Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

British National Formulary 2017, Study Guides, Projects, Research of Pharmacy

The British National Formulary is a United Kingdom pharmaceutical reference book that contains a wide spectrum of information and advice on prescribing and pharmacology, along with specific facts

Typology: Study Guides, Projects, Research

2017/2018

Uploaded on 04/29/2018

javaid-iqbal-2
javaid-iqbal-2 🇸🇦

4

(1)

2 documents

1 / 1493

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18
pf19
pf1a
pf1b
pf1c
pf1d
pf1e
pf1f
pf20
pf21
pf22
pf23
pf24
pf25
pf26
pf27
pf28
pf29
pf2a
pf2b
pf2c
pf2d
pf2e
pf2f
pf30
pf31
pf32
pf33
pf34
pf35
pf36
pf37
pf38
pf39
pf3a
pf3b
pf3c
pf3d
pf3e
pf3f
pf40
pf41
pf42
pf43
pf44
pf45
pf46
pf47
pf48
pf49
pf4a
pf4b
pf4c
pf4d
pf4e
pf4f
pf50
pf51
pf52
pf53
pf54
pf55
pf56
pf57
pf58
pf59
pf5a
pf5b
pf5c
pf5d
pf5e
pf5f
pf60
pf61
pf62
pf63
pf64

Partial preview of the text

Download British National Formulary 2017 and more Study Guides, Projects, Research Pharmacy in PDF only on Docsity!

Medicines Information Services

Information on drug therapy Information on any aspect of drug therapy can be obtained from Regional and District Medicines Information Services. Details regarding the local services provided within your Region can be obtained by telephoning the following numbers.

England

Birmingham: ( 0121 ) 424 7298

Bristol: ( 0117 ) 342 2867

Ipswich: ( 01473 ) 704 431

Leeds: ( 0113 ) 206 5377

Leicester: ( 0116 ) 258 6491

Liverpool: ( 0151 ) 794 8113/ 7 ,

or ( 0151 ) 794 8118

London:

. Guy’s Hospital ( 020 ) 7188 8750,

or ( 020 ) 7188 3849,

or ( 020 ) 7188 3855

. Northwick Park Hospital ( 020 ) 8869 2761,

or ( 020 ) 8869 3973

Newcastle: ( 0191 ) 282 4631

Southampton: ( 023 ) 8120 6908/ 9

Wales

Cardiff: ( 029 ) 2074 2979,

or ( 029 ) 2074 2251

Scotland

Aberdeen: ( 01224 ) 552 316

Dundee: ( 01382 ) 632 351,

or ( 01382 ) 660 111 Extn 32351

Edinburgh: ( 0131 ) 242 2920

Glasgow: ( 0141 ) 211 4407

Northern Ireland

Belfast: ( 028 ) 9504 0558

Republic of Ireland

Dublin: ( 01 ) 473 0589,

or ( 01 ) 453 7941 Extn 2348

United Kingdom Medicines Information Pharmacists Group (UKMIPG) website www.ukmi.nhs.uk

Proprietary Manufacturers Telephone numbers and email addresses of proprietary manufacturers listed in BNF Publications are shown in the

Index of proprietary manufacturers p. 1417

UK Teratology Information Service Information on drug and chemical exposures in pregnancy.

Tel: 0344 892 0909

www.uktis.org

UK Drugs in Lactation Advisory Service (UKDILAS) Information on the compatibility of drugs with breastfeeding.

Tel: ( 0116 ) 258 6491,

or ( 0121 ) 424 7298

www.ukmi.nhs.uk/ukdilas

Medicines in Dentistry Specialist Advisory Service Information on drug therapy relating to dental treatment.

Liverpool: ( 0151 ) 794 8206

Driver and Vehicle Licensing Agency (DVLA) Information on the national medical guidelines of fitness to drive is available from: www.gov.uk/government/publications/at-a-glance

Patient Information Lines

NHS Urgent Care Services 111

Poisons Information Services

UK National Poisons Information Service 0344 892 0111

www.toxbase.org

Sport ▶ Information regarding the use of medicines in sport is available from UK Anti-Doping: www.ukad.org.uk

Tel: ( 020 ) 7842 3450

ukad@ukad.org.uk UK Anti-Doping Fleetbank House

2 - 6 Salisbury Square

London

EC 4 Y 8 AE

▶ Information about the prohibited status of specific medicines based on the current World Anti-Doping Agency Prohibited List is available from Global Drug Reference Online: www.globaldro.com/UK/search

Travel Immunisation Up-to-date information on travel immunisation requirements may be obtained from: ▶ National Travel Health Network and Centre (for

healthcare professionals only) 0845 602 6712 Monday –

Friday (closed Wednesday afternoons and Bank

Holidays): 09 : 00 – 11 : 45 and 13 : 00 – 15 : 45

▶ Travel Medicine Team, Health Protection Scotland

( 0141 ) 300 1100 ( 14. 00 – 16. 00 hours weekdays)

www.travax.nhs.uk(for registered users of the NHS website Travax only) ▶ Welsh Government Switchboard English language

0300 0603300 ( 09. 00 – 17. 30 hours weekdays only)

▶ Welsh Government Switchboard Yr laith Gymraeg

0300 0604400 ( 09. 00 – 17. 30 hours weekdays only)

▶ Department of Health and Social Services (Belfast)

( 028 ) 9052 2118 (weekdays)

List of Registered Medical Practitioners Details on whether doctors are registered and hold a licence to practise medicine in the UK can be obtained from the General Medical Council.

Tel: ( 0161 ) 923 6602

www.gmc-uk.org/register

How to purchase

Stay up to date – sign up to the BNF

eNewsletter at www.bnf.org/newsletter

Buy direct from Pharmaceutical Press by visiting

www.pharmpress.com/bnf

For enquiries about the BNF or BNFC in print, contact

direct@macmillan.co.uk

Tel: +44 (0) 1256 302 699

For enquiries concerning MedicinesComplete,

FormularyComplete, or bulk orders of the print edition, contact

pharmpress-support@rpharms.com

Tel: +44 (0) 20 7572 2266

Download mobile apps by visiting your appropriate app store.

Available for iOS, Android and Blackberry

For pricing information please visit the website at

www.pharmpress.com/bnf

For international sales contact your local sales agent.

Contact details at www.pharmpress.com/agents

BNF subscription – Take advantage of our print subscription option. We will send you the new BNF as soon as the book is

published. One or two year packages (including or excluding

BNFC) are available. Discounted pricing is also available on

bulk sales.

PRINT SUBSCRIPTION

MOBILE

BNF app – Stay up to date anywhere with the BNF app

available for iOS, Android and Blackberry.

BNF eBook – Available as an ePDF via a range of

suppliers. See www.pharmpress.com/bnf.

BNF on MedicinesComplete – Now mobile responsive.

BNF

March –

September 2017

Preface

The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. It is published under the authority of a Joint Formulary Committee which comprises representatives of the two professional bodies, the UK Health Departments, the Medicines and Healthcare products Regulatory Agency, and a national guideline producer. The Dental Advisory Group oversees the preparation of advice on the drug management of dental and oral conditions; the Group includes representatives of the British Dental Association and a representative from the UK Health Departments. The Nurse Prescribers’ Advisory Group advises on the content relevant to nurses and includes representatives from different parts of the nursing community and from the UK Health Departments. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines. The BNF includes key information on the selection, prescribing, dispensing and administration of medicines. Medicines generally prescribed in the UK are covered and those considered less suitable for prescribing are clearly identified. Little or no information is included on medicines promoted for purchase by the public. Information on drugs is drawn from the manufacturers’ product literature, medical and pharmaceutical literature, UK health departments, regulatory authorities, and professional bodies. Advice is constructed from clinical literature and reflects, as far as possible, an evaluation of the evidence from diverse sources. The BNF also takes account of authoritative national guidelines and emerging safety concerns. In addition, the editorial team receives advice on all therapeutic areas from expert clinicians; this ensures that the BNF’s recommendations are relevant to practice. The BNF is designed as a digest for rapid reference and it may not always include all the information necessary for prescribing and dispensing. Also, less detail is given on areas such as obstetrics, malignant disease, and anaesthesia since it is expected that those undertaking treatment will have specialist knowledge and access to specialist literature. BNF for Children should be consulted for detailed information on the use of medicines in children. The BNF should be interpreted in the light of professional knowledge and supplemented as necessary by specialised publications and by reference to the product literature. Information is also available from medicines information services, see Medicines Information Services (see inside front cover). It is important to use the most recent BNF information for making clinical decisions. The print edition of the BNF is updated in March and September each year. Monthly updates are provided online via Medicines Complete and the NHS Evidence portal. The more important changes are listed under Changes; changes listed online are cumulative (from one print edition to the next), and can be printed off each month to show the main changes since the last print edition as an aide memoire for those using print copies. The BNF Publications website (www.bnf.org) includes additional information of relevance to healthcare professionals. Other digital formats of the BNF—including versions for mobile devices and integration into local formularies—are also available.

BNF Publications welcomes comments from healthcare professionals. Comments and constructive criticism should be sent to:

British National Formulary, Royal Pharmaceutical Society,

66 – 68 East Smithfield

London

E 1 W 1 AW

editor@bnf.org

The contact email for manufacturers or pharmaceutical companies wishing to contact BNF Publications is manufacturerinfo@bnf.org

BNF 73 iii

Contents

Preface page iii

Acknowledgements v How BNF publications are constructed ix How to use BNF Publications in print xii

  • Guidance on Prescribing Changes xix
  • Prescription writing
  • Emergency supply of medicines
  • Controlled drugs and drug dependence
  • Adverse reactions to drugs
  • Guidance on intravenous infusions
  • Prescribing for children
  • Prescribing in hepatic impairment
  • Prescribing in renal impairment
  • Prescribing in pregnancy
  • Prescribing in breast-feeding
  • Prescribing in palliative care
  • Prescribing for the elderly
  • Drugs and sport
  • Prescribing in dental practice - 1 Gastro-intestinal system page NOTES ON DRUGS AND PREPARATIONS - 2 Cardiovascular system - 3 Respiratory system - 4 Nervous system - 5 Infection - 6 Endocrine system - 7 Genito-urinary system - 8 Malignant disease - 9 Blood and nutrition - 10 Musculoskeletal system - 11 Eye - 12 Ear, nose and oropharynx - 13 Skin - 14 Vaccines - 15 Anaesthesia - 16 Emergency treatment of poisoning - Appendix APPENDICES AND INDICES - Interactions - Appendix - Borderline substances - Appendix - Cautionary and advisory labels for dispensed medicines - Appendix - Wound management products and elasticated garments - Dental Practitioners’ Formulary - Nurse Prescribers’ Formulary - Non-medical prescribing - Index of proprietary manufacturers - Special-order Manufacturers - Index
    • iv BNF Medical emergencies in the community inside back cover

BNF Staff

BNF DIRECTOR

Karen Baxter BSc, MSc, MRPharmS

HEAD OF CONTENT Kate Towers BPharm (AU), GCClinPharm

CONTENT MANAGERS Thomas F. Corbett BScPharm (IRL), MPharm (IRL)

Kristina Fowlie MPharm, CertPharmPract, MRPharmS

Claire McSherry BPharm (NZ), PGCertClinPharm (NZ)

Heenaben Patel MPharm, DipClinPharm, MRPharmS

QUALITY AND PROCESS MANAGER Angela M.G. McFarlane BSc, DipClinPharm

CLINICAL WRITERS Abby Calder BPharm (NZ), PGCertClinPharm (NZ)

Naimah Callachand MPharm

Angela L. Kam BPharm (NZ), PGDipPharmPrac (NZ), PGCertPharmPres (NZ)

Philip D. Lee BSc, PhD

Kirsty Luck BPharm (AU)

Kere Odumah MPharm

Paridhi K. Prashar MPharm, MRPharmS

Jacob M. Warner BPharm (AU)

Sharyn Young BPharm (NZ), PGDipClinPharm (NZ)

CLINICAL ASSISTANTS Elizabeth King

EDITORIAL ASSISTANTS Hima Bhatt BSc, MA

Jaya Venkitachalam BSc, MRes

SENIOR BNF ADMINISTRATOR Heidi Homar BA

MANAGING DIRECTOR, PHARMACEUTICAL PRESS Alina Lourie B.Ed, MSc

SENIOR MEDICAL ADVISER Derek G. Waller BSc, MB, BS, DM, FRCP

vi BNF 73

Joint Formulary

Committee 2016– 2017

CHAIR

Derek G. Waller BSc, MB BS, DM, FRCP

DEPUTY CHAIR Alison Blenkinsopp BPharm, PhD, FRPharmS, OBE

COMMITTEE MEMBERS Julie Beynon MB ChB, FRCA, FFPM

Carmel M. Darcy BSc, MSc, IP, MPSNI, MRPharmS

Sue Faulding BPharm, MSc, FRPharmS Tracy Hall BSc, MSc, Cert N, Dip N, RGN, DN

Simon Hurding MB, ChB, MRCGP

W. Moira Kinnear BSc, MSc, MRPharmS

Mark P. Lythgoe MB BS, MRPharmS

Louise Picton BSc, DipCommPharm, MSc, MRPharmS

Michael J. Stewart MB ChB, MD, FRCP(Ed), FRCP

Esther Wong BSc, MPharm, MSc, DipEthics, DipPharmPract, IP, MRPharmS

LAY MEMBERS Andy Burman

Elaine Keen

EXECUTIVE SECRETARY Heidi Homar BA

Dental Advisory Group

2016 – 2017

CHAIR

Sarah Manton BDS, FDSRCS Ed, FHEA, PhD

COMMITTEE MEMBERS Karen Baxter BSc, MSc, MRPharmS Andrew K. Brewer BSc, BchD Lesley P. Longman BSc, BDS, FDSRCS Ed, PhD Michelle Moffat BDS, MFDS RCS Ed, M Paed Dent RCPS, FDS (Paed Dent) RCS Ed

SECRETARY Arianne J. Matlin MA, MSc, PhD

EXECUTIVE SECRETARY Heidi Homar BA

ADVICE ON DENTAL PRACTICE The British Dental Association has contributed to the advice on medicines for dental practice through its representatives on the Dental Advisory Group.

BNF 73 vii

How BNF Publications are constructed

Overview

The BNF is an independent professional publication that addresses the day-to-day prescribing information needs of healthcare professionals. Use of this resource throughout the health service helps to ensure that medicines are used safely, effectively, and appropriately. Hundreds of changes are made between print editions, and are published monthly in a number of digital formats. The most clinically significant updates are listed under Changes p. xix. The BNF is unique in bringing together authoritative, independent guidance on best practice with clinically validated drug information. Validation of information follows a standardised process, reviewing emerging evidence, best-practice guidelines, and advice from a network of clinical experts. Where the evidence base is weak, further validation is undertaken through a process of peer review. The process and its governance are outlined in greater detail in the sections that follow.

Joint Formulary Committee

The Joint Formulary Committee (JFC) is responsible for the content of the BNF. The JFC includes pharmacy, medical, nursing and lay representatives; there are also representatives from the Medicines and Healthcare products Regulatory Agency (MHRA), the UK Health Departments, and a national guideline producer. The JFC decides on matters of policy and reviews amendments to the BNF in the light of new evidence and expert advice.

Dental Advisory Group

The Dental Advisory Group oversees the preparation of advice on the drug management of dental and oral conditions; the group includes representatives from the British Dental Association and a representative from the UK Health Departments.

Nurse Prescribers’ Advisory Group

The Nurse Prescribers’ Advisory Group oversees the list of drugs approved for inclusion in the Nurse Prescribers’ Formulary; the group includes representatives from a range of nursing disciplines and stakeholder organisations.

Expert advisers

The BNF uses about 60 expert clinical advisers (including

doctors, pharmacists, nurses, and dentists) throughout the UK to help with clinical content. The role of these expert advisers is to review existing text and to comment on amendments drafted by the clinical writers. These clinical experts help to ensure that the BNF remains reliable by:

. commenting on the relevance of the text in the context of best clinical practice in the UK; . checking draft amendments for appropriate interpretation of any new evidence; . providing expert opinion in areas of controversy or when reliable evidence is lacking; . providing independent advice on drug interactions, prescribing in hepatic impairment, renal impairment, pregnancy, breast-feeding, children, the elderly, palliative care, and the emergency treatment of poisoning.

In addition to consulting with regular advisers, the BNF calls on other clinical specialists for specific developments when particular expertise is required. The BNF works closely with a number of expert bodies that produce clinical guidelines. Drafts or pre-publication copies of guidelines are often received for comment and assimilation into the BNF.

Editorial team

BNF clinical writers have all worked as pharmacists or possess a pharmacy degree and a further, relevant post- graduate qualification, and have a sound understanding of

how drugs are used in clinical practice. As a team, the clinical writers are responsible for editing, maintaining, and updating BNF content. They follow a systematic prioritisation process in response to updates to the evidence base in order to ensure the most clinically important topics are reviewed as quickly as possible. In parallel the team of clinical writers undertakes a process of rolling revalidation,

aiming to review all of the content in the BNF over a 3 - to

4 -year period.

Amendments to the text are drafted when the clinical writers are satisfied that any new information is reliable and relevant. A set of standard criteria define when content is referred to expert advisers, the Joint Formulary Committee or other advisory groups, or submitted for peer review. Clinical writers prepare the text for publication and undertake a number of validation checks on the knowledge at various stages of the production process.

Sources of BNF information

The BNF uses a variety of sources for its information; the main ones are shown below.

Summaries of product characteristics The BNF reviews summaries of product characteristics (SPCs) of all new products as well as revised SPCs for existing products. The SPCs are the principal source of product information and are carefully processed. Such processing involves:

. verifying the approved names of all relevant ingredients including ’non-active’ ingredients (the BNF is committed to using approved names and descriptions as laid down by

the Human Medicine Regulations 2012 );

. comparing the indications, cautions, contra-indications, and side-effects with similar existing drugs. Where these are different from the expected pattern, justification is sought for their inclusion or exclusion; . seeking independent data on the use of drugs in pregnancy and breast-feeding; . incorporating the information into the BNF using established criteria for the presentation and inclusion of the data; . checking interpretation of the information by a second clinical writer before submitting to a content manager; changes relating to doses receive a further check; . identifying potential clinical problems or omissions and seeking further information from manufacturers or from expert advisers; . constructing, with the help of expert advisers, a comment on the role of the drug in the context of similar drugs. Much of this processing is applicable to the following sources as well.

Literature Clinical writers monitor core medical and pharmaceutical journals. Research papers and reviews relating to drug therapy are carefully processed. When a difference between the advice in the BNF and the paper is noted, the new information is assessed for reliability (using tools based on SIGN methodology) and relevance to UK clinical practice. If necessary, new text is drafted and discussed with expert advisers and the Joint Formulary Committee. The BNF enjoys a close working relationship with a number of national information providers. In addition to the routine process, which is used to identify ’triggers’ for changing the content, systematic literature searches are used to identify the best quality evidence available to inform an update. Clinical writers receive training in critical appraisal, literature evaluation, and search strategies.

BNF 73 ix

Consensus guidelines The advice in the BNF is checked against consensus guidelines produced by expert bodies. The quality of the guidelines is assessed using adapted versions of the AGREE II tool. A number of bodies make drafts or pre-publication copies of the guidelines available to the BNF; it is therefore possible to ensure that a consistent message is disseminated. The BNF routinely processes guidelines from the National Institute for Health and Care Excellence (NICE), the Scottish Medicines Consortium (SMC), and the Scottish Intercollegiate Guidelines Network (SIGN).

Reference sources Textbooks and reference sources are used to provide background information for the review of existing text or for the construction of new text. The BNF team works closely with the editorial team that produces Martindale: The Complete Drug Reference. The BNF has access to Martindale information resources and each team keeps the other informed of significant developments and shifts in the trends of drug usage.

Peer review Although every effort is made to identify the most robust data available, inevitably there are areas where the evidence base is weak or contradictory. While the BNF has the valuable support of expert advisers and the Joint Formulary Committee, the recommendations made may be subject to a further level of scrutiny through peer review to ensure they reflect best practice. Content for peer review is posted on bnf.org and interested parties are notified via a number of channels, including the BNF e-newsletter.

Statutory information The BNF routinely processes relevant information from various Government bodies including Statutory Instruments and regulations affecting the Prescriptions only Medicines Order. Official compendia such as the British Pharmacopoeia and its addenda are processed routinely to ensure that the BNF complies with the relevant sections of the Human

Medicines Regulations 2012.

The BNF maintains close links with the Home Office (in relation to controlled drug regulations) and the Medicines and Healthcare products Regulatory Agency (including the British Pharmacopoeia Commission). Safety warnings issued by the Commission on Human Medicines (CHM) and guidelines on drug are issued by the UK health departments are processed as a matter of routine. Relevant professional statements issued by the Royal Pharmaceutical Society are included in the BNF as are guidelines from bodies such as the Royal College of General Practitioners.

Medicines and devices NHS Prescription Services (from the NHS Business Services Authority) provides non-clinical, categorical information (including prices) on the medicines and devices included in the BNF.

Comments from readers Readers of the BNF are invited to send in comments. Numerous letters and emails are received by the BNF team. Such feedback helps to ensure that the BNF provides practical and clinically relevant information. Many changes in the presentation and scope of the BNF have resulted from comments sent in by users.

Comments from industry Close scrutiny of BNF by the manufacturers provides an additional check and allows them an opportunity to raise issues about BNF’s presentation of the role of various drugs; this is yet another check on the balance of BNF’s advice. All comments are looked at with care and, where necessary, additional information and expert advice are sought.

Market research Market research is conducted at regular intervals to gather feedback on specific areas of development.

Assessing the evidence

From January 2016 , recommendations made in BNF

publications have been evidence graded to reflect the strength of the recommendation. The addition of evidence grading is to support clinical decision making based on the best available evidence.

The BNF aims to revalidate all content over a rolling 3 - to

4 -year period and evidence grading will be applied to

recommendations as content goes through the revalidation process. Therefore, initially, only a small number of recommendations will have been graded.

Grading system The BNF has adopted a five level grading system from A to E, based on the former SIGN grading system. This grade is displayed next to the recommendation within the text. Evidence used to make a recommendation is assessed for validity using standardised methodology tools based on AGREE II and assigned a level of evidence. The recommendation is then given a grade that is extrapolated from the level of evidence, and an assessment of the body of evidence and its applicability.

Evidence assigned a level 1 - or 2 - score has an

unacceptable level of bias or confounding and is not used to form recommendations.

Levels of evidence

. Level 1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias. . Level 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias. . Level 1– Meta-analyses, systematic reviews, or RCTs with a high risk of bias. . Level 2++ High quality systematic reviews of case control or cohort studies; or high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal. . Level 2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal. . Level 2– Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal. . Level 3 Non-analytic studies, e.g. case reports, case series. . Level 4 Expert advice or clinical experience from respected authorities. Grades of recommendation . Grade A: High strength NICE-accredited guidelines; or guidelines that pass AGREE II assessment; or at least one meta-analysis, systematic

review, or RCT rated as 1 ++, and directly applicable to the

target population; or a body of evidence consisting

principally of studies rated as 1 +, directly applicable to the

target population, and demonstrating overall consistency of results.

x BNF 73

How to use BNF Publications in print

How to use the BNF

This edition of the BNF continues to display the fundamental change to the structure of the content that was

first shown in BNF 70. The changes were made to bring

consistency and clarity to BNF content, and to the way that the content is arranged within print and digital products, increasing the ease with which information can be found. For reference, the most notable changes to the structure of the content include:

. Drug monographs – where possible, all information that relates to a single drug is contained within its drug monograph, moving information previously contained in the prescribing notes. Drug monographs have also changed structurally: additional sections have been added, ensuring greater regularity around where information is located within the publication. . Drug class monographs – where substantial amounts of information are common to all drugs within a drug class

(e.g. macrolides p. 494 ), a drug class monograph has been

created to contain the common information.

. Medicinal forms – categorical information about marketed medicines, such as price and pack size, continues to be sourced directly from the Dictionary of Medicines and Devices provided by the NHS Business Services Authority. However, clinical information curated by the BNF team has been clearly separated from the categorical pricing and pack size information and is included in the relevant section of the drug monograph. . Section numbering – the BNF section numbering has been removed. This section numbering tied the content to a rigid structure and enforced the retention of defunct classifications, such as mercurial diuretics, and hindered the relocation of drugs where therapeutic use had altered. It also caused constraints between the BNF and BNF for Children, where drugs had different therapeutic uses in children.

. Appendix 4 – the content has been moved to individual

drug monographs. The introductory notes have been replaced with a new guidance section, Guidance on

intravenous infusions p. 16.

Introduction

In order to achieve the safe, effective, and appropriate use of medicines, healthcare professionals must be able to use the BNF effectively, and keep up to date with significant changes in the BNF that are relevant to their clinical practice. This How to Use the BNF is key in reinforcing the details of the new structure of the BNF to all healthcare professionals involved with prescribing, monitoring, supplying, and administering medicines, as well as supporting the learning of students training to join these professions.

Structure of the BNF

This BNF edition continues to broadly follows the high-level structure of earlier editions of the BNF (i.e. those published

before BNF 70 ):

Front matter, comprising information on how to use the BNF, the significant content changes in each edition, and guidance on various prescribing matters (e.g. prescription writing, the use of intravenous drugs, particular considerations for special patient populations). Chapters, containing drug monographs describing the uses, doses, safety issues and other considerations involved in the use of drugs; drug class monographs; and treatment summaries, covering guidance on the selection of drugs. Monographs and treatment summaries are divided into chapters based on specific aspects of medical care, such as

Chapter 5 , Infections, or Chapter 16 , Emergency treatment

of poisoning; or drug use related to a particular system of the

body, such as Chapter 2 , Cardiovascular.

Within each chapter, content is organised alphabetically by therapeutic use (e.g. Airways disease, obstructive), with the treatment summaries first, (e.g. asthma), followed by the monographs of the drugs used to manage the conditions discussed in the treatment summary. Within each therapeutic use, the drugs are organised alphabetically by

classification (e.g. Antimuscarinics, Beta 2 -agonist

bronchodilators) and then alphabetically within each classification (e.g. Aclidinium bromide, Glycopyrronium bromide, Ipratropium bromide). Appendices, covering interactions, borderline substances, cautionary and advisory labels, and woundcare. Back matter, covering the lists of medicines approved by the NHS for Dental and Nurse Practitioner prescribing, proprietary and specials manufacturers’ contact details, and the index. Yellow cards are also included, to facilitate the reporting of adverse events, as well as quick reference guides for life support and key drug doses in medical emergencies, for ease of access.

Navigating the BNF

The contents page provides the high-level layout of information within the BNF; and in addition, each chapter begins with a small contents section, describing the therapeutic uses covered within that chapter. Once in a chapter, location is guided by the side of the page showing the chapter number (the thumbnail), alongside the chapter title. The top of the page includes the therapeutic use (the running head) alongside the page number. Once on a page, visual cues aid navigation: treatment summary information is in black type, with therapeutic use titles similarly styled in black, whereas the use of colour indicates drug-related information, including drug classification titles, drug class monographs, and drug monographs. Although navigation is possible by browsing, primarily access to the information is via the index, which covers the titles of drug class monographs, drug monographs, and treatment summaries. The index also includes the names of branded medicines and other topics of relevance, such as abbreviations, guidance sections, tables, and images.

Content types

Treatment summaries

Treatment summaries are of three main types;

. an overview of delivering a drug to a particular body

system (e.g. Skin conditions, management p. 1074 )

. a comparison between a group or groups of drugs (e.g.

beta-adrenoceptor blockers (systemic) p. 139 )

. an overview of the drug management or prophylaxis of common conditions intended to facilitate rapid appraisal

of options (e.g. Hypertension p. 132 , or Malaria,

prophylaxis p. 560 ).

In order to select safe and effective medicines for individual patients, information in the treatment summaries must be used in conjunction with other prescribing details about the drugs and knowledge of the patient’s medical and drug history.

Monographs

Overview

In earlier editions (i.e. before BNF 70 ), a systemically

administered drug with indications for use in different body systems was split across the chapters relating to those body

systems. So, for example, codeine phosphate p. 421 was

found in chapter 1 , for its antimotility effects and chapter 4

for its analgesic effects. However, the monograph in chapter

xii BNF 73

1 contained only the dose and some selected safety

precautions. Now, all of the information for the systemic use of a drug is contained within one monograph, so codeine phosphate

p. 421 is now included in chapter 4. This carries the

advantage of providing all of the information in one place, so the user does not need to flick back and forth across several pages to find all of the relevant information for that drug.

Cross references are included in chapter 1 , where the

management of diarrhoea is discussed, to the drug monograph to assist navigation. Where drugs have systemic and local uses, for example,

chloramphenicol p. 524 , and the considerations around drug

use are markedly different according to the route of administration, the monograph is split, as with earlier editions, into the relevant chapters. This means that the majority of drugs are still placed in the same chapters and sections as earlier editions, and although there may be some variation in order, all of the relevant information will be easier to locate. One of the most significant changes to the monograph structure is the increased granularity, with a move from

around 9 sections to over 20 sections; sections are only

included when relevant information has been identified. The following information describes these sections and their uses in more detail.

Nomenclature

Monograph titles follow the convention of recommended international non-proprietary names (rINNs), or, in the absence of a rINN, British Approved Names. Relevant synonyms are included below the title and, in some instances a brief description of the drug action is included. Over future editions these drug action statements will be rolled out for all drugs. In some monographs, immediately below the nomenclature or drug action, there are a number of cross references or flags used to signpost the user to any additional information they need to consider about a drug. This is most common for drugs formulated in combinations, where users will be signposted to the monographs for the

individual ingredients (e.g. senna with ispaghula husk p. 59 )

or for drugs that are related to a drug class monograph (see Drug class monographs, below).

Indication and dose

User feedback has highlighted that one of the main uses of the BNF is identifying indications and doses of drugs. Therefore, indication and dose information has been promoted to the top of the monograph and highlighted by a coloured panel to aid quick reference. The indication and dose section is more highly structured than in earlier editions, giving greater clarity around which doses should be used for which indications and by which route. In addition, if the dose varies with a specific preparation or formulation, that dosing information has been moved out of the preparations section and in to the indication and dose panel, under a heading of the preparation name. Doses are either expressed in terms of a definite frequency

(e.g. 1 g 4 times daily) or in the total daily dose format (e.g.

6 g daily in 3 divided doses); the total daily dose should be

divided into individual doses (in the second example, the

patient should receive 2 g 3 times daily).

Doses for specific patient groups (e.g. the elderly) may be included if they are different to the standard dose. Doses for children can be identified by the relevant age range and may vary according to their age or body-weight. In earlier editions of the BNF, age ranges and weight ranges overlapped. For clarity and to aid selection of the correct dose, wherever possible these age and weight ranges now do not overlap. When interpreting age ranges it is

important to understand that a patient is considered to be 64

up until the point of their 65 thbirthday, meaning that an age

range of adult 18 to 64 is applicable to a patient from the day

of their 18 thbirthday until the day before their 65 thbirthday.

All age ranges should be interpreted in this way. Similarly, when interpreting weight ranges, it should be understood

that a weight of up to 30 kg is applicable to a patient up to,

but not including, the point that they tip the scales at 30 kg

and a weight range of 35 to 59 kg is applicable to a patient as

soon as they tip the scales at 35 kg right up until, but not

including, the point that they tip the scales at 60 kg. All

weight ranges should be interpreted in this way. In all circumstances, it is important to consider the patient in question and their physical condition, and select the dose most appropriate for the individual.

Other information relevant to Indication and dose

The dose panel also contains, where known, an indication of pharmacokinetic considerations that may affect the choice of dose, and dose equivalence information, which may aid the selection of dose when switching between drugs or preparations. The BNF includes unlicensed use of medicines when the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience. When the BNF recommends an unlicensed medicine or the ‘off-label’ use of a licensed medicine, this is shown below the indication and dose panel in the unlicensed use section.

Minimising harm and drug safety

The drug chosen to treat a particular condition should minimise the patient’s susceptibility to adverse effects and, where co-morbidities exist, have minimal detrimental effects on the patient’s other diseases. To achieve this, the Contra- indications, Cautions and Side-effects of the relevant drug should be reviewed. The information under Cautions can be used to assess the risks of using a drug in a patient who has co-morbidities that are also included in the Cautions for that drug—if a safer alternative cannot be found, the drug may be prescribed while monitoring the patient for adverse-effects or deterioration in the co-morbidity. Contra-indications are far more restrictive than Cautions and mean that the drug should be avoided in a patient with a condition that is contra-indicated. The impact that potential side-effects may have on a patient’s quality of life should also be assessed. For instance, in a patient who has difficulty sleeping, it may be preferable to avoid a drug that frequently causes insomnia. Clinically relevant Side-effects for drugs are included in the monographs or class monographs. Side-effects are listed in order of frequency, where known, and arranged alphabetically. The frequency of side-effects follows the regulatory standard:

. Very common — occurs more frequently than 1 in 10

administrations of a drug

. Common — occurs between 1 in 10 and 1 in 100

administrations of a drug

. Uncommon — between 1 in 100 and 1 in 1 , 000

administrations of a drug

. Rare — between 1 in 1 , 000 and 1 in 10 , 000 administrations

of a drug

. Very rare — occurs less than 1 in 10 , 000 administrations of

a drug

. Frequency not known An exhaustive list of side-effects is not included, particularly for drugs that are used by specialists (e.g. cytotoxic drugs and drugs used in anaesthesia). The BNF also omits effects that are likely to have little clinical consequence (e.g. transient increase in liver enzymes). Recognising that hypersensitivity reactions can occur with virtually all medicines, this effect is generally not listed, unless the drug carries an increased risk of such reactions,

BNF 73 xiii

l (^) HEPATIC IMPAIRMENT advice on the use of a drug in hepatic impairment

l RENAL IMPAIRMENT advice on the use of a drug in renal impairment

l PRE-TREATMENT SCREENING covers one off tests required to assess the suitability of a patient for a particular drug

l MONITORING REQUIREMENTS specifies any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow therapeutic index

l EFFECTS ON LABORATORY TESTS for drugs that can interfere with the accuracy of seemingly unrelated laboratory tests

l TREATMENT CESSATION specifies whether further monitoring or precautions are advised when the drug is withdrawn

l DIRECTIONS FOR ADMINISTRATION practical information on the preparation of intravenous drug infusions; general advice relevant to other routes of administration

l PRESCRIBING AND DISPENSING INFORMATION practical information around how a drug can be prescribed and dispensed including details of when brand prescribing is necessary

l HANDLING AND STORAGE includes information on drugs that can cause adverse effects to those who handle them before they are taken by, or administered to, a patient; advice on storage conditions

l PARENT AND CARER ADVICE for drugs with a special need for counselling

l PROFESSION SPECIFIC INFORMATION provides details of the restrictions certain professions such as dental practitioners or nurse prescribers need to be aware of when prescribing on the NHS l (^) NATIONAL FUNDING/ACCESS DECISIONS details of NICE Technology Appraisals and SMC advice

l LESS SUITABLE FOR PRESCRIBING preparations that are considered by the Joint Formulary Committee to be less suitable for prescribing

l EXCEPTION TO LEGAL CATEGORY advice and information on drugs which may be sold without a prescription under specific conditions

l MEDICINAL FORMS

Form

CAUTIONARY AND ADVISORY LABELS if applicable EXCIPIENTS clinically important but not comprehensive [consult manufacturer information for full details] ELECTROLYTES if clinically significant quantities occur ▶ Preparation name (Manufacturer/Non-proprietary) Drug name and strength pack sizes P * 6 Prices Combinations available this indicates a combination preparation is available and a cross reference page number is provided to locate this preparation

  • 6 Legal categories P This symbol has been placed against those preparations that are available only on a prescription issued by an appropriate practitioner. For more detailed information see

Medicines, Ethics and Practice, London, Pharmaceutical Press

(always consult latest edition)

a b c d e m These symbols indicate that the preparations are subject to the prescription requirements of the Misuse of Drugs Act

For regulations governing prescriptions for such preparations, see Controlled Drugs and Drug Dependence

Not all monographs include all possible sections; sections are only included when relevant information has been identified

BNF 73 xv

when the information is included under Allergy and cross sensitivity. The Important safety advice section in the BNF, delineated by a coloured outline box, highlights important safety concerns, often those raised by regulatory authorities or guideline producers. Safety warnings issued by the Commission on Human Medicines (CHM) or Medicines and Healthcare products Regulatory Agency (MHRA) are found here. Drug selection should aim to minimise drug interactions. If it is necessary to prescribe a potentially serious combination of drugs, patients should be monitored appropriately. The mechanisms underlying drug interactions

are explained in Appendix 1 , followed by details of drug

interactions.

Use of drugs in specific patient populations

Drug selection should aim to minimise the potential for drug accumulation, adverse drug reactions, and exacerbation of pre-existing hepatic or renal disease. If it is necessary to prescribe drugs whose effect is altered by hepatic or renal disease, appropriate drug dose adjustments should be made, and patients should be monitored adequately. The general principles for prescribing are outlined under Prescribing in

hepatic impairment p. 19 , and Prescribing in renal

impairment p. 19. Information about drugs that should be

avoided or used with caution in hepatic disease or renal impairment can be found in drug monographs under Hepatic

impairment and Renal impairment (e.g. fluconazole p. 548 ).

Similarly, drug selection should aim to minimise harm to the fetus, nursing infant, and mother. The infant should be monitored for potential side-effects of drugs used by the mother during pregnancy or breast-feeding. The general principles for prescribing are outlined under Prescribing in

pregnancy p. 21 and Prescribing in breast-feeding p. 21. The

Treatment Summaries provide guidance on the drug treatment of common conditions that can occur during

pregnancy and breast-feeding (e.g. Asthma p. 225 ).

Information about the use of specific drugs during pregnancy and breast-feeding can be found in their drug monographs

under Pregnancy, and Breast-feeding (e.g. fluconazole p. 548 ).

A section, Conception and contraception, containing information around considerations for females of childbearing potential or men who might father a child (e.g.

isotretinoin p. 1122 ) has been included.

Administration and monitoring

When selecting the most appropriate drug, it may be necessary to screen the patient for certain genetic markers or metabolic states. This information is included within a

section called Pre-treatment screening (e.g. abacavir p. 596 ).

This section covers one-off tests required to assess the suitability of a patient for a particular drug. Once the drug has been selected, it needs to be given in the most appropriate manner. A Directions for administration section contains the information about intravenous

administration previously located in Appendix 4. This

provides practical information on the preparation of intravenous drug infusions, including compatibility of drugs with standard intravenous infusion fluids, method of dilution or reconstitution, and administration rates. In addition, general advice relevant to other routes of administration is provided within this section (e.g. fentanyl

p. 424 ).

After selecting and administering the most appropriate drug by the most appropriate route, patients should be monitored to ensure they are achieving the expected benefits from drug treatment without any unwanted side- effects. The Monitoring section specifies any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow

therapeutic index (e.g. theophylline p. 256 ). Monitoring may,

in certain cases, be affected by the impact of a drug on

laboratory tests (e.g. hydroxocobalamin p. 899 ), and this

information is included in Effects on laboratory tests. In some cases, when a drug is withdrawn, further monitoring or precautions may be advised (e.g. clonidine

hydrochloride p. 136 ): these are covered under Treatment

cessation.

Choice and supply

The prescriber and the patient should agree on the health outcomes that the patient desires and on the strategy for achieving them (see Taking Medicines to Best Effect). Taking the time to explain to the patient (and carers) the rationale and the potential adverse effects of treatment may improve adherence. For some medicines there is a special need for counselling (e.g. appropriate posture during administration

of doxycycline p. 521 ); this is shown in Patient and carer

advice. Other information contained in the latter half of the monograph also helps prescribers and those dispensing medicines choose medicinal forms (by indicating information such as flavour or when branded products may

not be interchangeable (e.g. diltiazem hydrochloride p. 148 ),

assess the suitability of a drug for prescribing, understand

the NHS funding status for a drug (e.g. sildenafil p. 744 ), or

assess when a patient may be able to purchase a drug

without prescription (e.g. loperamide hydrochloride p. 63 ).

Medicinal forms

In the BNF, preparations follow immediately after the monograph for the drug that is their main ingredient. In earlier editions, when a particular preparation had safety information, dose advice or other clinical information specific to the product, it was contained within the preparations section. This information has been moved to the relevant section in the main body of the monograph under a heading of the name of the specific medicinal form

(e.g. peppermint oil p. 43 ).

The medicinal forms (formerly preparations) section provides information on the type of formulation (e.g. tablet), the amount of active drug in a solid dosage form, and the concentration of active drug in a liquid dosage form. The legal status is shown for prescription-only medicines and controlled drugs, as well as pharmacy medicines and medicines on the general sales list. Practitioners are reminded, by a statement under the heading of “Medicinal Forms” that not all products containing a specific drug ingredient may be similarly licensed. To be clear on the precise licensing status of specific medicinal forms, practitioners should check the product literature for the particular product being prescribed or dispensed. Details of all medicinal forms available on the dm+d for each drug in BNF Publications appears online on MedicinesComplete. In print editions, due to space constraints, only certain branded products are included in detail. Where medicinal forms are listed they should not be inferred as equivalent to the other brands listed under the same form heading. For example, all the products listed under a heading of “Modified release capsule” will be available as modified release capsules, however, the brands listed under that form heading may have different release profiles, the available strengths may vary and/or the products may have different licensing information. As with earlier editions of the BNF, practitioners must ensure that the particular product being prescribed or dispensed is appropriate. As medicinal forms are derived from dm+d data, some drugs may appear under names derived from that data; this may vary slightly from those in previous BNF versions, e.g. sodium acid phosphate, is now sodium dihydrogen phosphate anhydrous. Patients should be prescribed a preparation that complements their daily routine, and that provides the right dose of drug for the right indication and route of administration. When dispensing liquid preparations, a

xvi BNF 73