Ebook BNF 74 september 2017 – march 2018: Part 2

(BQ) Part 2 book “BNF 74 september 2017 – march 2018” has contents: Genito-urinary system, immune system and malignant disease, musculoskeletal system, emergency treatment of poisoning, blood and nutrition, ear, nose and oropharynx,… and other contents.

Urinary frequency, enuresis, and incontinence 731 BNF 74 Chapter Genito-urinary system Bladder and urinary disorders 1.1 Urinary frequency, enuresis, and incontinence 1.2 Urinary retention 1.3 Urological pain page 731 731 736 742 Bladder instillations and urological surgery Contraception Contraception, combined Contraception, devices Contraception, emergency Contraception, oral progestogen-only Contraception, parenteral progestogen-only Contraception, spermicidal Erectile and ejaculatory conditions 4.1 Erectile dysfunction 3.1 3.2 3.3 3.4 3.5 3.6 743 745 749 756 757 758 762 764 765 765 Bladder and urinary disorders 1.1 Urinary frequency, enuresis, and incontinence Urinary frequency, enuresis and incontinence Urinary frequency and incontinence Incontinence in adults which arises from detrusor instability is managed by combining drug therapy with conservative methods for managing urge incontinence such as pelvic floor exercises and bladder training; stress incontinence is generally managed by non-drug methods Duloxetine p 350 can be added and is licensed for the treatment of moderate to severe stress incontinence in women; it may be more effective when used as an adjunct to pelvic floor exercises Antimuscarinic drugs reduce symptoms of urgency and urge incontinence and increase bladder capacity Oxybutynin hydrochloride p 733 also has a direct relaxant effect on urinary smooth muscle Side-effects limit the use of oxybutynin hydrochloride, but they may be reduced by starting at a lower dose A modified-release preparation of oxybutynin hydrochloride is effective and has fewer sideeffects; a transdermal patch is also available The efficacy and side-effects of tolterodine tartrate p 735 are comparable to those of modified-release oxybutynin hydrochloride Flavoxate hydrochloride p 733 has less marked side-effects but it is also less effective Darifenacin p 732, fesoterodine fumarate p 732, propiverine hydrochloride p 735, solifenacin succinate p 734, and trospium chloride p 734 are newer antimuscarinic drugs licensed for urinary frequency, urgency, and incontinence The need for continuing antimuscarinic drug therapy should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months 4.2 Premature ejaculation page 773 Obstetrics Induction of labour Postpartum haemorrhage Premature labour Termination of pregnancy Vaginal and vulval conditions 6.1 Vaginal and vulval infections 6.1a Vaginal and vulval bacterial infections 6.1b Vaginal and vulval fungal infections 6.2 Vaginal atrophy 5.1 5.2 5.3 5.4 773 774 776 777 777 779 780 780 781 782 Propantheline bromide p 84 and tricyclic antidepressants were used for urge incontinence but they are little used now because of their side-effects The use of imipramine hydrochloride p 359 is limited by its potential to cause cardiac side-effects Mirabegron p 736, a selective beta3 agonist, is licensed for the treatment of urinary frequency, urgency, and urge incontinence associated with overactive bladder syndrome Purified bovine collagen implant (Contigen ®, Bard) is indicated for urinary incontinence caused by intrinsic sphincter deficiency (poor or non-functioning bladder outlet mechanism) The implant should be inserted only by surgeons or physicians trained in the technique for injection of the implant See also Nocturnal enuresis in children, below Nocturnal enuresis in children 23-May-2017 Description of condition Nocturnal enuresis is the involuntary discharge of urine during sleep, which is common in young children Children are generally expected to be dry by a developmental age of years, and historically it has been common practice to consider children for treatment only when they reach years; however, symptoms may still persist in a small proportion by the age of 10 years Treatment Children under years For children under years, treatment is usually unnecessary as the condition is likely to resolve spontaneously Reassurance and advice can be useful for some families h g Non Drug Treatment g Initially, advice should be given on fluid intake, diet, toileting behaviour, and use of reward systems For children who not respond to this advice (more than 1–2 wet beds per week), an enuresis alarm should be the recommended treatment for motivated, well-supported children Alarms in Genito-urinary system CONTENTS 732 Bladder and urinary disorders Genito-urinary system BNF 74 children under years should be considered depending on the child’s maturity, motivation and understanding of the alarm Alarms have a lower relapse rate than drug treatment when discontinued Treatment using an alarm should be reviewed after weeks and continued until a minimum of weeks’ uninterrupted dry nights have been achieved If complete dryness is not achieved after months but the condition is still improving and the child remains motivated to use the alarm, it is recommended to continue the treatment Combined treatment with desmopressin p 628, or the use of desmopressin alone, is recommended if the initial alarm treatment is unsuccessful or it is no longer appropriate or desirable h Drug Treatment g Treatment with oral or sublingual desmopressin is recommended for children over years of age when alarm use is inappropriate or undesirable, or when rapid or shortterm results are the priority (for example, to cover periods away from home) Desmopressin alone can also be used if there has been a partial response to a combination of desmopressin and an alarm following initial treatment with an alarm alone Treatment should be assessed after weeks and continued for months if there are signs of response Repeated courses of desmopressin can be used in responsive children who experience repeated recurrences of bedwetting, but should be withdrawn gradually at regular intervals (for week every months) for full reassessment Under specialist supervision, nocturnal enuresis associated with daytime symptoms (overactive bladder) can be managed with desmopressin alone or in combination with an antimuscarinic drug (such as oxybutynin hydrochloride p 733 or tolterodine tartrate p 735 [unlicensed indication]) Treatment should be continued for months; the course can be repeated if necessary The tricyclic antidepressant imipramine hydrochloride p 359 can be considered for children who have not responded to all other treatments and have undergone specialist assessment, however relapse is common after withdrawal and children and their carers should be aware of the dangers of overdose Initial treatment should continue for months; further courses can be considered following a medical review every months Tricyclic antidepressants should be withdrawn gradually h Useful Resources Bedwetting in under 19s National Institute for Health and Care Excellence Clinical guideline CG111 October 2010 www.nice.org.uk/guidance/cg111 ANTIMUSCARINICS Antimuscarinics (systemic) l l f CONTRA-INDICATIONS Gastro-intestinal obstruction intestinal atony myasthenia gravis (but some antimuscarinics may be used to decrease muscarinic sideeffects of anticholinesterases) paralytic ileus prostatic enlargement (in adults) pyloric stenosis severe ulcerative colitis significant bladder outflow obstruction toxic megacolon urinary retention CAUTIONS Acute myocardial infarction (in adults) arrhythmias (may be worsened) autonomic neuropathy cardiac insufficiency (due to association with tachycardia) cardiac surgery (due to association with tachycardia) children (increased risk of side-effects) conditions characterised by tachycardia congestive heart failure (may be worsened) coronary artery disease (may be worsened) diarrhoea elderly (especially if frail) gastrooesophageal reflux disease hiatus hernia with reflux oesophagitis hypertension hyperthyroidism (due to association with tachycardia) individuals susceptible to l ▶ ▶ ▶ ▶ l angle-closure glaucoma prostatic hyperplasia (in adults) pyrexia ulcerative colitis SIDE-EFFECTS Common or very common Constipation dilation of pupils with loss of accommodation dry mouth photophobia reduced bronchial secretions skin dryness skin flushing transient bradycardia (followed by tachycardia, palpitation and arrhythmias) urinary retention urinary urgency Uncommon Confusion (in children) confusion (particularly in the elderly) giddiness nausea vomiting Very rare Angle-closure glaucoma Frequency not known Angioedema blurred vision blurred vision central nervous system stimulation convulsion diarrhoea difficulty in micturition disorientation dizziness drowsiness dry eyes euphoria fatigue flatulence hallucinations headache impaired memory palpitation photosensitivity rash reduced sweating (may lead to heat sensations and fainting in hot environments or patients with fever) restlessness taste disturbances PATIENT AND CARER ADVICE Driving and skilled tasks Antimuscarinics can affect the performance of skilled tasks (e.g driving) ANTIMUSCARINICS › URINARY eiii i F above Darifenacin INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Incontinence l ▶ BY MOUTH ▶ Adult: Initially 7.5 mg once daily, increased if necessary to 15 mg after weeks INTERACTIONS → Appendix 1: darifenacin SIDE-EFFECTS ▶ Uncommon Cough dyspnoea hypertension impotence insomnia oedema rhinitis ulcerative stomatitis vaginitis weakness l PREGNANCY Manufacturer advises avoid—toxicity in animal studies l BREAST FEEDING Present in milk in animal studies— manufacturer advises caution l HEPATIC IMPAIRMENT Max 7.5 mg daily in moderate impairment Avoid in severe impairment l PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months l l l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Modified-release tablet CAUTIONARY AND ADVISORY LABELS 3, 25 ▶ Emselex (Merus Labs Luxco S.a R.L.) Darifenacin (as Darifenacin hydrobromide) 7.5 mg Emselex 7.5mg modified-release tablets | 28 tablet P £25.48 DT price = £25.48 Darifenacin (as Darifenacin hydrobromide) 15 mg Emselex 15mg modified-release tablets | 28 tablet P £25.48 DT price = £25.48 eiii i F above Fesoterodine fumarate 08-May-2017 INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Urge incontinence l ▶ BY MOUTH ▶ Adult: mg once daily, increased if necessary up to mg once daily Urinary frequency, enuresis, and incontinence 733 DOSE ADJUSTMENTS DUE TO INTERACTIONS Manufacturer advises max mg daily with concurrent use of potent inhibitors of CYP3A4; avoid concurrent use in patients who also have hepatic or renal impairment For dose adjustments with concurrent use of moderate inhibitors of CYP3A4 in patients with hepatic or renal impairment, consult product literature l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral suspension, oral solution Tablet CAUTIONARY AND ADVISORY LABELS ▶ INTERACTIONS → Appendix 1: fesoterodine SIDE-EFFECTS ▶ Common or very common Insomnia ▶ Uncommon Cough nasal dryness pharyngolaryngeal pain vertigo l PREGNANCY Manufacturer advises avoid—toxicity in animal studies l BREAST FEEDING Manufacturer advises avoid—no information available l HEPATIC IMPAIRMENT Manufacturer advises increase dose cautiously in mild impairment; max mg daily in moderate impairment Manufacturer advises avoid in severe impairment l RENAL IMPAIRMENT Increase dose cautiously if eGFR 30–80 mL/minute/1.73m2; max mg daily if eGFR less than 30 mL/minute/1.73m2 l PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months l NATIONAL FUNDING/ACCESS DECISIONS l Urispas (Recordati Pharmaceuticals Ltd) Flavoxate hydrochloride 200 mg Urispas 200 tablets | 90 tablet P £11.67 DT price = £11.67 eiii i F 732 l Oxybutynin hydrochloride INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Urinary incontinence | Neurogenic bladder instability l ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ ▶ ▶ ▶ ▶ BY MOUTH USING MODIFIED-RELEASE TABLETS Child 5–17 years: Initially mg once daily, adjusted in steps of mg every week, adjusted according to response; maximum 15 mg per day ▶ Adult: Initially mg once daily, increased in steps of mg every week, adjusted according to response; maximum 20 mg per day Urinary frequency | Urinary urgency | Urinary incontinence ▶ Scottish Medicines Consortium (SMC) Decisions The Scottish Medicines Consortium has advised (June 2008) that fesoterodine (Toviaz ®) is accepted for restricted use within NHS Scotland as a second-line treatment for overactive bladder syndrome l ▶ BY TRANSDERMAL APPLICATION USING PATCHES Adult: Apply patch twice weekly, patch is to be applied to clean, dry unbroken skin on abdomen, hip or buttock Patch should be removed every 3–4 days and site replacement patch on a different area The same area should be avoided for days Nocturnal enuresis associated with overactive bladder ▶ MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Modified-release tablet CAUTIONARY AND ADVISORY LABELS 3, 25 ▶ Toviaz (Pfizer Ltd) Fesoterodine fumarate mg Toviaz 4mg modified-release tablets | 28 tablet P £25.78 DT price = £25.78 Fesoterodine fumarate mg Toviaz 8mg modified-release tablets | 28 tablet P £25.78 DT price = £25.78 ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ bedtime eiii i F 732 Child 5–17 years: Initially mg once daily, adjusted in steps of mg every week, adjusted according to response; maximum 15 mg per day DOSE EQUIVALENCE AND CONVERSION ▶ Patients taking immediate-release oxybutynin may be transferred to the nearest equivalent daily dose of Lyrinel ® XL ▶ INDICATIONS AND DOSE Urinary frequency | Urinary incontinence | Dysuria | Urinary urgency | Bladder spasm due to catheterisation, cytoscopy, or surgery l ▶ BY MOUTH Adult: 200 mg times a day l l l l l l l l CONTRA-INDICATIONS Gastro-intestinal haemorrhage INTERACTIONS → Appendix 1: flavoxate SIDE-EFFECTS Eosinophilia erythema leucopenia pruritus urticaria vertigo PREGNANCY Manufacturer advises avoid unless no safer alternative BREAST FEEDING Manufacturer advises caution—no information available PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months Child 5–17 years: 2.5–3 mg twice daily, increased to mg 2–3 times a day, last dose to be taken before ▶ BY MOUTH USING MODIFIED-RELEASE TABLETS Flavoxate hydrochloride ▶ Child 5–11 years: Initially 2.5–3 mg twice daily, increased to mg 2–3 times a day Child 12–17 years: Initially mg 2–3 times a day, increased if necessary up to mg times a day Adult: Initially mg 2–3 times a day, increased if necessary up to mg times a day Elderly: Initially 2.5–3 mg twice daily, increased if tolerated to mg twice daily, adjusted according to response l ▶ ▶ ▶ ▶ ▶ l l l l CAUTIONS Acute porphyrias p 969 INTERACTIONS → Appendix 1: oxybutynin SIDE-EFFECTS GENERAL SIDE-EFFECTS Uncommon Anorexia facial flushing Rare Night terrors Frequency not known Cognitive impairment (in adults) SPECIFIC SIDE-EFFECTS Rare With transdermal use Application site reactions with patches PREGNANCY Manufacturers advise avoid unless essential—toxicity in animal studies BREAST FEEDING Manufacturers advise avoid—present in milk in animal studies HEPATIC IMPAIRMENT Manufacturer advises caution RENAL IMPAIRMENT Manufacturer advises caution Genito-urinary system BNF 74 734 Bladder and urinary disorders l ▶ l ▶ Genito-urinary system ▶ l ▶ l DIRECTIONS FOR ADMINISTRATION With transdermal use in adults Apply patches to clean, dry, unbroken skin on abdomen, hip or buttock, remove after every 3–4 days and site replacement patch on a different area (avoid using same area for days) PRESCRIBING AND DISPENSING INFORMATION In adults The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months In children The need for therapy for urinary indications should be reviewed soon after it has been commenced and then at regular intervals; a response usually occurs within months but may take longer PATIENT AND CARER ADVICE Medicines for Children leaflet: Oxybutynin for daytime urinary symptoms www.medicinesforchildren.org.uk/oxybutynin-fordaytime-urinary-symptoms With transdermal use Patients or carers should be given advice on how to administer oxybutynin transdermal patches NATIONAL FUNDING/ACCESS DECISIONS Scottish Medicines Consortium (SMC) Decisions The Scottish Medicines Consortium has advised (July 2005) that Kentera ® should be restricted for use in patients who benefit from oral oxybutynin but cannot tolerate its sideeffects l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral suspension, oral solution Modified-release tablet CAUTIONARY AND ADVISORY LABELS 3, 25 ▶ Lyrinel XL (Janssen-Cilag Ltd) Oxybutynin hydrochloride mg Lyrinel XL 5mg tablets | 30 tablet P £13.77 DT price = £13.77 Oxybutynin hydrochloride 10 mg Lyrinel XL 10mg tablets | 30 tablet P £27.54 DT price = £27.54 Tablet BNF 74 eiii i F 732 Solifenacin succinate INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Urinary incontinence l ▶ BY MOUTH Adult: mg once daily, increased if necessary to 10 mg once daily DOSE ADJUSTMENTS DUE TO INTERACTIONS Manufacturer advises max dose mg daily with concurrent use of potent inhibitors of CYP3A4; avoid concurrent use in patients who also have moderate hepatic impairment or severe renal impairment ▶ CONTRA-INDICATIONS Narrow-angle glaucoma CAUTIONS Neurogenic bladder disorder susceptibility to QT-interval prolongation l INTERACTIONS → Appendix 1: solifenacin l SIDE-EFFECTS ▶ Uncommon Gastro-oesophageal reflux oedema ▶ Frequency not known Dysphonia hepatic impairment hyperkalaemia muscle weakness reduced appetite torsade de pointes l PREGNANCY Manufacturer advises caution—no information available l BREAST FEEDING Manufacturer advises avoid—present in milk in animal studies l HEPATIC IMPAIRMENT Max mg daily in moderate impairment Avoid in severe impairment l RENAL IMPAIRMENT Max mg daily if eGFR less than 30 mL/minute/1.73 m2 l PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months l l l CAUTIONARY AND ADVISORY LABELS ▶ ▶ ▶ Oxybutynin hydrochloride (Non-proprietary) Oxybutynin hydrochloride 2.5 mg Oxybutynin 2.5mg tablets | 56 tablet P £6.58 DT price = £1.15 | 84 tablet P £7.71 Oxybutynin hydrochloride mg Oxybutynin 3mg tablets | 56 tablet P £16.80 DT price = £16.80 Oxybutynin hydrochloride mg Oxybutynin 5mg tablets | 56 tablet P £13.85 DT price = £1.49 | 84 tablet P £20.77 Cystrin (Zentiva) Oxybutynin hydrochloride mg Cystrin 5mg tablets | 84 tablet P £21.99 Ditropan (Sanofi) Oxybutynin hydrochloride 2.5 mg Ditropan 2.5mg tablets | 84 tablet P £1.60 Oxybutynin hydrochloride mg Ditropan 5mg tablets | 84 tablet P £2.90 Tablet CAUTIONARY AND ADVISORY LABELS ▶ Transdermal patch CAUTIONARY AND ADVISORY LABELS ▶ Kentera (Orion Pharma (UK) Ltd) Oxybutynin 3.9 mg per 24 hour Kentera 3.9mg/24hours patches | patch P £27.20 DT price = £27.20 P eiii i F 732 INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Urinary incontinence l ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES CAUTIONARY AND ADVISORY LABELS Oxybutynin hydrochloride (Non-proprietary) Oxybutynin hydrochloride 500 microgram per ml Oxybutynin 2.5mg/5ml oral solution sugar free sugar-free | 150 ml P £144.50–£173.40 DT price = £144.50 Oxybutynin hydrochloride mg per ml Oxybutynin 5mg/5ml oral solution sugar free sugar-free | 150 ml P £199.20–£239.04 DT price = £199.20 Vesicare (Astellas Pharma Ltd) Solifenacin succinate mg Vesicare 5mg tablets | 30 tablet £27.62 DT price = £27.62 Solifenacin succinate 10 mg Vesicare 10mg tablets | 30 tablet P £35.91 DT price = £35.91 Trospium chloride Oral solution ▶ MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral suspension, oral solution ▶ Adult: 20 mg twice daily, to be taken before food ▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES ▶ Adult: 60 mg once daily INTERACTIONS → Appendix 1: trospium SIDE-EFFECTS ▶ Rare Asthenia chest pain dyspnoea ▶ Very rare Arthralgia myalgia l PREGNANCY Manufacturer advises caution l BREAST FEEDING Manufacturer advises caution l HEPATIC IMPAIRMENT Manufacturer advises caution in mild to moderate impairment Avoid in severe impairment l RENAL IMPAIRMENT Reduce dose to 20 mg once daily or 20 mg on alternate days if eGFR 10–30 mL/minute/1.73m2 Use with caution Avoid Regurin ® XL l l l Urinary frequency, enuresis, and incontinence 735 Propiverine hydrochloride 45 mg Detrunorm XL 45mg capsules | 28 capsule P £27.00 DT price = £27.00 PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months Tablet CAUTIONARY AND ADVISORY LABELS ▶ l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral solution eiii i F 732 Tolterodine tartrate Modified-release capsule CAUTIONARY AND ADVISORY LABELS 23, 25 ▶ ▶ Trospium chloride (Non-proprietary) Trospium chloride 60 mg Trospium chloride 60mg modified-release capsules | 28 capsule P no price available DT price = £23.05 | 30 capsule P no price available Regurin XL (Speciality European Pharma Ltd) Trospium chloride 60 mg Regurin XL 60mg capsules | 28 capsule P £23.05 DT price = £23.05 INDICATIONS AND DOSE Urinary frequency | Urinary urgency | Urinary incontinence l ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ Adult: mg once daily DOSE EQUIVALENCE AND CONVERSION ▶ Children stabilised on immediate-release tolterodine tartrate mg twice daily may be transferred to modified-release tolterodine tartrate mg once daily ▶ CAUTIONARY AND ADVISORY LABELS 23 ▶ ▶ ▶ Trospium chloride (Non-proprietary) Trospium chloride 20 mg Trospium chloride 20mg tablets | 60 tablet P £26.00 DT price = £13.01 Flotros (Galen Ltd) Trospium chloride 20 mg Flotros 20mg tablets | 60 tablet P £15.47 DT price = £13.01 Regurin (Speciality European Pharma Ltd) Trospium chloride 20 mg Regurin 20mg tablets | 60 tablet P £26.00 DT price = £13.01 Uraplex (Speciality European Pharma Ltd) Trospium chloride 20 mg Uraplex 20mg tablets | 60 tablet P £26.00 DT price = £13.01 ANTIMUSCARINICS › OTHER eiii i F 732 Propiverine hydrochloride INDICATIONS AND DOSE Urinary frequency, urgency and incontinence associated with overactive bladder l ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ Adult: 15 mg 1–2 times a day, increased if necessary up to 15 mg times a day ▶ BY MOUTH USING MODIFIED-RELEASE CAPSULES Adult: 30 mg once daily Urinary frequency, urgency and incontinence associated with neurogenic bladder instability ▶ ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ l l l l l l l Adult: 15 mg times a day INTERACTIONS → Appendix 1: propiverine PREGNANCY Manufacturer advises avoid (restriction of skeletal development in animals) BREAST FEEDING Manufacturer advises avoid—present in milk in animal studies HEPATIC IMPAIRMENT Avoid in moderate to severe impairment RENAL IMPAIRMENT Max daily dose 30 mg if eGFR less than 30 mL/minute/1.73m2 Manufacturer advises caution in mild or moderate impairment PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months CAUTIONS History of QT-interval prolongation INTERACTIONS → Appendix 1: tolterodine l SIDE-EFFECTS ▶ Common or very common Bronchitis chest pain fatigue paraesthesia peripheral oedema sinusitis vertigo weight gain ▶ Uncommon Memory impairment ▶ Frequency not known Flushing l PREGNANCY Manufacturer advises avoid—toxicity in animal studies l BREAST FEEDING Manufacturer advises avoid—no information available l HEPATIC IMPAIRMENT Reduce dose to mg twice daily Avoid modified-release preparations l RENAL IMPAIRMENT Reduce dose to mg twice daily if eGFR less than 30 mL/minute/1.73m2 Avoid modifiedrelease preparations if eGFR less than 30 mL/minute/1.73m2 l PRESCRIBING AND DISPENSING INFORMATION The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months l l l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral suspension, oral solution Tablet CAUTIONARY AND ADVISORY LABELS ▶ ▶ CAUTIONARY AND ADVISORY LABELS 3, 25 ▶ Modified-release capsule ▶ CAUTIONARY AND ADVISORY LABELS 3, 25 Detrunorm XL (AMCo) Propiverine hydrochloride 30 mg Detrunorm XL 30mg capsules | 28 capsule P £24.45 DT price = £24.45 Tolterodine tartrate (Non-proprietary) Tolterodine tartrate mg Tolterodine 1mg tablets | 56 tablet P £29.03 DT price = £1.85 Tolterodine tartrate mg Tolterodine 2mg tablets | 56 tablet P £30.56 DT price = £1.81 Detrusitol (Pfizer Ltd) Tolterodine tartrate mg Detrusitol 1mg tablets | 56 tablet P £29.03 DT price = £1.85 Tolterodine tartrate mg Detrusitol 2mg tablets | 56 tablet P £30.56 DT price = £1.81 Modified-release capsule MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug ▶ Adult: mg twice daily, reduced if not tolerated to mg twice daily ▶ BY MOUTH USING MODIFIED-RELEASE CAPSULES Tablet ▶ Detrunorm (AMCo) Propiverine hydrochloride 15 mg Detrunorm 15mg tablets | 56 tablet P £18.00 DT price = £18.00 ▶ Tolterodine tartrate (Non-proprietary) Tolterodine tartrate mg Tolterodine 2mg modified-release capsules | 28 capsule P no price available DT price = £11.60 Blerone XL (Zentiva) Tolterodine tartrate mg Blerone XL 4mg capsules | 28 capsule P £25.78 DT price = £25.78 Detrusitol XL (Pfizer Ltd) Tolterodine tartrate mg Detrusitol XL 4mg capsules | 28 capsule P £25.78 DT price = £25.78 Genito-urinary system BNF 74 736 Bladder and urinary disorders ▶ ▶ ▶ Genito-urinary system ▶ ▶ ▶ Efflosomyl XL (Mylan Ltd) Tolterodine tartrate mg Efflosomyl XL 4mg capsules | 28 capsule P £20.62 DT price = £25.78 Inconex XL (Sandoz Ltd) Tolterodine tartrate mg Inconex XL 4mg capsules | 28 capsule P £21.91 DT price = £25.78 Mariosea XL (Teva UK Ltd) Tolterodine tartrate mg Mariosea XL 2mg capsules | 28 capsule P £11.59 DT price = £11.60 Tolterodine tartrate mg Mariosea XL 4mg capsules | 28 capsule P £12.88 DT price = £25.78 Neditol XL (Aspire Pharma Ltd) Tolterodine tartrate mg Neditol XL 2mg capsules | 28 capsule P £11.60 DT price = £11.60 Tolterodine tartrate mg Neditol XL 4mg capsules | 28 capsule P £12.89 DT price = £25.78 Preblacon XL (Actavis UK Ltd) Tolterodine tartrate mg Preblacon XL 4mg capsules | 28 capsule P £25.78 DT price = £25.78 Santizor XL (Pfizer Ltd) Tolterodine tartrate mg Santizor XL 4mg capsules | 28 capsule P £25.78 DT price = £25.78 BETA -ADRENOCEPTOR AGONISTS Mirabegron INDICATIONS AND DOSE Urinary frequency, urgency, and urge incontinence BNF 74 l NATIONAL FUNDING/ACCESS DECISIONS NICE technology appraisals (TAs) ▶ Mirabegron for treating symptoms of overactive bladder (June 2013) NICE TA290 Mirabegron is recommended as an option only for patients in whom antimuscarinic drugs are ineffective, contraindicated, or not tolerated; patients currently receiving mirabegron who not meet these criteria should have the option to continue until they and their clinician consider it appropriate to stop www.nice.org.uk/TA290 l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Modified-release tablet CAUTIONARY AND ADVISORY LABELS 25 ▶ Betmiga (Astellas Pharma Ltd) A Mirabegron 25 mg Betmiga 25mg modified-release tablets | 30 tablet P £29.00 DT price = £29.00 Mirabegron 50 mg Betmiga 50mg modified-release tablets | 30 tablet P £29.00 DT price = £29.00 1.2 Urinary retention l ▶ BY MOUTH Adult: 50 mg once daily DOSE ADJUSTMENTS DUE TO INTERACTIONS Manufacturer advises reduce dose to 25 mg once daily in patients with mild hepatic impairment with concurrent use of potent inhibitors of CYP3A4; avoid in moderate impairment Manufacturer advises reduce dose to 25 mg once daily if eGFR 30–89 mL/minute/1.73 m2 with concurrent use of potent inhibitors of CYP3A4; avoid if eGFR less than 30 mL/minute/1.73 m2 ▶ CONTRA-INDICATIONS Severe uncontrolled hypertension (systolic blood pressure 180 mmHg or diastolic blood pressure 110 mmHg) l CAUTIONS History of QT-interval prolongation stage hypertension l INTERACTIONS → Appendix 1: mirabegron l SIDE-EFFECTS ▶ Common or very common Tachycardia urinary-tract infection ▶ Uncommon Atrial fibrillation dyspepsia gastritis hypertension joint swelling palpitation pruritus rash vulvovaginal infection vulvovaginal pruritus l CONCEPTION AND CONTRACEPTION Contraception advised in women of child-bearing potential l PREGNANCY Avoid—toxicity in animal studies l BREAST FEEDING Avoid—present in milk in animal studies l HEPATIC IMPAIRMENT Reduce dose to 25 mg once daily in moderate impairment Avoid in severe impairment—no information available l RENAL IMPAIRMENT Reduce dose to 25 mg once daily if eGFR 15–29 mL/minute/1.73 m2 Avoid if eGFR less than 15 mL/minute/1.73 m2—no information available l MONITORING REQUIREMENTS Blood pressure should be monitored before starting treatment and regularly during treatment, especially in patients with pre-existing hypertension l Urinary retention 31-May-2017 Description of condition Urinary retention is the inability to voluntarily urinate It may be secondary to urethral blockage, drug treatment (such as use of antimuscarinic drugs, sympathomimetics, tricyclic antidepressants), conditions that reduce detrusor contractions or interfere with relaxation of the urethra, neurogenic causes, or it may occur postpartum or postoperatively Acute urinary retention is a medical emergency characterised by the abrupt development of the inability to pass urine (over a period of hours) Chronic urinary retention is the gradual (over months or years) development of the inability to empty the bladder completely, characterised by a residual volume greater than one litre or associated with the presence of a distended or palpable bladder Urinary retention due to benign prostatic hyperplasia The most common cause of urinary retention in men is benign prostatic hyperplasia Men with an enlarged prostate can have lower urinary tract symptoms associated with obstruction, such as urinary retention (acute or chronic), frequency, urgency or nocturia Treatment Treatment of urinary retention depends on the underlying condition Catheterisation is used to relieve acute painful urinary retention or when no cause can be found Surgical procedures or dilatation are often used to correct mechanical outflow obstructions Acute urinary retention g Acute retention is painful and requires immediate treatment by catheterisation Before the catheter is removed an alpha-adrenoceptor blocker (such as alfuzosin hydrochloride p 737, doxazosin p 738, tamsulosin hydrochloride p 739, prazosin p 739, indoramin p 738 or terazosin p 741) should be given for at least two days to manage acute urinary retention h Chronic urinary retention g In patients with chronic urinary retention, intermittent bladder catheterisation should be offered before an indwelling catheter Catheters may be used as a long-term solution where persistent urinary retention is causing Urinary retention 737 BNF 74 Urinary retention due to benign prostatic hyperplasia In patients with benign prostatic hyperplasia, treatment is influenced by the severity of symptoms and their effect on the patient’s quality of life g Watchful waiting is suitable for men with symptoms that are not troublesome and in those who have not yet developed complications of benign prostatic hyperplasia such as renal impairment, urinary retention or recurrent infection The recommended treatment of benign prostatic hyperplasia is usually an alpha-adrenoceptor blocker The alpha1-selective adrenoceptor blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary flow-rate and an improvement in obstructive symptoms In patients with an enlarged prostate, a raised prostate specific antigen concentration, and who are considered to be at high risk of progression (such as the elderly), a 5a-reductase inhibitor (such as finasteride p 742 or dutasteride p 741) should be used A combination of an alpha-adrenoceptor blocker and a 5a-reductase inhibitor can be offered if symptoms remain a problem Surgery is recommended for men with more severe symptoms that not respond to drug therapy, or who have complications such as acute urinary retention, haematuria, renal failure, bladder calculi or recurrent urinary-tract infection h Useful Resources Lower urinary tract symptoms in men National Institute for Health and Care Excellence Clinical guideline CG97 May 2010 (updated June 2015) www.nice.org.uk/guidance/cg97 CONTRA-INDICATIONS Avoid if history micturition syncope avoid if history of postural hypotension l CAUTIONS Acute heart failure concomitant antihypertensives (reduced dosage and specialist supervision may be required) discontinue if angina worsens elderly history of QT-interval prolongation patients undergoing cataract surgery (risk of intraoperative floppy iris syndrome) l INTERACTIONS → Appendix 1: alpha blockers l SIDE-EFFECTS ▶ Uncommon Chest pain flushes ▶ Frequency not known Angioedema asthenia blurred vision cholestasis depression dizziness drowsiness dry mouth erectile disorders (including priapism) gastrointestinal disturbances headache hypersensitivity hypotension (notably postural hypotension) intraoperative floppy iris syndrome liver damage oedema palpitations pruritus rash rhinitis syncope tachycardia SIDE-EFFECTS, FURTHER INFORMATION ▶ First dose effect First dose may cause collapse due to hypotensive effect (therefore should be taken on retiring to bed) Patient should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying down until they abate completely l HEPATIC IMPAIRMENT Initial dose 2.5 mg once daily, adjusted according to response to 2.5 mg twice daily in mild to moderate impairment—avoid if severe Avoid modified-release preparations l RENAL IMPAIRMENT Initial dose 2.5 mg twice daily and adjust according to response Manufacturers advise avoid use of modified-release preparations if eGFR less than 30 mL/minute/1.73 m2 as limited experience l PATIENT AND CARER ADVICE Patient should be counselled on the first dose effect Driving and skilled tasks May affect performance of skilled tasks e.g driving l l MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: oral solution Modified-release tablet CAUTIONARY AND ADVISORY LABELS 21, 25 ▶ ▶ Other drugs used for Urinary retention Tadalafil, p 767 ▶ ALPHA-ADRENOCEPTOR BLOCKERS Alfuzosin hydrochloride l INDICATIONS AND DOSE Benign prostatic hyperplasia ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ ▶ Adult: 2.5 mg times a day; maximum 10 mg per day Elderly: Initially 2.5 mg twice daily, adjusted according to response; maximum 10 mg per day ▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES Adult: 10 mg once daily Acute urinary retention associated with benign prostatic hyperplasia ▶ ▶ BY MOUTH USING MODIFIED-RELEASE TABLETS ▶ Elderly: 10 mg once daily for 2–3 days during catheterisation and for one day after removal; max days ▶ ▶ Alfuzosin hydrochloride (Non-proprietary) Alfuzosin hydrochloride 10 mg Alfuzosin 10mg modified-release tablets | 30 tablet P no price available DT price = £12.51 Besavar XL (Zentiva) Alfuzosin hydrochloride 10 mg Besavar XL 10mg tablets | 30 tablet P £12.51 DT price = £12.51 Fuzatal XL (Teva UK Ltd) Alfuzosin hydrochloride 10 mg Fuzatal XL 10mg tablets | 30 tablet P £12.76 DT price = £12.51 Vasran XL (Ranbaxy (UK) Ltd) Alfuzosin hydrochloride 10 mg Vasran XL 10mg tablets | 30 tablet P £11.48 DT price = £12.51 Xatral XL (Sanofi) Alfuzosin hydrochloride 10 mg Xatral XL 10mg tablets | 10 tablet P £4.17 | 30 tablet P £12.51 DT price = £12.51 Tablet ▶ ▶ Alfuzosin hydrochloride (Non-proprietary) Alfuzosin hydrochloride 2.5 mg Alfuzosin 2.5mg tablets | 60 tablet P £21.20 DT price = £2.10 Xatral (Sanofi) Alfuzosin hydrochloride 2.5 mg Xatral 2.5mg tablets | 60 tablet P £20.37 DT price = £2.10 Genito-urinary system incontinence, infection, or renal dysfunction and a surgical solution is not feasible h Their use is associated with an increased risk of adverse events including recurrent urinary infections, trauma to the urethra, pain, and stone formation g In men who have symptoms that are bothersome, drug treatment should only be offered when other conservative management options have failed Men with moderate-to-severe symptoms should be offered an alphaadrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin) Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months h The parasympathomimetic bethanechol chloride p 741 increases detrusor muscle contraction It is licensed for acute postoperative, postpartum and neurogenic urinary retention but its use has largely been superseded by catheterisation 738 Bladder and urinary disorders Doxazosin BNF 74 l INDICATIONS AND DOSE Hypertension l Modified-release tablet ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: capsule, oral suspension, oral solution CAUTIONARY AND ADVISORY LABELS 25 Adult: Initially mg once daily for 1–2 weeks, then increased to mg once daily, then increased if necessary to mg once daily; maximum 16 mg per day ▶ ▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES Adult: Initially mg once daily, dose can be adjusted after weeks, then increased if necessary to mg once daily Benign prostatic hyperplasia Genito-urinary system ▶ ▶ ▶ ▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES ▶ Adult: Initially mg daily, dose may be doubled at intervals of 1–2 weeks according to response; usual maintenance 2–4 mg daily; maximum mg per day ▶ ▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES Adult: Initially mg once daily, dose can be adjusted after weeks, then increased if necessary to mg once daily DOSE EQUIVALENCE AND CONVERSION ▶ Patients stabilised on immediate-release doxazosin can be transferred to the equivalent dose of modifiedrelease doxazosin ▶ ▶ l l l l ▶ ▶ ▶ ▶ l l l l CONTRA-INDICATIONS History of micturition syncope (in patients with benign prostatic hypertrophy) history of postural hypotension monotherapy in patients with overflow bladder or anuria CAUTIONS Care with initial dose (postural hypotension) cataract surgery (risk of intra-operative floppy iris syndrome) elderly heart failure pulmonary oedema due to aortic or mitral stenosis INTERACTIONS → Appendix 1: alpha blockers SIDE-EFFECTS Common or very common Anxiety back pain coughing dyspnoea fatigue influenza-like symptoms myalgia paraesthesia sleep disturbance vertigo Uncommon Agitation angina arthralgia epistaxis gout hypoaesthesia micturition disturbance myocardial infarction tinnitus tremor weight changes Very rare Abnormal ejaculation alopecia arrhythmias bradycardia bronchospasm cholestasis gynaecomastia hepatitis hot flushes jaundice leucopenia thrombocytopenia Frequency not known Angioedema asthenia blurred vision depression dizziness drowsiness dry mouth erectile disorders gastro-intestinal disturbances headache hypersensitivity hypotension intra-operative floppy iris syndrome oedema palpitations postural hypotension priapism pruritus rash rhinitis syncope tachycardia PREGNANCY No evidence of teratogenicity; manufacturers advise use only when potential benefit outweighs risk BREAST FEEDING Accumulates in milk in animal studies— manufacturer advises avoid HEPATIC IMPAIRMENT Use with caution Manufacturer advises avoid in severe impairment—no information available PATIENT AND CARER ADVICE Patient counselling is advised for doxazosin tablets (initial dose) Driving and skilled tasks May affect performance of skilled tasks e.g driving Cardura XL (Pfizer Ltd) Doxazosin (as Doxazosin mesilate) mg 28 tablet P £5.00 DT price = £5.00 Doxazosin (as Doxazosin mesilate) mg 28 tablet P £9.98 DT price = £9.98 Doxadura XL (Discovery Pharmaceuticals) Doxazosin (as Doxazosin mesilate) mg | 28 tablet P £4.75 DT price = £5.00 Larbex XL (Teva UK Ltd) Doxazosin (as Doxazosin mesilate) mg 28 tablet P £6.08 DT price = £5.00 Raporsin XL (Actavis UK Ltd) Doxazosin (as Doxazosin mesilate) mg | 28 tablet P £5.70 DT price = £5.00 Slocinx XL (Zentiva) Doxazosin (as Doxazosin mesilate) mg 28 tablet P £5.96 DT price = £5.00 Cardura XL 4mg tablets | Cardura XL 8mg tablets | Doxadura XL 4mg tablets Larbex XL 4mg tablets | Raporsin XL 4mg tablets Slocinx XL 4mg tablets | Tablet ▶ ▶ ▶ Doxazosin (Non-proprietary) Doxazosin (as Doxazosin mesilate) mg 28 tablet P £10.56 DT price = £0.71 Doxazosin (as Doxazosin mesilate) mg 28 tablet P £14.08 DT price = £0.74 Doxazosin (as Doxazosin mesilate) mg 28 tablet P £14.08 DT price = £0.84 Cardura (Pfizer Ltd) Doxazosin (as Doxazosin mesilate) mg tablet P £10.56 DT price = £0.71 Doxazosin (as Doxazosin mesilate) mg tablet P £14.08 DT price = £0.74 Doxadura (Discovery Pharmaceuticals) Doxazosin (as Doxazosin mesilate) mg 28 tablet P £0.64 DT price = £0.71 Doxazosin (as Doxazosin mesilate) mg 28 tablet P £0.66 DT price = £0.74 Doxazosin (as Doxazosin mesilate) mg 28 tablet P £0.73 DT price = £0.84 Doxazosin 1mg tablets | Doxazosin 2mg tablets | Doxazosin 4mg tablets | Cardura 1mg tablets | 28 Cardura 2mg tablets | 28 Doxadura 1mg tablets | Doxadura 2mg tablets | Doxadura 4mg tablets | Indoramin INDICATIONS AND DOSE Hypertension l ▶ BY MOUTH ▶ Adult: Initially 25 mg twice daily, increased in steps of 25–50 mg every weeks, maximum daily dose should be given in divided doses; maximum 200 mg per day Benign prostatic hyperplasia ▶ BY MOUTH Adult: 20 mg twice daily, increased in steps of 20 mg every weeks if required, increased if necessary up to 100 mg daily in divided doses ▶ Elderly: 20 mg daily may be adequate, dose to be taken at night DOSE ADJUSTMENTS DUE TO INTERACTIONS Caution with concomitant antihypertensives in benign prostatic hyperplasia—reduced dosage and specialist supervision may be required ▶ l l l CONTRA-INDICATIONS Established heart failure history micturition syncope (when used for benign prostatic hyperplasia) history of postural hypotension (when used for benign prostatic hyperplasia) CAUTIONS Cataract surgery (risk of intra-operative floppy iris syndrome) control incipient heart failure before initiating indoramin elderly epilepsy (convulsions in animal studies) history of depression Parkinson’s disease (extrapyramidal disorders reported) INTERACTIONS → Appendix 1: alpha blockers Urinary retention 739 l SIDE-EFFECTS ▶ Common or very common Sedation ▶ Uncommon Failure of ejaculation fatigue weight gain ▶ Frequency not known Angioedema asthenia blurred vision depression dizziness drowsiness dry mouth erectile disorders extrapyramidal disorders gastrointestinal disturbances headache hypersensitivity reactions hypotension incontinence intra-operative floppy iris syndrome oedema palpitations postural hypotension priapism pruritus rash rhinitis syncope tachycardia urinary frequency l l l l l l PREGNANCY No evidence of teratogenicity; manufacturers advise use only when potential benefit outweighs risk BREAST FEEDING No information available HEPATIC IMPAIRMENT Manufacturer advises caution RENAL IMPAIRMENT Manufacturer advises caution PATIENT AND CARER ADVICE Driving and skilled tasks Drowsiness may affect performance of skilled tasks (e.g driving); effects of alcohol may be enhanced MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug l l l ▶ ▶ ▶ ▶ l l Tablet CAUTIONARY AND ADVISORY LABELS ▶ ▶ Indoramin (Non-proprietary) Indoramin hydrochloride 20 mg Indoramin 20mg tablets | 60 tablet P £61.00 DT price = £8.21 Indoramin (as Indoramin hydrochloride) 25 mg Indoramin 25mg tablets | 84 tablet P £60.26 DT price = £60.26 Doralese Tiltab (Chemidex Pharma Ltd) Indoramin hydrochloride 20 mg Doralese Tiltab 20mg tablets | 60 tablet P £11.44 DT price = £8.21 l l l Prazosin INDICATIONS AND DOSE Hypertension l ▶ BY MOUTH Adult: Initially 500 micrograms 2–3 times a day for 3–7 days, the initial dose should be taken on retiring to bed at night to avoid collapse, increased to mg 2–3 times a day for a further 3–7 days, then increased if necessary up to 20 mg daily in divided doses Congestive heart failure (rarely used) l ▶ congestive heart failure due to mechanical obstruction (e.g aortic stenosis) CAUTIONS Cataract surgery (risk of intra-operative floppy iris syndrome) elderly first dose hypotension INTERACTIONS → Appendix 1: alpha blockers SIDE-EFFECTS Common or very common Blurred vision depression dizziness drowsiness dry mouth dyspnoea gastrointestinal disturbances headache nasal congestion nervousness oedema palpitations syncope urinary frequency vertigo weakness Uncommon Arthralgia epistaxis eye disorders insomnia paraesthesia pruritus rash sweating tachycardia tinnitus urticaria Rare Alopecia bradycardia flushing gynaecomastia hallucinations pancreatitis priapism urinary incontinence vasculitis worsening of narcolepsy Frequency not known Angioedema asthenia erectile disorders hypersensitivity reactions hypotension intraoperative floppy iris syndrome postural hypotension rhinitis PREGNANCY No evidence of teratogenicity; manufacturers advise use only when potential benefit outweighs risk BREAST FEEDING Present in milk, amount probably too small to be harmful; manufacturer advises use with caution HEPATIC IMPAIRMENT Initially 500 micrograms daily; increased with caution RENAL IMPAIRMENT Initially 500 micrograms daily in moderate to severe impairment; increased with caution PATIENT AND CARER ADVICE First dose effect First dose may cause collapse due to hypotensive effect (therefore should be taken on retiring to bed) Patients should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying down until they abate completely Driving and skilled tasks May affect performance of skilled tasks e.g driving MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Forms available from special-order manufacturers include: tablet, oral suspension, oral solution Tablet ▶ ▶ BY MOUTH Adult: 500 micrograms 2–4 times a day, initial dose to be taken at bedtime, then increased to mg daily in divided doses; maintenance 4–20 mg daily in divided doses Raynaud’s syndrome (but efficacy not established) ▶ ▶ ▶ BY MOUTH Adult: Initially 500 micrograms twice daily, initial dose to be taken at bedtime, dose may be increased after 3–7 days, then increased if necessary to 1–2 mg twice daily Benign prostatic hyperplasia Prazosin (Non-proprietary) Prazosin (as Prazosin hydrochloride) mg Minipress 2mg tablets | 100 tablet P no price available Prazosin (as Prazosin hydrochloride) mg Minipress 5mg tablets | 100 tablet P no price available Hypovase (Pfizer Ltd) Prazosin (as Prazosin hydrochloride) 500 microgram Hypovase 500microgram tablets | 60 tablet P £2.69 DT price = £2.69 Prazosin (as Prazosin hydrochloride) mg Hypovase 1mg tablets | 60 tablet P £3.46 DT price = £3.46 ▶ Tamsulosin hydrochloride INDICATIONS AND DOSE Benign prostatic hyperplasia l ▶ BY MOUTH ▶ initiate with lowest possible dose in elderly patients DOSE ADJUSTMENTS DUE TO INTERACTIONS Caution with concomitant antihypertensives in benign prostatic hyperplasia—reduced dosage and specialist supervision may be required l ▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES Adult: Initially 500 micrograms twice daily for 3–7 days, subsequent doses should be adjusted according to response, maintenance mg twice daily, CONTRA-INDICATIONS History of micturition syncope history of postural hypotension not recommended for ▶ l l l l Adult: 400 micrograms once daily CONTRA-INDICATIONS History of micturition syncope history of postural hypotension CAUTIONS Cataract surgery (risk of intra-operative floppy iris syndrome) concomitant antihypertensives (reduced dosage and specialist supervision may be required) elderly INTERACTIONS → Appendix 1: alpha blockers SIDE-EFFECTS Angioedema asthenia blurred vision depression dizziness drowsiness dry mouth erectile Genito-urinary system BNF 74 740 Bladder and urinary disorders l l Genito-urinary system l l l disorders gastro-intestinal disturbances headache hypersensitivity reactions hypotension (notably postural hypotension) intra-operative floppy iris syndrome oedema palpitations priapism pruritus rash rhinitis syncope tachycardia HEPATIC IMPAIRMENT Avoid in severe impairment RENAL IMPAIRMENT Use with caution if eGFR less than 10 mL/minute/1.73 m2 PATIENT AND CARER ADVICE Driving and skilled tasks May affect performance of skilled tasks e.g driving EXCEPTIONS TO LEGAL CATEGORY Tamsulosin hydrochloride 400 microgram capsules can be sold to the public for the treatment of functional symptoms of benign prostatic hyperplasia in men aged 45–75 years to be taken for up to weeks before clinical assessment by a doctor BNF 74 ▶ ▶ Tamsulosin with dutasteride The properties listed below are those particular to the combination only For the properties of the components please consider, tamsulosin hydrochloride p 739, dutasteride p 741 INDICATIONS AND DOSE Benign prostatic hyperplasia l ▶ BY MOUTH MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug ▶ Modified-release tablet l CAUTIONARY AND ADVISORY LABELS 25 l ▶ ▶ ▶ ▶ ▶ Tamsulosin hydrochloride (Non-proprietary) Tamsulosin hydrochloride 400 microgram Tamsulosin 400microgram modified-release tablets | 30 tablet P £10.47 DT price = £10.47 Cositam XL (Consilient Health Ltd) Tamsulosin hydrochloride 400 microgram Cositam XL 400microgram tablets | 30 tablet P £8.89 DT price = £10.47 Faramsil (Sandoz Ltd) Tamsulosin hydrochloride 400 microgram Faramsil 400microgram modified-release tablets | 30 tablet P £8.89 DT price = £10.47 Flectone XL (Teva UK Ltd) Tamsulosin hydrochloride 400 microgram Flectone XL 400microgram tablets | 30 tablet P £9.95 DT price = £10.47 Flomaxtra XL (Astellas Pharma Ltd) Tamsulosin hydrochloride 400 microgram Flomaxtra XL 400microgram tablets | 30 tablet P £10.47 DT price = £10.47 Modified-release capsule CAUTIONARY AND ADVISORY LABELS 25 ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ ▶ Tamsulosin hydrochloride (Non-proprietary) Tamsulosin hydrochloride 400 microgram Tamsulosin 400microgram modified-release capsules | 30 capsule P £5.08 DT price = £3.89 Contiflo XL (Ranbaxy (UK) Ltd) Tamsulosin hydrochloride 400 microgram Contiflo XL 400microgram capsules | 30 capsule P £7.44 DT price = £3.89 Diffundox XL (Zentiva) Tamsulosin hydrochloride 400 microgram Diffundox XL 400microgram capsules | 30 capsule P £9.55 DT price = £3.89 Flomax MR (Boehringer Ingelheim Self-Medication Division) Tamsulosin hydrochloride 400 microgram Flomax Relief MR 400microgram capsules | 14 capsule p £5.58 | 28 capsule p £10.55 Galebon (Consilient Health Ltd) Tamsulosin hydrochloride 400 microgram Galebon 400microgram modified-release capsules | 30 capsule P £3.78 DT price = £3.89 Losinate MR (Aspire Pharma Ltd) Tamsulosin hydrochloride 400 microgram Losinate MR 400microgram capsules | 30 capsule P £10.14 DT price = £3.89 Pamsvax XL (Almus Pharmaceuticals Ltd, Actavis UK Ltd) Tamsulosin hydrochloride 400 microgram Pamsvax XL 400microgram capsules | 30 capsule P £1.31 DT price = £3.89 Petyme MR (Teva UK Ltd) Tamsulosin hydrochloride 400 microgram Petyme 400microgram MR capsules | 30 capsule P £4.06 DT price = £3.89 Pinexel PR (Wockhardt UK Ltd) Tamsulosin hydrochloride 400 microgram Pinexel PR 400microgram capsules | 30 capsule P £2.50 DT price = £3.89 Prosurin XL (Mylan Ltd) Tamsulosin hydrochloride 400 microgram Prosurin XL 400microgram capsules | 30 capsule P £4.28 DT price = £3.89 Tabphyn MR (Genus Pharmaceuticals Ltd) Tamsulosin hydrochloride 400 microgram Tabphyn MR 400microgram capsules | 30 capsule P £4.45 DT price = £3.89 Tamfrex XL (Milpharm Ltd) Tamsulosin hydrochloride 400 microgram Tamfrex XL 400microgram capsules | 30 capsule P no price available DT price = £3.89 Tamurex (Somex Pharma) Tamsulosin hydrochloride 400 microgram Tamurex 400microgram modified-release capsules | 30 capsule P £3.50 DT price = £3.89 l Adult (male): capsule daily INTERACTIONS → Appendix 1: alpha blockers, dutasteride PATIENT AND CARER ADVICE Driving and skilled tasks May affect performance of skilled tasks e.g driving MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Capsule CAUTIONARY AND ADVISORY LABELS 25 ▶ Combodart (GlaxoSmithKline UK Ltd) Tamsulosin hydrochloride 400 microgram, Dutasteride 500 microgram Combodart 0.5mg/0.4mg capsules | 30 capsule P £23.76 DT price = £23.76 Tamsulosin with solifenacin The properties listed below are those particular to the combination only For the properties of the components please consider, tamsulosin hydrochloride p 739, solifenacin succinate p 734 INDICATIONS AND DOSE Moderate to severe urinary frequency, urgency, and obstructive symptoms associated with benign prostatic hyperplasia when monotherapy ineffective l ▶ BY MOUTH Adult (male): tablet daily DOSE ADJUSTMENTS DUE TO INTERACTIONS Manufacturer advises max Vesomni ® tablet daily with concurrent use of potent inhibitors of CYP3A4; avoid concurrent use in patients who also have moderate hepatic impairment, severe renal impairment, are poor metabolisers of CYP2D6, or in patients also taking a potent inhibitor of CYP2D6 ▶ l l l l INTERACTIONS → Appendix 1: alpha blockers, solifenacin HEPATIC IMPAIRMENT Max Vesomni ® tablet daily in moderate impairment RENAL IMPAIRMENT Max Vesomni ® tablet daily if eGFR less than 30 mL/minute/1.73 m2 MEDICINAL FORMS There can be variation in the licensing of different medicines containing the same drug Modified-release tablet CAUTIONARY AND ADVISORY LABELS 3, 25 ▶ Vesomni (Astellas Pharma Ltd) Tamsulosin hydrochloride 400 microgram, Solifenacin succinate mg Vesomni 6mg/0.4mg modified-release tablets | 30 tablet P £27.62 DT price = £27.62 Umeclidinium, 240 ▶ With vilanterol, 241 Undecenoic acid with cetrimide, see Cetrimide with undecenoic acid Undecenoic acid with zinc undecenoate, 1133 Unguentum M, 1123 Uniphyllin Continus, 264 Uniroid HC, 91 Univer, 160 Unlicensed medicines (prescribing), Unstable angina, 150 Unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI), 206 Upostelle, 762 Uptravi, 178 Uraplex, 735 Urea (13C), 81 Urea cycle disorders, 977 Urea hydrogen peroxide, 1098 Urea with hydrocortisone, see Hydrocortisone with urea UrgoCell preparations, 1470 UrgoClean, 1464 Urgosorb preparations, 1468, 1470 UrgoSTART preparations, 1472 UrgotulDuo preparations, 1464, 1471 Urgotul preparations, 1464, 1467, 1471 Uricosurics, 1020 Uricto, 1021 Urinalysis, 675, 693 Urinary frequency, enuresis and incontinence, 731 Urinary retention, 736 Urinary-tract infections, 556 Urispas, 733 Urofollitropin, 704 Urokinase, 133 Urological anti-inflammatory drugs, 744 Urological pain, 742 Urological surgery, 744 Uro-Tainer products, 744 Urothelial toxicity, 827 Ursodeoxycholic acid, 86 Ursofalk, 87 Ustekinumab, 1006 Utovlan, 721 Utrogestan, 722 V Vaccines, 1190, 1201 ▶ Anthrax vaccine, 1192 ▶ BCG vaccine, 1192 ▶ Botulism antitoxin, 1193 ▶ Cholera vaccine, 1193 ▶ Diphtheria vaccine, 1193 ▶ Haemophilus influenzae type B conjugate vaccine, 1193 ▶ Hepatitis A vaccine, 1194 ▶ Hepatitis B vaccine, 1194 ▶ Human papillomavirus vaccine, 1195 ▶ Immunisation schedule, 1190 ▶ Influenza vaccine, 1195 ▶ Invasive Haemophilus influenzae type b disease, 1194 ▶ Japanese encephalitis vaccine, 1195 ▶ Measles, Mumps and Rubella vaccine, 1196 ▶ Meningococcal vaccines, 1196 Pertussis vaccine, 1197 Pneumococcal vaccine, 1197 ▶ Poliomyelitis vaccine, 1198 ▶ Rabies vaccine, 1198 ▶ Rotavirus vaccine, 1199 ▶ Smallpox vaccine, 1199 ▶ Tetanus vaccine, 1199 ▶ Tick-borne encephalitis vaccine, 1200 ▶ Typhoid vaccine, 1200 ▶ Varicella-zoster vaccine, 1200 ▶ Yellow fever vaccine, 1200 Vaccines for travel, 1200 V.A.C products, 1473 Vacunet, 1461 Vacutex, 1468 Vagifem, 783 Vaginal and vulval conditions, 779 Vaginal atrophy, 782 Valaciclovir, 602 Valcyte, 604 Valdoxan, 344 Valganciclovir, 603 Valine50, 1450 Valios, 292 Valket Retard, 1045 Valproate, 296 Valproic acid, 337 Valsartan, 174 ▶ With amlodipine, see Amlodipine with valsartan ▶ With hydrochlorothiazide, 174 ▶ With sacubitril, 186 Valtrex, 603 Vamju, 666 Vancocin preparations, 506 Vancomycin, 505 Vandetanib, 916 Vaniqa, 1171 Vanquoral, 790 Vantobra, 494 Vapour-permeable films and membranes, 1461 VAQTA, 1209 Vardenafil, 768 Varenicline, 475 Vargatef, 918 Varicella-zoster, 1189 Varicella-zoster immunoglobulin, 1189 Varicella-zoster infections, 598 Varicella-zoster vaccine, 1200, 1216 Varilrix, 1217 Variquel, 87 Varivax, 1217 Vascalpha, 155 Vascular disease, 226 Vaseline, 1124 Vasoconstrictor sympathomimetics, 181 Vasodilator antihypertensive drugs, 137 Vasopressin, 630 Vasran XL, 737 Vectibix, 817 Vecuronium bromide, 1229 Vedolizumab, 44 Vedrop, 996 Vehicles, 1117 Vein malformations, 228 Velaglucerase alfa, 973 Velband, 1480 Velcade, 890 Veletri, 112 ▶ ▶ Vellafilm products, 1462 Velphoro, 967 Vemurafenib, 917 Venaxx XL, 352 Vencarm XL, 352 Venclyxto, 920 Venetoclax, 919 Venlablue XL, 352 Venladex XL, 352 Venlafaxine, 351 Venlalic XL, 352 Venofer, 933 Venous thromboembolism, 112 Vensir XL, 352 Ventavis, 179 Ventra, 77 Ventricular arrhythmias, 99 Ventricular tachycardia, 98 Venturi products, 1473 Vepesid, 853 Veracur, 1180 Verapamil hydrochloride, 159 Verapress MR, 160 Vermox, 572 Vernaid, 1473, 1476, 1478 Verrugon, 1182 Versatis, 1243 Vertab SR, 160 Verteporfin, 1090 Vertine, 244 Vesicare, 734 Vesomni, 740 VFEND, 567 Viagra, 767 ViATIM, 1210 Viazem XL, 154 Vibativ, 505 Vibramycin preparations, 535, 1115 Victanyl, 438 Victoza, 659 Vidaza, 839 Videne preparations, 1173 Videx preparations, 612 Viekirax, 593 ViePax preparations, 352 Vigabatrin, 316 Vigam preparations, 1188 Vilanterol with fluticasone, see Fluticasone furoate with vilanterol Vilanterol with umeclidinium, see Umeclidinium with vilanterol Vildagliptin, 656 ▶ With metformin, 656 Vimizim, 974 Vimovo, 1049 Vimpat, 303 Vinblastine sulfate, 858 Vinca alkaloids, 827 Vincristine sulfate, 858 Vindesine sulfate, 859 Vinflunine, 859 Vinorelbine, 860 Vipdomet, 654 Vipidia, 653 Viraferon preparations, 590 Viral eye infection, 1073 Viral infection, 587 Viral skin infections, 1135 Viral vaccines, 1208 Viramune, 610 INDEX Umeclidinium – Viramune 1527 BNF 74 INDEX 1528 Virazole – Zestoretic preparations Virazole, 594 Viread, 617 Virgan, 1073 Viridal, 771 Viscopaste, 1481 Viscotears, 1066 Viskaldix, 145 Visken, 145 Vismed, 1069 Vismodegib, 920 Vistamethasone preparations, 1061, 1096, 1103 Visudyne, 1091 VitaBite, 1445 Vita-E, 996 Vitaflo Choices, 1445 Vitajoule, 1435 Vital 1.5 kcal, 1425 Vitalograph, 265 Vitamin A, 988 Vitamin and mineral supplements, 1439 Vitamin B complex, 989 Vitamin B group, 987 Vitamin B6, see Pyridoxine hydrochloride Vitamin B1, see Thiamine Vitamin B substances with ascorbic acid, 990 Vitamin C, 987 Vitamin D, 987 Vitamin deficiency, 986 Vitamin D3, see Colecalciferol Vitamin D2, see Ergocalciferol Vitamin E, 987 Vitamin K, 987 Vitamins, 986 Vitamins A and D, 987 Vitamins A, C and D, 988 Vitamins with minerals and trace elements, 990 VitA-POS, 1068 Vitaquick, 1441 Vitaros, 771 Vitasavoury, 1439 Vitekta, 607 Vitlipid N preparations, 985 Vitreomacular traction, 1092 Vividrin, 1060 Vivotif, 1208 Vizarsin, 767 Vizulize preparations, 1067 Vokanamet, 662 Volatile liquid anaesthetics, 1219 Voleze, 291 Volibris, 179 Volplex, 961 Voltarol preparations, 1036 Volulyte, 962 Volumatic, 265 Volume, 1536 Voluven, 962 Vomiting during pregnancy, 408 Voractiv, 551 Voriconazole, 566 Vortex, 265 Vortioxetine, 363 Votrient, 910 Votubia, 901 VPRIV, 973 VSL#3, 1440 Vulvovaginal candidiasis in pregnancy, 779 W Wakix, 467 Warburtons products, 1442 Warfarin sodium, 135 Warticon, 1180 Warts and calluses, 1179 ▶ Anogenital warts, 1179 Wasp Venom, 278 Wasp venom extract, 278 WaveSense JAZZ, 679 Waxsol, 1098 Weak opioids, 422 Welland, 1473 Wellfoods products, 1442 Wellvone, 569 White soft paraffin with liquid paraffin and wool alcohols, see Liquid paraffin with white soft paraffin and wool alcohols White soft paraffin with retinol palmitate with light liquid with liquid paraffin and wool, see Retinol palmitate with white soft paraffin and light liquid paraffin and liquid paraffin and wool fat Wilson’s disease, 978 Wilzin, 978 WoundASSIST products, 1473 Wounds, 1457 ▶ Adjunct dressings and appliances, 1472 ▶ Advanced wound dressings, 1460 ▶ Antimicrobial dressings, 1468 ▶ Bandages, 1476 ▶ Basic wound contact dressings, 1457 ▶ Compression hosiery and garments, 1481 ▶ Specialised dressings, 1472 ▶ Topical negative pressure therapy, 1473 ▶ Wound care accessories, 1474 X Xadago, 407 Xagrid, 945 Xailin preparations, 1066 Xalacom, 1084 Xalatan, 1084 Xalkori, 897 Xaluprine, 844 Xanax, 326 Xanthine oxidase inhibitors, 1021 Xanthines, 261 Xarelto, 125 Xatral preparations, 737 Xeloda, 840 Xemacort, 1147 Xenazine, 387 Xenical, 89 Xeomin, 388 Xepin, 1161 Xeplion, 381 Xerotin, 1107 Xetinin XL, 509 Xgeva, 692 Xiapex, 1056 Xifaxanta, 544 Xigduo, 664 BNF 74 Xipamide, 225 XLYS TRY Glutaridon, 1447 XMET preparations, 1448 XMTVI preparations, 1449 Xolair, 257 Xomolix, 419 XPHEN TYR preparations, 1453 XPTM preparations, 1453 Xtandi, 874 Xultophy, 671 XuPad, 1473 Xylocaine preparations, 1243 Xylometazoline hydrochloride, 1100 ▶ With antazoline, see Antazoline with xylometazoline Xyloproct, 91 Xyrem, 467 Xyzal, 270 Y Yacella, 752 Yasmin, 752 Yellow card scheme, 12 Yellow fever vaccine, 1200, 1217 Yellox, 1076 Yemex, 438 Yentreve, 351 Yervoy, 813 Yiznell, 752 Yondelis, 851 Z Zacin, 458 Zaditen, 275, 1060 Zafirlukast, 259 Zalasta, 380 Zaleplon, 460, 465 Zaltrap, 921 Zaluron XL, 383 Zalviso, 446 Zamadol preparations, 448 Zanamivir, 625 Zanidip, 156 Zantac, 75 Zapain, 431 Zaponex, 378 Zarzio, 943 Zavedos, 837 Zavesca, 976 Zebinix, 300 Zedbac, 508 Zeffix, 616 Zelapar, 408 Zelboraf, 918 Zelleta, 759 Zemon XL, 215 Zemplar, 995 Zemtard XL, 154 Zenalb, 960 Zepatier, 591 Zerbaxa, 503 Zeridame SR, 448 Zerit, 616 ZeroAQS, 1123 Zerobase, 1123 Zerocream, 1123 Zeroguent, 1124 Zerolatum preparations, 1121 Zeroneum, 1122 Zestoretic preparations, 166 Zestril, 165 Zetuvit preparations, 1459 Zevtera, 503 Ziagen, 611 Ziclaseg, 666 Zicron preparations, 666 Zidoval, 514 Zidovudine, 617 ▶ With abacavir and lamivudine, see Abacavir with lamivudine and zidovudine ▶ With lamivudine, 618 Zimovane, 466 Zinacef, 499 Zinamide, 556 Zinbryta, 804 Zinc, 979 Zinc acetate, 978 ▶ With erythromycin, see Erythromycin with zinc acetate Zinc deficiency, 979 Zinc oxide ▶ With benzyl benzoate, bismuth oxide, bismuth subgallate, hydrocortisone acetate and peru balsam, see Benzyl benzoate with bismuth oxide, bismuth subgallate, hydrocortisone acetate, peru balsam and zinc oxide ▶ With benzyl benzoate, bismuth oxide, hydrocortisone acetate, peru balsam and pramocaine hydrochloride, see Benzyl benzoate with bismuth oxide, hydrocortisone acetate, peru balsam, pramocaine hydrochloride and zinc oxide ▶ With calamine, see Calamine with zinc oxide ▶ With coal tar, see Coal tar with zinc oxide ▶ With dithranol and salicylic acid, see Dithranol with salicylic acid and zinc oxide ▶ With ichthammol, see Ichthammol with zinc oxide ▶ With salicyclic acid, see Salicylic acid with zinc oxide Zinc sulfate, 979 Zinc undecenoate with undecenoic acid, see Undecenoic acid with zinc undecenoate Zindaclin, 1164 Zineryt, 1164 Zinforo, 503 Zinnat, 499 Zipzoc, 1481 Zispin preparations, 355 Zithromax, 508 Zlatal, 846 Zocor, 199 Zoely, 751 Zofran preparations, 415 Zoladex preparations, 696 Zoledronic acid, 688 Zolmitriptan, 456 Zolpidem tartrate, 460, 465 Zomacton, 707 Zomestine, 444 Zometa, 689 Zomig preparations, 457 Zomorph, 442 Zonegran, 318 Zonisamide, 296, 317 Zopiclone, 460, 466 Zorac, 1158 Zostavax, 1217 Zoton preparations, 78 Zovirax, 601, 1073, 1136 Zuclopenthixol, 373 Zuclopenthixol acetate, 373 Zuclopenthixol decanoate, 375 Zumenon, 714 Zutectra, 1186 Zyban, 473 Zyclara, 1182 Zydelig, 904 Zydol preparations, 448 Zykadia, 895 Zyloric, 1021 Zyomet, 1128 Zypadhera, 385 Zyprexa preparations, 380 Zytiga, 873 Zyvox, 541 INDEX Zestril – Zyvox 1529 BNF 74 Adult Advanced Life Support Algorithm Reproduced with the kind permission of the Resuscitation Council (UK) from Resuscitation Guidelines, 2015 Medical emergencies in the community Overview Airways disease, obstructive Drug treatment outlined below is intended for use by ▶ ASTHMA: ACUTE appropriately qualified healthcare professionals Only Regard each emergency consultation as being for severe drugs that are used for immediate relief are shown; advice on acute asthma until shown otherwise; failure to respond supporting care is not given Where the patient’s condition adequately at any time requires immediate transfer to requires investigation and further treatment, the patient hospital should be transferred to hospital promptly ▶ EITHER Salbutamol aerosol inhaler p 244 (100 micrograms/metered inhalation) Acute coronary syndromes ▶ ANGINA: UNSTABLE Aspirin dispersible tablets p 117 (75 mg, 300 mg) BY MOUTH (DISPERSED IN WATER OR CHEWED) ▶ Adult: 300 mg BY AEROSOL INHALATION VIA LARGE-VOLUME SPACER (AND A CLOSE-FITTING FACE MASK IF CHILD UNDER YEARS) ▶ Adult and Child: 2–10 puffs each inhaled separately, repeated every 10–20 minutes or as necessary ▶ OR Salbutamol nebuliser solution (1 mg/mL, mg/mL) ▶ PLUS BY INHALATION OF NEBULISED SOLUTION (VIA OXYGEN-DRIVEN NEBULISER IF AVAILABLE) ▶ EITHER Glyceryl trinitrate aerosol spray p 212 ▶ (400 micrograms/metered dose) SUBLINGUALLY ▶ ▶ OR Glyceryl trinitrate tablets (300 micrograms, 500 micrograms, 600 micrograms) SUBLINGUALLY ▶ ▶ Adult: 1–2 sprays, repeated as required Adult: 0.3–1 mg, repeated as required ▶ MYOCARDIAL INFARCTION: NON-ST-SEGMENT ELEVATION Treat as for Angina: unstable ▶ ▶ ▶ OR Terbutaline sulfate nebuliser solution p 246 (2.5 mg/mL) BY INHALATION OF NEBULISED SOLUTION (VIA OXYGEN-DRIVEN NEBULISER IF AVAILABLE) ▶ ▶ MYOCARDIAL INFARCTION: ST-SEGMENT ELEVATION Aspirin dispersible tablets (75 mg, 300 mg) ▶ BY MOUTH (DISPERSED IN WATER OR CHEWED) ▶ Adult: 300 mg Glyceryl trinitrate aerosol spray (400 micrograms/metered dose) SUBLINGUALLY ▶ Adult: 1–2 sprays, repeated as required ▶ OR Glyceryl trinitrate tablets (300 micrograms, 500 micrograms, 600 micrograms) SUBLINGUALLY ▶ ▶ ▶ ▶ EITHER Prednisolone tablets p 639 (or prednisolone soluble tablets) (5 mg) BY MOUTH ▶ Adult: 0.3–1 mg, repeated as required BY INTRAVENOUS INJECTION ▶ ▶ Adult 18–19 years (body-weight up to 60 kg): mg Adult 18–19 years (body-weight 60 kg and over): 10 mg Adult over 19 years: 10 mg Diamorphine hydrochloride injection p 433 (5 mg powder for reconstitution) ▶ ▶ ▶ Adult: mg followed by a further 2.5–5 mg if necessary Elderly or frail patients: reduce dose by half ▶ OR Morphine sulfate injection (10 mg/mL) BY SLOW INTRAVENOUS INJECTION (1–2 MG/MINUTE) ▶ ▶ Adult: 5–10 mg followed by a further 5–10 mg if necessary Elderly or frail patients: reduce dose by half Oxygen, if appropriate Child 11 years and below: 1–2 mg/kg (max 40 mg) once daily for up to days or longer if necessary; if child has been taking an oral corticosteroid for more than a few days, give prednisolone mg/kg (max 60 mg) once daily Child 12–17 years: 40–50 mg once daily for at least days Adult: 40–50 mg once daily for at least days ▶ OR Hydrocortisone p 637 (preferably as sodium succinate) BY INTRAVENOUS INJECTION ▶ BY SLOW INTRAVENOUS INJECTION (1–2 MG/MINUTE) ▶ Child years and below: mg every 20–30 minutes or as necessary Child 5–11 years: 5–10 mg every 20–30 minutes or as necessary Child 12–17 years: 10 mg every 20–30 minutes or as necessary Adult: 10 mg every 20–30 minutes or as necessary ▶ PLUS (in all cases) Metoclopramide hydrochloride injection p 411 (5 mg/mL) ▶ Child years and below: 2.5 mg every 20–30 minutes or as necessary Child 5–11 years: 2.5–5 mg every 20–30 minutes or as necessary Child 12–17 years: mg every 20–30 minutes or as necessary Adult: mg every 20–30 minutes or as necessary ▶ ▶ ▶ ▶ Child 17 years and below: mg/kg (max.100 mg) every hours until conversion to oral prednisolone is possible; alternative dose if weight unavailable: Child year and below: 25 mg Child 2–4 years: 50 mg Child 5–17 years: 100 mg Adult: 100 mg every hours until conversion to oral prednisolone is possible High-flow oxygen should be given if available (via face mask in children) Monitor response 15 to 30 minutes after nebulisation; if any signs of acute asthma persist, arrange hospital admission While awaiting ambulance, repeat nebulised beta2 agonist (as above) and give with Ipratropium bromide nebuliser solution p 239 (250 micrograms/mL) BY INHALATION OF NEBULISED SOLUTION (VIA OXYGEN-DRIVEN NEBULISER IF AVAILABLE) ▶ ▶ ▶ Child 11 years and below: 250 micrograms, repeated every 20–30 minutes for the first hours, then every 4–6 hours as necessary Child 12–17 years: 500 micrograms every 4–6 hours as necessary Adult: 500 micrograms every 4–6 hours as necessary ▶ CROUP ▶ OR if history of immediate hypersensitivity reaction (including anaphylaxis, angioedema, urticaria, or rash immediately after administration) to penicillin or to cephalosporins Chloramphenicol injection p 537 (1 g) BY INTRAVENOUS INJECTION Child: 12.5–25 mg/kg Adult: 12.5–25 mg/kg NOTE A single dose can be given before urgent transfer to hospital, so long as this does not delay the transfer See also Central nervous system infections, bacterial p 485 ▶ ▶ Dexamethasone oral solution p 635 (2 mg/5 mL) BY MOUTH ▶ Child month–2 years: 150 micrograms/kg as a single dose Hypoglycaemia ▶ DIABETIC HYPOGLYCAEMIA Anaphylaxis ▶ ANAPHYLAXIS Glucose or sucrose BY MOUTH ▶ Adrenaline/epinephrine injection p 216 (1 mg/mL (1 in 1000)) BY INTRAMUSCULAR INJECTION Adult and Child over years: approx 10–20 g (55–110 mL Lucozade ® Energy Original or 100–200 mL Coca-Cola ®—both non-diet versions or 2–4 teaspoonfuls of sugar or 3–6 sugar lumps) repeated after 10–15 minutes if necessary Child years and below: 150 micrograms (0.15 mL), repeated every minutes if necessary ▶ Child 6–11 years: 300 micrograms (0.3 mL), repeated every ▶ OR if hypoglycaemia unresponsive or if oral route minutes if necessary cannot be used ▶ Child 12–17 years: 500 micrograms (0.5 mL), repeated Glucagon injection p 681 (1 mg/mL) every minutes if necessary; 300 micrograms (0.3 mL) BY SUBCUTANEOUS OR INTRAMUSCULAR INJECTION should be given if child is small or prepubertal ▶ Child body-weight up to 25 kg: 500 micrograms (0.5 mL) ▶ Adult: 500 micrograms (0.5 mL), repeated every ▶ Child body-weight 25 kg and over: mg (1 mL) minutes if necessary ▶ Adult: mg (1 mL) High-flow oxygen and intravenous fluids should be given ▶ OR if hypoglycaemia prolonged or unresponsive to glucagon as soon as available after 10 minutes Chlorphenamine maleate injection p 272 Glucose intravenous infusion p 955 (10%) ▶ BY INTRAMUSCULAR OR INTRAVENOUS INJECTION May help counter histamine-mediated vasodilation and bronchoconstriction Hydrocortisone (preferably as sodium succinate) BY INTRAVENOUS INJECTION Has delayed action but should be given to severely affected patients to prevent further deterioration BY INTRAVENOUS INJECTION INTO LARGE VEIN ▶ Child: mL/kg (glucose 500 mg/kg) Glucose intravenous infusion (20%) BY INTRAVENOUS INJECTION INTO LARGE VEIN ▶ Adult: 50 mL Seizures Bacterial infection ▶ MENINGOCOCCAL DISEASE Benzylpenicillin sodium injection p 517 (600 mg, 1.2 g) BY INTRAVENOUS INJECTION (OR BY INTRAMUSCULAR INJECTION IF VENOUS ACCESS NOT AVAILABLE) Neonate: 300 mg ▶ Child month–11 months: 300 mg ▶ Child 1–9 years: 600 mg ▶ Child 10–17 years: 1.2 g ▶ Adult: 1.2 g NOTE A single dose should be given before urgent transfer to hospital, so long as this does not delay the transfer ▶ CONVULSIVE (INCLUDING FEBRILE) SEIZURES LASTING LONGER THAN MINUTES ▶ EITHER Diazepam rectal solution p 327 (2 mg/mL, mg/mL) BY RECTUM ▶ ▶ ▶ OR if history of allergy to penicillin Cefotaxime injection p 500 (1 g) BY INTRAVENOUS INJECTION (OR BY INTRAMUSCULAR INJECTION IF VENOUS ACCESS NOT AVAILABLE) Neonate: 50 mg/kg ▶ Child month–11 years: 50 mg/kg (max g) ▶ Child 12–17 years: g ▶ Adult: g NOTE A single dose can be given before urgent transfer to hospital, so long as this does not delay the transfer ▶ ▶ ▶ ▶ ▶ ▶ Neonate: 1.25–2.5 mg, repeated once after 10–15 minutes if necessary Child month–1 year: mg, repeated once after 10–15 minutes if necessary Child 2–11 years: 5–10 mg, repeated once after 10–15 minutes if necessary Child 12–17 years: 10–20 mg, repeated once after 10–15 minutes if necessary Adult: 10–20 mg, repeated once after 10–15 minutes if necessary Elderly: 10 mg, repeated once after 10–15 minutes if necessary ▶ OR Midazolam oromucosal solution p 323 BY BUCCAL ADMINISTRATION, REPEATED ONCE AFTER 10 MINUTES IF NECESSARY ▶ ▶ ▶ ▶ ▶ ▶ ▶ Neonate: 300 micrograms/kg [unlicensed] Child 1–2 months: 300 micrograms/kg (max 2.5 mg) [unlicensed] Child months–11 months: 2.5 mg Child 1–4 years: mg Child 5–9 years: 7.5 mg Child 10–17 years: 10 mg Adult: 10 mg [unlicensed] Approximate Conversions and Units Conversion of pounds to kilograms lb kg 10 11 12 13 14 0.45 0.91 1.36 1.81 2.27 2.72 3.18 3.63 4.08 4.54 4.99 5.44 5.90 6.35 Conversion of stones to kilograms stones kg 10 11 12 13 14 15 6.35 12.70 19.05 25.40 31.75 38.10 44.45 50.80 57.15 63.50 69.85 76.20 82.55 88.90 95.25 Conversion from millilitres to fluid ounces mL fl oz 50 100 150 200 500 1000 1.8 3.5 5.3 7.0 17.6 35.2 Length metre (m) = 1000 millimetres (mm) centimetre (cm) = 10 mm inch (in) = 25.4 mm foot (ft) = 12 inches 12 inches = 304.8 mm Mass kilogram (kg) = 1000 grams (g) gram (g) = 1000 milligrams (mg) milligram (mg) = 1000 micrograms microgram = 1000 nanograms nanogram = 1000 picograms Volume litre = 1000 millilitres (mL) millilitre (1 mL) = 1000 microlitres pint ≈ 568 mL Other units kilocalorie (kcal) = 4186.8 joules (J) 1000 kilocalories (kcal) = 4.1868 megajoules (MJ) megajoule (MJ) = 238.8 kilocalories (kcal) millimetre of mercury (mmHg) = 133.3 pascals (Pa) kilopascal (kPa) = 7.5 mmHg (pressure) Plasma-drug concentrations Plasma-drug concentrations in BNF publications are expressed in mass units per litre (e.g mg/litre) The approximate equivalent in terms of amount of substance units (e.g micromol/litre) is given in brackets Prescribing for children: weight, height, and gender The table below shows the mean values for weight, height, and gender by age; these values have been derived from the UK-WHO growth charts 2009 and UK1990 standard centile charts, by extrapolating the 50th centile, and may be used to calculate doses in the absence of measurements However, an individual’s weight and height might vary considerably from the values in the table and it is important to ensure that the value chosen is appropriate In most cases the actual measurement should be obtained as soon as possible and the dose re-calculated Age Weight (kg) Height (cm) Full-term neonate 3.5 4.3 5.4 6.1 6.7 7.6 14 18 23 32 39 49 50 68 58 51 55 58 61 63 67 75 96 109 122 138 149 163 159 176 164 month 2months months months months year years years years 10 years 12 years 14 year old boy 14 year old girl Adult male Adult female Recommended wording of cautionary and advisory labels For details including Welsh Language translation see p 1454 Warning: This medicine may make you sleepy Warning: This medicine may make you sleepy If this happens, not drive or use tools or machines Do not drink alcohol Warning: This medicine may make you sleepy If this happens, not drive or use tools or machines Warning: Do not drink alcohol Do not take indigestion remedies hours before or after you take this medicine Do not take indigestion remedies, or medicines containing iron or zinc, hours before or after you take this medicine Do not take milk, indigestion remedies, or medicines containing iron or zinc, hours before or after you take this medicine Warning: Do not stop taking this medicine unless your doctor tells you to stop Space the doses evenly throughout the day Keep taking this medicine until the course is finished, unless you are told to stop 10 Warning: Read the additional information given with this medicine 11 Protect your skin from sunlight—even on a bright but cloudy day Do not use sunbeds 12 Do not take anything containing aspirin while taking this medicine 13 Dissolve or mix with water before taking 14 This medicine may colour your urine This is harmless 15 Caution: flammable Keep your body away from fire or flames after you have put on the medicine 16 Dissolve the tablet under your tongue—do not swallow Store the tablets in this bottle with the cap tightly closed Get a new supply weeks after opening 17 Do not take more than in 24 hours 18 Do not take more than in 24 hours Also, not take more than in any one week 19 Warning: This medicine makes you sleepy If you still feel sleepy the next day, not drive or use tools or machines Do not drink alcohol 21 Take with or just after food, or a meal 22 Take 30 to 60 minutes before food 23 Take this medicine when your stomach is empty This means an hour before food or hours after food 24 Suck or chew this medicine 25 Swallow this medicine whole Do not chew or crush 26 Dissolve this medicine under your tongue 27 Take with a full glass of water 28 Spread thinly on the affected skin only 29 Do not take more than at any one time Do not take more than in 24 hours 30 Contains paracetamol Do not take anything else containing paracetamol while taking this medicine Talk to a doctor at once if you take too much of this medicine, even if you feel well 32 Contains aspirin Do not take anything else containing aspirin while taking this medicine Abbreviations and Symbols Internationally recognised units and symbols are used in the BNF publications where possible ACBS Advisory Committee on Borderline Substances, see Borderline Substances ACE Angiotensin-converting enzyme ADHD Attention deficit hyperactivity disorder AIDS Acquired immunodeficiency syndrome approx approximately AV atrioventricular AWMSG All Wales Medicines Strategy Group BAN British Approved Name BMI body mass index BP British Pharmacopoeia 2013, unless otherwise stated BPC British Pharmaceutical Codex 1973 and Supplement 1976, unless otherwise stated BRCA breast cancer gene CAPD Continuous ambulatory peritoneal dialysis a preparation in Schedule of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p b preparation in Schedule of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p c preparation in Schedule of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p d preparation in Schedule (Part I) of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p e preparation in Schedule (Part II) of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p m preparation in Schedule of the Misuse of Drugs Regulations 2001 (and subsequent amendments) For regulations see Controlled drugs and drug dependence p CHM Commission on Human Medicines CHMP Committee for Medicinal Products for Human Use CNS central nervous system CSM Committee on Safety of Medicines (now subsumed under Commission on Human Medicines) d c direct current DMARD Disease-modifying antirheumatic drug DPF Dental Practitioners’ Formulary e/c enteric-coated (termed gastro-resistant in BP) ECG electrocardiogram EEG electro-encephalogram eGFR estimated glomerular filtration rate, see Prescribing in renal impairment p 19 f/c film-coated G6PD glucose 6-phosphate dehydrogenase HIV Human immunodeficiency virus HRT Hormone replacement therapy i/m intramuscular i/v intravenous INR international normalised ratio MAOI Monoamine-oxidase inhibitor max maximum MHRA Medicines and Healthcare products Regulatory Agency m/r modified-release NCL no cautionary labels (prescription endorsement made by prescriber when recommended cautionary labels are not required) NHS National Health Service NICE National Institute for Health and Care Excellence NPF Nurse Prescribers’ Formulary NSAID Non-steroidal anti-inflammatory drug NSTEMI non-ST-segment elevation myocardial infarction PARP poly (ADP-ribose) polymerase PGD patient group direction PHE Public Health England (formerly Health Protection Agency (HPA)) P prescription-only medicine, see Fig How to use BNF publications ® trade mark rINN Recommended International Non-proprietary Name RSV respiratory syncytial virus s/c sugar-coated SLS Selected List Scheme SMC SPC spp SSRI STEMI UK Units WHO Scottish Medicines Consortium Summary of Product Characteristics species Selective serotonin reuptake inhibitor ST-segment elevation myocardial infarction United Kingdom for SI units see Prescription writing p World Health Organization A limited experience of the use of this product and the MHRA requests that all suspected adverse reactions should be reported, see Adverse reactions to drugs p 12 G general sales list p pharmacy only medicine f drug-class monograph, see How to use BNF Publications, p xii eii F 1234 i drug monograph has a corresponding drug-class monograph; the page number of the class monograph is indicated within the tab, see How to use BNF Publications, p xii g precedes evidence graded content, see How BNF Publications are constructed p ix h to l symbols will be displayed – grades reflect the strengths of recommendations in evidence graded content, see How BNF Publications are constructed p ix Latin abbreviations Directions should be in English without abbreviation However, Latin abbreviations have been used when prescribing The following is a list of appropriate abbreviations It should be noted that the English version is not always an exact translation a c = ante cibum (before food) b d = bis die (twice daily) o d = omni die (every day) o m = omni mane (every morning) o n = omni nocte (every night) p c = post cibum (after food) p r n = pro re nata (when required) q d s = quater die sumendum (to be taken four times daily) q q h = quarta quaque hora (every four hours) stat = immediately t d s = ter die sumendum (to be taken three times daily) t.i.d = ter in die (three times daily) E numbers The following is a list of common E numbers and the inactive ingredients to which they correspond E102 E211 E104 E223 E110 E320 E123 E321 E124 E322 E127 E420 E132 E421 E142 E422 E171 E901 E172 E1520 E200 Tartrazine Sodium Benzoate Quinoline Yellow Sodium Metabisulfite Sunset Yellow FCF Butylated Hydroxyanisole Amaranth Butylated Hydroxytoluene Ponceau 4R Lecithins Erythrosine BS Sorbitol Indigo Carmine Mannitol Green S Glycerol Titanium Dioxide Beeswax (white and yellow) Iron oxides, iron hydroxides Propylene Glycol Sorbic Acid ... Levonorgesterol1 5–7 5–7 5–7 6–1 2 6–1 2 9–1 2 9–1 2 9–1 2 Genito-urinary system Norgestimate1 Norethisterone1 Etonogestrel1 Norelgestromin1 Gestodene1 Desogestrel1 Drospirenone ▶ Dienogest2 Not known—insufficient... 5–1 1 years: Initially 2. 5–3 mg twice daily, increased to mg 2 3 times a day Child 1 2 1 7 years: Initially mg 2 3 times a day, increased if necessary up to mg times a day Adult: Initially mg 2 3 ... sugar-free | 150 ml P £199 .2 0– 23 9.04 DT price = £199 .20 Vesicare (Astellas Pharma Ltd) Solifenacin succinate mg Vesicare 5mg tablets | 30 tablet 27 . 62 DT price = 27 . 62 Solifenacin succinate 10