaClinical)
Liquid(emulsion)
per100mL
1850kJ
(450kcal)
100mg50g
(LCT
100%)
NilGluten-free
Seeabove
200mL=£4.00
500mL=£9.83
,neutral,strawberry
5kcal
(FreseniusKabi)
Liquid(emulsion)
per100mL
2100kJ
(500kcal)
4.0g
(sucrose)
53.8g400mgGluten-free
Seeabove
Notsuitableforchildunder3years
120mL=£2.55
Lemon,neutral
Liquid(emulsion)
per100mL
1850kJ
(450kcal)
50g
97%)
coconut
NilGluten-free
Steatorrhoeaassociatedwithcystic
brosisofthepancreas,intestinal
lymphangiectasia,intestinalsur-
gery,chronicliverdisease,liver
cirrhosis,otherprovenmalabsorp-
BNFC2011–
A2.4Feedsupplements
Appendix2:Borderlinesubstances
Medium-chain
Triglyceride(MCT)
per100mL
3515kJ
(855kcal)
100%
Nutritionalsupplementforsteator-
rhoeaassociatedwithcysticbrosis
ofthepancreas,intestinallymph-
angiectasia,intestinalsurgery,
chronicliverdiseaseandlivercirrh-
osis,otherprovenmalabsorption
A2.4Feedsupplements
BNFC2011–
Appendix2:Borderlinesubstances
A2.4.1.3High-energysupplements:protein
(productlistcontinued)
ACBSindications
:disease-relatedmalnutrition,malabsorptionstates,orotherconditionsrequiringforticationwithahighfatorcarbohydrate(withprotein)supplement
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
Protifar
(NutriciaClinical)
per100g
1580kJ
(373kcal)
88.5g
cows’milk
lessthan1.5g1.6gNilGluten-free
Residuallactose
Electrolytes/100mL:
1.3mmol
1.28mmol
33.75mmol
22.58mmol
Nutritionalsupplementforusein
biochemicallyprovenhypoprotein-
Can:
225g=£7.44
Unavoured
(2.5-gmeasuringscoopprovided)
Powderprovides:protein2.2gper2.5g
per100g
1506kJ
(360kcal)
75g
wheyprotein
9g
6gNilContainslactose
Biochemicallyprovenhypoprotein-
Tub:
250g=£7.47
2kg=£58.69
(5-gmeasuringscoopprovided)
Proteinandcarbohydrate
Standarddilution
(20%)ofpowder
per100mL
264kJ
(62kcal)
4.3g
andnon-
aminoacids)
11.2g
(sugars10.2g)
NilNilContainsvitaminCHypoproteinaemia,chronicrenal
failure,woundstulaleakagewith
excessiveproteinloss,conditions
requiringacontrollednitrogen
intake,andhaemodialysis
Notsuitableforchildunder6
Can:400g=£61.74
Powderprovides:proteinequivalent25g,carbohydrate65g,vitaminC125mg,energy1530kJ(360kcal)/100g
ProSource
per30mL
420kJ
(100kcal)
10g
collagenpro-
wheyprotein
15g
(sugars8g)
NilNilGluten-free
Maycontainporcinederi-
Biochemicallyprovenhypoprotein-
Notrecommendedforchildunder3
BNFC2011–
A2.4Feedsupplements
Appendix2:Borderlinesubstances
Calshake
(FreseniusKabi)
per87g
1841kJ
(439kcal)
4.1g
cows’milk
56.4g
(sugars20g)
22gNilContainslactose
Seeabove
Notsuitableforchildunder1year
A2.4Feedsupplements
BNFC2011–
Appendix2:Borderlinesubstances
A2.4.2Fibre,vitamin,andmineralsupplements
FormulationEnergyProteinCarbohydrateFatFibreSpecial
Indications
Presentation
&Flavour
High-Þbresupplements
per100g
323kJ
(76kcal)
19g
guargum,par-
tiallyhydro-
lysed
Nil78gGluten-free
Standard,p.743exceptdysphagia
Notsuitableforchildunder5years
Feedadditives
A2.5.1
Specialadditivesfor
conditionsofintolerance
Colief
(GlutenFreeFoodsLtd)
.Loaf,multigrain500g=£4.83.Loaf,sliced,
wholemeal500g=£3.36.Loaf,sliced,part-baked,country-
style250g=£3.69.Loaf,sliced,part-baked,white550g=
£4.88.Ricebread,brown500g=£4.83;white500g=£4.83
Appendix2:Borderlinesubstances
(NutritionPoint)
.Loaf,sliced,fresh,brown400g=£3.25;white
400g=£3.25.Loaf,sliced,bre400g=£3.12;white400g=
£3.12.Loaf,seeded400g=£3.39
.Loaf,sliced,fresh,bre400g=£2.97;white
400g=£3.23.Loaf,sliced,white400g=£3.10;bre400g=
£3.10.Loaf,white400g=£3.10;bre400g=£3.10.Loaf,
part-baked,bre400g=£3.33;white400g=£3.46
.Loaf,sliced,brown400g=£2.82;highbre
400g=£2.82;white400g=£2.82.Loaf,brown400g=
£2.82;highbre400g=£2.82;white400g=£2.82
.Loaf,sliced,brown(seeded)200g=£2.25;
white200g=£2.25
Pasticely
(GFFTrade)
.Loaf,sandwich,sliced,white260g=£3.29;
rustic,sliced,white260g=£3.29
Proceli
.Loaf,sliced,white165g=£2.30;sandwich
155g=£2.32.Ricebread,brown220g=£2.30;sandwich
220g=£2.30
(Everfresh)
.Loaf,mixedgrain,sourdough400g=£1.91
.Loaf,white400g=£2.46;highbre500g=
Wellfoods
(Wellfoods)
.Loaf,sliced600g=£4.95;unsliced600g=
Specialitybreads
.Flatbread(pitta)4=£3.00.Tear-dropshape
(naan)2
90g=£3.00
Proceli
.Flatbread(pitta),part-baked3
40g=£4.36
Cookiesandbiscuits
(GlutenFreeFoodsLtd)
.Biscuits,coffee-style200g=£2.86;digestive
175g=£2.20
Appendix2:Borderlinesubstances
Flourmixesandxanthangum
Flourmixes
(GlutenFreeFoodsLtd)
.Flourmix,bread500g=£5.74.Plain750g=
Xanthangum
Appendix2:Borderlinesubstances
Proceli
.Pizzabase2
250g=£3.90
.Pizzabase2
200g=£2.65
Wellfoods
(Wellfoods)
.Pizzabase2
300g=£8.95
A2.6.1.1
Gluten-andwheat-freefoods
ACBSindications:
establishedgluten-sensitive
enteropathieswithcoexistingestablishedwheatsen-
sitivityonly.
Appendix2:Borderlinesubstances
LoproÞn
.Mix,plain500g=£7.09;chocolate500g=
£7.50;lemon500g=£7.50.Eggreplacer2
250g=£13.03.
Egg-whitereplacer100g=£8.38
PKFoods
(GlutenFreeFoodsLtd)
.Flourmix750g=£9.91.Eggreplacer350g=
ACBSIndications
LoproÞn
.Pasta,animalshapes500g=£7.13;conchigle
Maxamaidproductsaregenerallyintendedforusein
children1–8years
BNFC2011–
Appendix2:Borderlinesubstances
HCUcooler
,protein(essentialandnon-essentialaminoacids
Maxamaidproductsaregenerallyintendedforusein
children1–8years
Maxamumproductsaregenerallyintendedforusein
childrenover8years
Appendix2:Borderlinesubstances
MSUDAnamix
,proteinequivalent(essentialandnon-essential
aminoacidsexceptisoleucine,leucine,andvaline)13.1g,
carbohydrate49.5g,fat23g,bre5.3g,energy1915kJ
(457kcal)/100g,withvitamins,minerals,andtraceele-
standarddilution
(15%)providesproteinequivalent
2g,carbohydrate7.4g,fat3.5g,bre800mg,energy287kJ
Maxamaidproductsaregenerallyintendedforusein
children1–8years
Maxamumproductsaregenerallyintendedforusein
childrenover8years
BNFC2011–
Appendix2:Borderlinesubstances
,protein(cows’milk,soya)100mg,carbohydrate
3.2g,fat500mg(ofwhichdocosahexaenoicacid200mg),
Appendix2:Borderlinesubstances
PKUAnamix
FirstSpoon
,proteinequivalent(essentialandnon-essential
aminoacidsexceptphenylalanine)5g,carbohydrate4.8g,
Maxamaidproductsaregenerallyintendedforusein
children1–8years
BNFC2011–
Appendix2:Borderlinesubstances
XPMaxamum
,proteinequivalent(essentialandnon-essential
aminoacidsexceptphenylalanine)39g,carbohydrate34g,
fatlessthan500mg,energy1260kJ(297kcal)/100g,with
vitamins,minerals,andtraceelements.Orange,oruna-
voured(avouring;see
FlavourSystem,p.777),
Maxamumproductsaregenerallyintendedforusein
childrenover8years
Maxamaidproductsaregenerallyintendedforusein
children1–8years
Appendix2:Borderlinesubstances
DisÞguringskinlesions(birthmarks,mutilating
lesions,scars,vitiligo)
classicfoundationandnishingpowder;
Camouagecreamandxingpowder;
maskingcreamandnishingpowder;
CovercreamandFinishingPowder.(CleansingCreams,
CleansingMilks,andCleansingLotionsareexcluded)
Disinfectants(antiseptics)
MaybeprescribedonanFP10onlywhenorderedin
suchquantitiesandwithsuchdirectionsasareappro-
priateforthetreatmentofpatients,butnotforgeneral
hygenicpurposes
Drymouth(xerostomia)
Forpatientssufferingfromdrymouthasaresultof
having(orhavingundergone)radiotherapy,orsicca
syndrome.
ASSalivaOrthana
neOralbalance
Appendix2:Borderlinesubstances
Cautionaryandadvisory
labelsfordispensed
Preparationsinthe
BNFforChildren
includecode
numbersofthecautionarylabelsthatpharmacistsare
recommendedtoaddwhendispensing.Itisalso
expectedthat,whennecessary,pharmacistswill
counselchildrenortheircarers.
Counsellingneedstoberelatedtotheage,experi-
ence,background,andunderstandingofthechildor
carer.Thepharmacistshouldensureunderstandingof
howtotakeorusethemedicineandhowtofollowthe
correctdosageschedule.Anyeffectsofthemedicine
onco-ordination,performanceofskilledtasks,any
foodsormedicinestobeavoided,andwhattodoifa
doseismissedshouldalsobeexplained.Othermat-
ters,suchasthepossibilityofstainingoftheclothesor
skin,ordiscolorationofurineorstoolsbyamedicine
shouldalsobementioned.
Forsomepreparationsthereisaspecialneedfor
Appendix3:Cautionaryandadvisorylabels
Ifseparatelabelsareuseditisrecommendedthatthe
wordingsbeusedwithoutmodiÞcation.Ifchangesare
madetosuitcomputerrequirements,careshouldbe
Appendix3:Cautionaryandadvisorylabels
13Dissolveormixwithwaterbeforetaking
Tobeusedon
preparationsthatareintendedtobe
dissolvedinwater
Appendix3:Cautionaryandadvisorylabels
Intravenousinfusionsfor
neonatalintensivecare
Intravenouspolicy
Alocalpolicyonthedilutionof
drugswithintravenousßuidsshouldbedrawnupbya
multi-disciplinaryteamandissuedasadocumenttothe
membersofstaffconcerned.
Centralisedadditiveservicesareprovidedinanumber
ofhospitalpharmacydepartmentsandshouldbeused
inpreferencetomakingadditionsonwards.
Theinformationthatfollowsshouldbereadinconjunc-
tionwithlocalpolicydocuments.
1.Drugsshouldonlybedilutedwithinfusionßuid
whenconstantplasmaconcentrationsareneeded
orwhentheadministrationofamoreconcentrated
solutionwouldbeharmful.
2.Ingeneral,onlyonedrugshouldbemixedwithan
infusionßuidinasyringeandthecomponents
shouldbecompatible.Ready-preparedsolutions
shouldbeusedwheneverpossible.Drugsshould
notnormallybeaddedtobloodproducts,mannitol,
orsodiumbicarbonate.Onlyspeciallyformulated
additivesshouldbeusedwithfatemulsionsor
amino-acidsolutions(section9.3).
3.Solutionsshouldbethoroughlymixedbyshaking
andcheckedforabsenceofparticulatematter
beforeuse.
4.Strictasepsisshouldbemaintainedthroughoutand
Appendix4:Intravenousinfusionsforneonatalintensivecare
Otherinfusions
Infusionsthatfrequentlygiveriseto
incompatibilityincludeaminoacids,mannitol,andsod-
iumbicarbonate.
(p.113)
Dilute3mg/kgbody-weighttoaÞnalvolumeof
50mLwithGlucose5%
SodiumChloride0.9%;an
intravenousinfusionrateof0.1mL/hourprovidesa
doseof100nanograms/kg/minute;infusethrougha
Appendix4:Intravenousinfusionsforneonatalintensivecare
Glyceryltrinitrate
(p.104)
Dilute3mg/kgbody-weighttoaÞnalvolumeof
50mLwithGlucose5%
SodiumChloride0.9%;an
intravenousinfusionrateof1mL/hourprovidesa
doseof1microgram/kg/minute;max.concentration
of400micrograms/mL(butconcentrationof1mg/
Appendix4:Intravenousinfusionsforneonatalintensivecare
DentalPractitioners’
Formulary
ListofDentalPreparations
Thefollowinglisthasbeenapprovedbytheappropriate
IndicationsapprovedbytheACBSare:patientssuffering
fromdrymouthasaresultofhaving(orhavingundergone)
radiotherapyorsiccasyndrome
Thispreparationdoesnotappearinsubsequenteditionsof
theBP
DentalPractitioners’
Formulary
SodiumChlorideMouthwash,Compound,BP
SodiumFluorideMouthwash,BP
SodiumFluorideOralDrops,BP
DentalPractitioners’
Formulary
NursePrescribers’
Formulary
NursePrescribers’Formularyfor
CommunityPractitioners
NursePrescribers’FormularyAppendix
(Appendix
IncludedintheDrugTariff(PartIXA),theScottishDrug
Tariff(Part2)andtheNorthernIrelandDrugTariff(part
IncludedintheDrugTariff(PartIXA)andtheNorthern
IrelandDrugTariff(partIII)
Exceptpacksizesthatarenottobeprescribedunderthe
NHS(seePartXVIIIAoftheDrugTariff,PartXIofthe
NorthernIrelandDrugTariff)
BNFC2011–
NursePrescribers’
Formulary
GlycerolSuppositories,BP
IbuprofenOralSuspension,BP
Exceptforindicationsanddosesthatare
NursePrescribersinFamilyPlanningClinics—whereitis
notappropriatefornurseprescribersinfamilyplanning
clinicstoprescribecontraceptivedevicesusingform
FP10(P)(formsFP10(CN)andFP10(PN),orwhenavailable
WP10CNandWP10PN,inWales),theymayprescribe
usingthesamesystemasdoctorsintheclinic
BNFC2011–
NursePrescribers’Formulary
NursePrescribers’
Formulary
ControlleddrugsprescribablebyNurseIndependentPrescriberssolelyforthemedical
conditionsindicated
Indication
RouteofAdministration
Transdermaluseinpalliativecare
Transdermal
ChlordiazepoxidehydrochlorideTreatmentofinitialoracutewithdrawalsymptomscaused
bythewithdrawalofalcoholfrompersonshabituatedtoit
Codeinephosphate
Co-phenotrope
DiamorphinehydrochlorideUseinpalliativecare,painreliefinrespectofsuspected
myocardialinfarctionorforreliefofacuteorseverepain
aftertrauma,includingineithercasepostoperativepain
Oral,parenteral
Useinpalliativecare,treatmentofinitialoracutewith-
drawalsymptomscausedbythewithdrawalofalcohol
frompersonshabituatedtoit,tonic-clonicseizures
Oral,parenteral,rectal
Dihydrocodeinetartrate–
Transdermaluseinpalliativecare
Transdermal
Useinpalliativecare,tonic-clonicseizures
Oral,parenteral
Useinpalliativecare,tonic-clonicseizures
Parenteral,buccal
MorphinehydrochlorideUseinpalliativecare,painreliefinrespectofsuspected
myocardialinfarctionorforreliefofacuteorseverepain
aftertrauma,includingineithercasepostoperativepain
Morphinesulphate
Useinpalliativecare,painreliefinrespectofsuspected
myocardialinfarctionorforreliefofacuteorseverepain
aftertrauma,includingineithercasepostoperativepain
Oral,parenteral,rectal
OxycodonehydrochlorideUseinpalliativecare
Oral,parenteral
Forthepurposesofnurseindependentprescribing,palliativecaremeansthecareofpatientswithadvanced,
progressiveillness
NursePrescribers’Formulary
BNFC2011–
NursePrescribers’
Formulary
Non-medicalprescribing
Arangeofnon-medicalhealthcareprofessionalscan
prescribemedicinesforpatientsaseitherIndepen-
dentorSupplementaryPrescribers.
Independentprescribersarepractitionersresponsible
andaccountablefortheassessmentofpatientswith
previouslyundiagnosedordiagnosedconditionsand
fordecisionsabouttheclinicalmanagementrequired,
includingprescribing.Theyarerecommendedtopre-
scribegenerically,exceptwherethiswouldnotbe
clinicallyappropriateorwherethereisnoapproved
Non-medicalprescribing
Indexofmanufacturers
tel:(01565)757783
AcorusTherapeuticsLtd
tel:(01244)625152
enquiries@acorus-therapeutics.com
ActavisUKLtd
tel:(01271)311257
medinfo@actavis.co.uk
Actelion
ActelionPharmaceuticalsUKLtd
tel:(020)89873333
medinfo_uk@actelion.com
ActivaHealthcare
tel:08450606707
advice@activahealthcare.co.uk
ADIMedical
ADIMedicalUK
tel:(01628)485159
info@adimedical.co.uk
AdvancisMedicalLtd
tel:(01623)751500
info@advancis.co.uk
AgephaGmbH
tel:(020)32396241
uk@agepha.com
Indexofmanufacturers
AspirePharmaLtd
tel:(01730)234527
info@aspirepharma.co.uk
AstellasPharmaLtd
tel:(01784)419615
AstraZeneca
AstraZenecaUKLtd
tel:08007830033
medical.informationuk@astrazeneca.
AudenMckenzie
AudenMckenzie(PharmaDivision)Ltd
tel:(01895)627420
Axcan
AxcanPharmaSA
tel:(0033)130461900
AyrtonSaunders
AyrtonSaundersLtd
tel:(0151)7092074
info@ayrtons.com
BardLtd
tel:(01293)527888
BasileaPharmaceuticalsLtd
tel:(01483)790023
ukmedinfo@basilea.com
Bausch&Lomb
Bausch&LombUKLtd
tel:(01748)828864
medicalinformationUK@bausch.com
BaxterHealthcareLtd
tel:(01635)206345
surecall@baxter.com
BayerConsumerCare
SeeBayerSchering
Indexofmanufacturers
CliniMedLtd
tel:(01628)535250
enquires@clinimed.co.uk
Clinisupplies
ClinisuppliesLtd
tel:(020)88634168
info@clinisupplies.co.uk
Colgate-Palmolive
Colgate-PalmoliveLtd
tel:(01483)302222
Coloplast
ColoplastLtd
tel:(01733)392000
Indexofmanufacturers
FentonPharmaceuticalsLtd
tel:(020)72241388
mail@Fent-Pharm.co.uk
FerndalePharmaceuticalsLtd
tel:(01937)541122
info@ferndalepharma.co.uk
FerringPharmaceuticals(UK)
tel:08449310054
medical@ferring.com
Indexofmanufacturers
INCA-PharmUK
tel:(01748)828812
info@inca-pharm.com
InfaiUKLtd
tel:(01904)435228
info@infai.co.uk
InnovativeSolutionsUKLtd
tel:(01706)746713
enquiries@innovative-solutions.org.uk
InsenseLtd
tel:(01234)782870
enquiries@insense.co.uk
InsightMedicalProductsLtd
tel:(01666)500055
Indexofmanufacturers
Medicare
MedicarePlusInternationalLtd
tel:(020)88108811
info@medicare-plus.com
MedicomHealthcareLtd
tel:(01489)574119
info@medicomhealthcare.com
Medihoney(Europe)Ltd
tel:08000713912
Medlock
MedlockMedicalLtd
tel:(0161)6212100
medical.information@
medlockmedical.com
MedLogicGlobalLtd
tel:(01752)209955
enquiries@mlgl.co.uk
A.MenariniPharmaUKSRL
tel:(01628)856400
menarini@medinformation.co.uk
MenariniDiagnostics
A.MenariniDiagnostics
tel:(0118)9444100
MerckSerono
MerckSeronoLtd
tel:(020)88187200
Indexofmanufacturers
OxfordNutrition
OxfordNutritionLtd
tel:(01626)832067
info@nutrinox.com
Paines&Byrne
Paines&ByrneLtd
tel:(01784)419620
PARIMedicalLtd
tel:(01932)341122
infouk@pari.de
ParksideHealthcare
tel:(0161)7952792
Peckforton
PeckfortonPharmaceuticalsLtd
tel:(01270)582255
info@peckforton.com
PennPharmaceuticalsServicesLtd
tel:(01495)711222
penn@pennpharm.co.uk
PzerLtd
tel:(01304)616161
EUMEDINFO@pzer.com
PGRHealthFoods
PGRHealthFoodsLtd
tel:(01992)581715
info@pgrhealthfoods.co.uk
SeePzer
Pharma-GlobalLtd
tel:(00353)12801104
eyecare@pharmaglobal.ie
PharmaMar
SeeIdis
PharmaNord
PharmaNord(UK)Ltd
tel:(01670)519989
uksales@pharmanord.co.uk
PharmasureLtd
tel:(01923)233466
info@pharmasure.co.uk
PinewoodHealthcare
tel:(00353)5236253
info@pinewood.ie
PottersHerbalMedicines
tel:(01942)219960
info@pottersherbals.co.uk
Proceli
Proceli
tel:(01226)713044
admin@proceli.co.uk
Procter&Gamble
Procter&Gamble(HealthandBeauty
Care)Ltd
tel:(0191)2975000
ProlePharmaLtd
tel:08001300855
info@prolepharma.com
ProStrakan
ProStrakanLtd
tel:(01896)664000
medinfo@prostrakan.com
Protex
ProtexHealthcare(UK)Ltd
tel:08700114112
orders@protexhealthcare.co.uk
RanbaxyUKLtd
tel:(020)82801986
medinfoeurope@ranbaxy.com
RansomConsumerHealthcare
tel:(01462)437615
info@williamransom.com
RatiopharmUK
RatiopharmUKLtd
tel:(023)92313592
info@ratiopharm.co.uk
ReckittBenckiser
ReckittBenckiserHealthcare
tel:(01482)326151
info.MIU@reckittbenckiser.com
Recordati
RecordatiPharmaceuticalsLtd
tel:(01491)576336
medinfo@recordati.co.uk
ReSourceMedical
ReSourceMedicalUKLtd
tel:(01484)531489
info@resource-medical.co.uk
Respironics
PhilipsRespironics(UK)Ltd
tel:08001300840
Indexofmanufacturers
ScopeOphthalmics
ScopeOphthamicsLtd
tel:(0161)2661011
info@scopeophthalmics.com
SDHealthcare
SDHealthcare
tel:(0161)7767626
sales@sdhealthcare.com
SeptodontLtd
tel:(01622)695520
Servier
ServierLaboratoriesLtd
tel:(01753)666409
Sovereign
SeeAmdipharm
SpecialityEuropean
SpecialityEuropeanPharmaLtd
tel:(020)74217400
info@spepharma.com
SpectrumThea
SpectrumTheaPharmaceuticals
tel:08455211290
theasupport@spectrum-thea.co.uk
SpePharmUKLtd
tel:08448007579
medinfo.uk@spepharm.com
SpiritHealthcareLtd
tel:08008815423
info@spirit-healthcare.co.uk
SeeBristol-MyersSquibb
SSL
SSLInternationalplc
tel:08701222690
medical.information@ssl-international.
STDPharmaceutical
STDPharmaceuticalProductsLtd
tel:(01432)373555
enquiries@stdpharm.co.uk
Steraid
Steraid(Gainsborough)Ltd
tel:(01427)677659
StiefelLaboratories(UK)Ltd
tel:(01628)612000
general@stiefel.co.uk
StragenUKLtd
tel:08703518744
info@stragenuk.com
Su-MedInternationalUKLtd
tel:(01457)890980
sales@sumed.co.uk
SutherlandHealthLtd
tel:(01635)874488
SwedishOrphan
SwedishOrphanBiovitrumLtd
tel:(01638)722380
SynergyHealthcare
SynergyHealthcare(UK)Ltd
tel:(0161)6245641
healthcaresolutions@synergyhealthplc.
Syner-Med(PharmaceuticalProducts)
tel:08456342100
mail@syner-med.com
SystagenixWoundManagement
tel:(01344)871000
Takeda
TakedaUKLtd
tel:(01628)537900
Talley
TalleyGroupLtd
tel:(01794)503500
Taro
TaroPharmaceuticals(UK)Ltd
tel:08707369544
customerservice@taropharma.co.uk
Teofarma
TeofarmaS.r.l.
tel:(01748)828857
teofarma@professionalinformation.co.
Teva
TevaPharmaceuticalsLtd
med.info@tevapharma.co.uk
TEVAUK
TEVAUKLtd
tel:08705020304
medinfo@tevauk.com
TheMedicinesCompany
TheMedicinesCompany
tel:0080084363326
GCHS.MI@quintiles.com
TherabelPharmaUKLtd
tel:08000665446
info@therabel.co.uk
TheUrologyCo.
TheUrologyCompanyLtd
tel:(020)30775411
info@theurologyco.com
ThomasBlake
Indexofmanufacturers
TMCPharmaServicesLtd
tel:(01252)842255
info@tmcpharma.com
TobiaTeff
TobiaTeffUKLtd
tel:(020)73282045
info@tobiateff.co.uk
Indexofmanufacturers
Special-order
Manufacturers
Unlicensedmedicinesareavail-
ablefrom‘special-order’manu-
facturersandspecialistimporting
companies;theMHRAmaintains
aregisterofthesecompaniesat
hospitalmanufactur-
ingunits
alsomanufacture‘spe-
cial-order’productsasunlicensed
medicines,theprincipalNHS
unitsarelistedbelow.Adatabase
www.pro-le.nhs.uk
providesinformationonallmed-
icinesmanufacturedintheNHS;
accessisrestrictedtoNHSphar-
macystaff.
TheAssociationofCommercial
SpecialsManufacturersmayalso
beabletoprovidefurtherinfor-
mationaboutcommercialcompa-
nies(
www.acsm.uk.com
Thecharacteristicsofunlicensed
formulationsmayvary,seealso
UnlicensedMedicines(p.6)and
ExtemporaneousPreparations
(p.6).
TheMHRArecommendsthat
anunlicensedmedicineshould
onlybeusedwhenapatienthas
specialrequirementsthatcan-
Special-orderManufacturers
NottinghamUniversityHospitals
NHSTrust
MsJ.Kendall
AssistantHeadofPharmacy,Technical,
andLogisticalServices
PharmacyProductionUnits
NottinghamUniversityHospitalsNHS
Trust
QueensMedicalCentreCampus
Nottingham,NG72UH.
tel:(0115)8754521(order)
tel:(0115)9249924ext:64177
(enquiry)
fax:(0115)9709780
tel:(028)90633310(sterile)
tel:(028)90553407(non-sterile)
fax:(028)90328972(sterile)
fax:(028)90553498(non-sterile)
Special-orderManufacturers
Principalpagereferencesare
printedin
Alfentanil,
,641
Alginate-containingantacids,
Alglucosidasealfa,
,768
allergicdisorders,153,
premedication,155,637
Alkalinisationofurine,412
,421
Alkylatingdrugs,419
,186
Allergy,153
allergenimmunotherapy,157
anaphylaxis,159
conjunctivitis,522
corticosteroidsin,371
food,56
rhinitis,153,538
Almondoil,ear,538
,523
Alphatocopherol,
Index
,582
Anthelmintics,344
Anthracyclines,421
Dithranol
Anthraquinones,59
Anthrax,297
vaccine,603
Anti-androgens,380
Anti-arrhythmicdrugs,82,83
Antibacterials
acne,575,576,578
diarrhoea,47
ear,534
eye,518
oral,244
skin,585
vaginal,394
policies,243
principlesforselecting,
prophylaxis(table),254
prophylaxis,surgery,256
therapy,initial(table),244
Antibiotic-associatedcolitis
Clostridiumdifcile
Antibacterials
Anticholinergicdrugs
Anticholinergicsyndrome,635
Anticholinesterases,512
anaesthesia,646
(naproxen),505
Articaine,649,
ArtiÞcialsaliva,548
palliativecare,18
ArtiÞcialtears,529
Index
Benzodiazepines
antagonist,647
anxiolytics,169
palliativecare,18
clinicalprocedures,637
epilepsy,230
palliativecare,19
mania,181
musclespasm,514
neonatalseizures,217
poisoningby,30
premedication,637
Benzoicacidointment,
compound,588,589
Benzointincture,compound,166
Benzoylperoxide
acne,575
clindamycinwith,575
hydroxyquinolinewith,575
adapalenewith,577
Benzydamine,
Benzylalcohol,presenceof,3
Benzylbenzoate,592
Benzylpenicillinsodium,257,
gas-gangreneprophylaxis,255
,162
BeriplexP/N
(driedprothrombin
complex),124
,420
Buspirone,171
,420
Busulphan
,420
Butylcyanoacrylate,594
Butyrophenones,173
C1-esteraseinhibitor,
,472
CacitD3
,484
Caffeine,
Calamine,557
,484
CalchanMR
(nifedipine),108
,472
CalcichewD3
preparations,484
Calciferol,482
,484
Calcipotriol,567,
Index
Co-careldopa,235,
Co-codamolpreparations,201
,569
Codliveroil
zincoxidewith,557
preparations,59
Co-danthramerpreparations,59
Co-danthrusatepreparations,60
coughsuppressant,167
diarrhoea,47
pain,203,
,205
Index
Coumarins,118
Coveringcreams,583
preparations,583
Cow&GatePepti
preparations,104
Crablice,592
Cradlecap,566,584
deÞnition,551
suitablequantities,551
Creatinineclearance
erularÞltrationrate,14
Creepingeruption
larvamigrans,346
preparations,71,72
,127
preparations,554,556
preparations,563
,453
Desferrioxamine
aluminiumoverload,
eye,529
ironoverload,451,
,453
ironpoisoning,
Desßurane,
Desloratadine,153,
Desloughingagents,596
,387
Desmopressin,387
assessmenttests,
Index
Disinfectants,594
ACBS,787
,148
,327
,141
Disodiumclodronate
clodronate,390
Disodiumcromoglicate
cromoglicate
Disodiumfolinate,418
Disodiumhydrogenphosphate,
Disodiumlevofolinate,419
Disodiumpamidronate,389,390
,220
,652
Emollients,552
eczema,565
pruritus,557
palliativecare,19
psoriasis,566
,553
,752
Emtricitabine,310,
,313
efavirenzandtenofovirwith,
tenofovirwith,314
,313
,556
Emulsifyingointment,552
,103
seealso
ACEinhibitors
,511
Enbucrilate,594
Encephalopathy,hepatic,61
preparations,477
Endocarditis,246,277
antibacterialprophylaxis,256
Endophthalmitis,518
gluten-andwheat-free,780
gluten-free,777,778,779
low-protein,780
,773
Energy,intravenousnutrition,466
preparations,765
thickened,767
Enfuvirtide,310,
,321
EngerixB
,609
,117
,775
EnsurePlus
preparations,757,
758,759
preparations,750,756
Entamoebahistolytica
,339
Entecavir,325
feedingtubes
administeringdrugsvia,68
clearingblockages,68
nutrition,469
foods,ACBS,743
Entericinfections,245
Enterobiasis,344
Enterocolitis,necrotising,245
preparations,53
,634
Enuresis,nocturnal,411
,612
Enzymeinduction,655
Þbrinolytic,121
preparations,553
preparations,225
ReadyMixedParenteral
,235
,607
nasalcongestion,
,542
,577
Epiglottitis,247
,593
Epilepsy,215,217
breast-feedingand,216
driving,216
neonatalseizures,217
pregnancyand,216
statusepilepticus,231
non-convulsive,232
syndromes,217
preparations,228,229
(carbamazepine),218
Epinastine,522,
Adrenaline
preparations,160,161
Epirubicin,421,
,423
preparations,229
,229
,313
Index
anaesthesia,local,529
antibacterials,518
frequencyof
administration,519
antifungals,520
antivirals,521
contactlenses,533
corticosteroids,521
cycloplegics,524
drops,administration,517
glaucoma,525
inßammation,521
lotions,administration,517
microbialcontamination,518
miotics,528
mydriatics,524
ointments,administration,517
prostaglandins,525,526
Formoterol,
budesonidewith,149
Formulary
Dental,794
Nurse,796
,768
,761
,757
FortimelRegular
,759
preparations,754
FortipineLA40
,108
preparations,758,759,
,270
preparations,389
Fosamprenavir,310,
Index
Glycogenstoragedisease
Homocystinuria,495,781
Hookworminfections,346
Hormonereplacement,377
androgens,379
oestrogens,377
progestogens,377
HowtouseBNFC,xi
,385
-receptoragonists,212
-receptorantagonists,192,
197,416
Immunoglobulins,
Index
Ibuprofen,503,504
ductusarteriosus,
juvenileidiopathicarthritis,503
migraine,212
pain,500,
postoperative,640
preparations,503
pyrexia,503
post-immunisation,600
rheumaticdisease,500,503
Ichthammol,565,
zincwith,566
Ichthyosis,552,567,571
Idiopathicthrombocytopenic
purpura
purpura
Idursulfase,491,
IlPanediAnna
products,779
,441
pulmonaryhypertension,95,
,97
RaynaudÕssyndrome,
,530
,429
Imidazoleantifungaldrugs,305
Imiglucerase,490,
preparations,213
Imipenem,
,273
attentiondeÞcithyperactivity
disorder,185
nocturnalenuresis,
,186,
,440
Immuneinterferon
gamma-1b,440
active,599
passive,602
internationaltravel,626
schedule,601
ImmunodeÞciency,622,626
syndrome,acquired,309
Immunoglobulins,602,
aplasticanaemia,447
hepatitisB,624,625
Kawasakisyndrome,622
myastheniagravis,512
normal,622,
,624
passiveimmunity,622
radioactive,367
skindisinfection,
thyrotoxicosis,367,368
,532
,51
,142
acute,134
rhinorrhoea,541,
,142
Poliomyelitis,immuni-
sation,617
deÞciency,442
neonatal,443
oral,442,443,444
overload,451
parenteral,444,445
poisoningby,30
Irondextran,444,
Ironsucrose,444,
,443
,594
,594
Irritablebowelsyndrome,39,
,321
Isoßurane,633,
,58
IsoleucineAminoAcid
Supplement,782
Isoniazid,292,
tuberculosisprophylaxis,255
tuberculosistreatment,290,
Isophaneprotamineinsulin
Insulin,isophane
,465
Isoprenaline,110
Alkaline,531
Plain,531
preparations,744,747,
750,755
Index
Laxatives,57
bulk-forming,57
faecalsofteners,61
osmotic,61
palliativecare,18
stimulant,59
palliativecare,18
LaxidoOrange
,62
,33
LegionnairesÕdisease,280
Leishmaniasis,340
Lennox-Gastautsyndrome,217
Lenograstim,454,
Leptospirosis,257,274
preparations,127
Leucineaminoacidsupplement,
,420
Leukotrienereceptorantagonists,
preparations,354
,401
,439
,300
,300
Macrogols,61
bowelcleansing,
constipation,
faecalimpaction,
Macrolides,280
,263
Magnaspartate
,474
Magnesiumcitrate,
sodiumpicosulfatewith,
Magnesiumglycerophosphate,
Magnesiumhydroxide,63
antacid,37
preparations,63
Magnesiumsalts
constipation,63
BNFC2011–
Laxatives—Magnesium
Magnesiumsulphate
arrhythmias,473
asthma,134
hypocalcaemianeonatal,
,474
pulmonaryhypertension,95,
torsadedepointes,
Magnesiumtrisilicate,
Magnesium-
-aspartate,
Malabsorptionsyndromes,49
electrolytes,457
vitaminK,486
falciparum,330
prophylaxis,331
treatment,329,331
,335
malariaprophylaxis,331,332,
333,334,336
malariatreatment,330,336
,337
Malathion,592,
Malignantdisease,414
pain,203
bone,199
Malignanthyperthermia,648
Maltitol,2
,60
Mania,172,181
Manicdepression
Bipolardis-
order,181
Mannitol,81
,82
glaucoma,525
presenceof,2
Mantouxtest,603
Manufacturers
indexof,800
Manufacturers,special-order,809
Maplesyrupurinedisease,480,
Maraviroc,310,
preparations,651
(warfarin),119
Marinestings,34
Index
MRSA,259
linezolidin,287
nasal,542
MSTContinus
,209
palliativecare,17
preparations,782,783
preparations,
,166
,37
Mucolytics,165
eye,530
Mucopolysaccharidosis,491
Mucosalbleeding
palliativecare,19
Index
Nicardipine,105,
,107
seealso
preparations(nicotine
replacementtherapy),240,241
NationalInstitutefor
HealthandClinicalExcellence,3
(cefradine),269
Niclosamide,345
,553
,555
Juniorbathadditive
,555
,556
showeremollient,555
Oilycream,552
deÞnition,551
eye,517
suitablequantities,551
psychosis,177,
Oligospermia,383
Oliveoil,ear,538
Olopatadine,522,
Olsalazine,48,50,
Omalizumab,
,159
Omeprazole,45,
,357
,384
,428
Onchocerciasis,346
,427
Index
,202
Paraproteinaemias,448
Parasiticidalpreparations,591,
concentrations,electrolytes,
substitutes,464,465
Plasma,freshfrozen,125
Plasmapheresis,myasthenia
gravis,512
,357
Pneumococcalinfection
antibacterialprophylaxis,255
immunisation,616
,617
vaccines,616
Pneumocystispneumonia,342
prophylaxis,342
Pneumonia,247
hospital-acquired,247
pneumococcal,616
PneumovaxII
,616
Index
products,778,779,780
Prochlorperazine,192,193,
ProctofoamHC
,67
,67
Procyclidine,
Productlicence,2
,233
Proßavinecream,593
Progesterone
hormonetherapy,378
Progestogen-onlypill
gestogens,contraceptives,oral,
Progestogens
emergency,408,409
intra-uterine,405,
oral,396,
parenteral,404,
hormonetherapy,378
,437
Proguanil,
,337
atovaquonewith,337
chloroquinewith,335
malariaprophylaxis,331,332,
333,334,336
(lactulose),62
Rehydration
oral,459
parenteral,461
,64
,327
,523
,202
,56
Remifentanil,640,
,642
,476
Index
ScottishMedicinesConsortium,3
Scurvy,481
Seasonalinßuenzavaccines,612
,569
SebominMR
,276
Seborrhoeic
dermatitis,566
eczema,566
preparations,109
Sedation,clinicalprocedures,637
Sedatives,169
seealso
Segawasyndrome,235
absence,217
neonatal,217
seealso
Sodiumpolystyrenesulphonate,
Sodiumstibogluconate,
Sodiumthiosulphate,32
Sodiumvalproate
Valproate
ear,536
eye,522
Softtissuedisorders,499
products,357
,583
,178
SolivitoN
,468
,376
,376
,478
Solvents,earwaxremoval,538
Somatomedins,391
Somatotrophin,383
,384,385
(nitrazepam),231
Sorbitol,presenceof,2
,92
Sotalol,82,87,88,
,92
seealso
Index
insulin,357
blindpatients,357
oral,2
,530
,444
TabphynMR
(tamsulosin),410
Tacalcitol,567,568,
Tachycardias
Arrhythmias
Tacrolimus
eczema,572,
,574
immunosuppression,431,433,
,437
Taenicides,345
,86
TambocorXL
,86
,327
Tamsulosin,409,
Tapeworminfections,345
Tar,
,570
seealso
Coaltar
products,780,781
Tardivedyskinesia,173
,287
Tartrazine,presenceof,3
Tazarotene,566
Tazobactam
piperacillinwith,
,265
,265
3TC
TeardeÞciency,529
Teargas,33
TearsNaturale
,531
Tears,artiÞcial,529
Tocopheryl,485
Index
,69
,69
Urticaria,153
UT380
devices,408
,379
UVB,psoriasis,567
preparations,583
Vaccination
HIV-positivesubjects,600
schedule,601
travel,626
Vaccines
activeimmunity,599
allergenextract,157
breast-feeding,600
cautions,599
contra-indications,599
post-immunisationpyrexia,600
pregnancy,600
side-effects,600
storageanduse,602
Vaginalinfection
oraltreatment,394
Vaginitis
candidal,394
Vaginosis,bacterial,395
,170
products,778,779,
,343
WestÕssyndrome,229
WhitÞeldÕsointment,588
Whoopingcough
Pertussis
(factorVIIIfraction),124
WilsonÕsdisease,488
,489
Withdrawal
antipsychotics
atypical,177
nicotine,238
opioids,204
Wolff-Parkinson-Whitesyndrome,
Woolfat,hydrous,553
Worminfestation,344
Wuchereriabancrofti
,346
,767
,453
,568
Xanthinebronchodilators
,191
,558
Xerostomia,548
,549
preparations,782
XLYSLowTRY
preparations,
preparations,782
XLYSTRY
preparations,781
Index
NEWBORN LIFE SUPPORT
Reproduced with the kind permission of the Resuscitation Council (UK) from Resuscitation Guidelines, October 2010
pre-ductal SpO
2 min 60%
3 min 70%
4 min 80%
5 min 85%
10 min 90%
Assess (tone), breathing and heart rate
30 s
STAGES
PAEDIATRIC BASIC LIFE SUPPORT
(Healthcare professionals with a duty to respond)
NOT BREATHING NORMALLY?
5 rescue breaths
Call resuscitation team
Reproduced with the kind permission of the Resuscitation Council (UK) from Resuscitation Guidelines, October 2010
15 chest compressions
2 rescue breaths
15 compressions
(5 initial breaths then 15:2)
brillator/monitor
Immediately resume
CPR for 2 min
Unresponsive?
Not breathing or only occasional gasps
Reproduced with the kind permission of the Resuscitation Council (UK) from Resuscitation Guidelines, October 2010
PAEDIATRIC ADVANCED LIFE SUPPORT
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Vascular access (intravenous, intraosseous)
• Give adrenaline every 3-5 min
• Consider advanced airway and capnography
• Continuous chest compressions when
• Correct reversible causes
Immediately resume
CPR for 2 min
Immediate post cardiac
arrest treatment
• Use ABCDE approach
• Controlled oxygenation
• Treat precipitating cause
• Temperature control
• Therapeutic hypothermia?
Surface area
(kg)
17
18
19
20
21
22
23
25
26
27
28
Surface area
(kg)
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
Surface area
(kg)
41
42
43
44
45
46
47
48
49
50
51
Surface area
(kg)
66
67
68
69
70
71
72
74
75
76
77
Medicalemergenciesinthe
Drugtreatmentoutlinedbelowisintendedforuseby
communityhealthcareprofessionals.Onlydrugsthat
areusedforimmediatereliefareshown;adviceon
supportingcareisnotgiven.Wherethechild’scon-
ditionrequiresinvestigationandfurthertreatment,the
childshouldbetransferredtohospitalpromptly.
(section3.4.3)
Adrenaline
(1mg/mL(1in1000))
Byintramuscularinjection
Childunder6years
150micrograms(0.15mL),
repeatedevery5minutesifnecessary
Child6–12years
300micrograms(0.3mL),
repeatedevery5minutesifnecessary
Child12–18years
500micrograms(0.5mL),
repeatedevery5minutesifnecessary;300micr-
ograms(0.3mL)shouldbegivenifchildissmallor
prepubertal
High-ow
oxygen
(section3.6)and
intravenous
ßuids
shouldbegivenassoonasavailable.
Chlorphenamine
byintramuscularorintra-
venousinjection(section3.4.1)mayhelpcounterhist-
amine-mediatedvasodilationandbronchoconstriction.
Hydrocortisone
(preferablyassodiumsuccinate)by
intravenousinjection(section6.3.2)hasdelayedaction
butitshouldbegiventoseverelyaffectedchildrento
Croup
(section3.1)
Approximateconversionsandunits
lbkgstoneskgmLßoz
10.4516.35501.8
20.91212.701003.5
31.36319.051505.3
41.81425.402007.0
52.27531.7550017.6
62.72638.10100035.2
73.18744.45
83.63850.80
94.08957.15
104.541063.50
114.991169.85
125.441276.20
135.901382.55
146.351488.90
1595.25
Length
Weight
Fulltermneonate3.5
1month
2months
3months
4months
6months
1year
3years
5years
7years
10years
12years
14year-oldboy49
14year-oldgirl50
Adultmale
Adultfemale
Recommendedwordingofcautionary
andadvisorylabels
Abbreviationsandsymbols
Internationallyrecognisedunitsandsymbolsareusedin
BNFforChildren
wherepossible.
ACBSAdvisoryCommitteeonBorderlineSubstances,
Appendix2
ACEAngiotensin-convertingenzyme
ADHDattentiondeÞcithyperactivitydisorder
AIDSAcquiredimmunodeÞciencysyndrome
approx.approximately
AVatrioventricular
BANBritishApprovedName
BMIbodymassindex
BPBritishPharmacopoeia2010,unlessotherwise
BPCBritishPharmaceuticalCodex1973andSupple-
ment1976,unlessotherwisestated
CAPDContinuousambulatoryperitonealdialysis
preparationinSchedule2oftheMisuseofDrugs
Regulations2001(andsubsequentamendments).
Forregulations
PrescribingControlledDrugs
preparationinSchedule3oftheMisuseofDrugs
Regulations2001(andsubsequentamendments).
Forregulations
PrescribingControlledDrugs
preparationinSchedule4(Part
)oftheMisuseof
DrugsRegulations2001(andsubsequent
amendments).Forregulations
ControlledDrugs
preparationinSchedule4(Part
)oftheMisuseof
DrugsRegulations2001(andsubsequent
amendments).Forregulations
ControlledDrugs
CHMCommissiononHumanMedicines
CHMPCommitteeforMedicinalProductsforHumanUse
CNScentralnervoussystem
NPFNursePrescribersÕFormulary
NSAIDnon-steroidalanti-inßammatorydrug
PGDpatientgroupdirection
prescription-onlymedicine
trademark

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