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Of all the valuable things that you do today, one of them will include reviewing important changes to the way that drug doses are adjusted in patients with chronic kidney disease.
To help you put these new recommendations into practice, we recommend that you complete the BNF case study. To facilitate this process, today's tip signposts you to relevant online calculators on the BNF website.
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| BNF UPDATE ON SIGNIFICANT CHANGES |
Drug dosage adjustments in renal impairment
For most drugs, and for most patients over 18 years of age of average build and height, the eGFR (derived from the Modification of Diet in Renal Disease formula) can be used to determine dosage adjustments in place of creatinine clearance. Exceptions include potentially toxic drugs with a small safety margin, and patients at both extremes of weight. Following a wide-ranging consultation, including the Department of Health, the regulatory authorities, and clinical experts in the field, references to creatinine clearance in the BNF have been replaced with eGFR where applicable. Appendix 3 also includes a table grading renal function according to the eGFR. For further information click on Appendix 3 . To help you put these changes into practice, we recommend you complete the BNF case study.
Wound dressings
Which dressing should be used on a red, granulating wound with low exudate? A new table on wound dressings in BNF 58 will make it easier to choose a dressing based on the appearance and condition of the wound. Other revisions have also been made to Appendix 8, for instance, advanced wound contact dressings (A8.2) have been classified in order of increasing absorbency, and dressings with antimicrobial properties have been moved to a separate section (A8.3). For further information click on Appendix 8
Measurement of HbA1C
What does a HbA1C value of 64mmol/mol mean? To prepare for the switch to reporting HbA1C values in mmol per mol of unglycosylated haemoglobin, BNF 58 includes a table showing equivalences between HbA1C values expressed as a percentage and those expressed in mmol/mol. For further information click on HbA1C
Exenatide, sitagliptin, and vildagliptin
What’s the role of these drugs in the treatment of type 2 diabetes? To find out, review summaries of the latest NICE guidance in BNF 58. For further information click on antidiabetic drugs
Influenza during pregnancy and breast-feeding
Although safety data are limited, BNF 58 recommends that either oseltamivir or zanamivir can be used in women who are pregnant or breast-feeding when the potential benefit outweighs the risk (e.g. during a pandemic). Zanamivir is the preferred drug during pregnancy; however, oseltamivir is recommended during severe infection or when zanamivir cannot be used. Oseltamivir is the preferred drug in women who are breast-feeding. For further information click on influenza
Clostridium difficile infection
Guidance on the antibacterial treatment of Clostridium difficile infection has been updated to take into account recent recommendations from the UK health departments (including Clostridium difficile infection: how to deal with the problem, December 2008). While oral metronidazole remains a first-line treatment, oral vancomycin is reserved for third or subsequent episodes of infection, for severe infection, for infection not responding to metronidazole, or for patients who are intolerant of metronidazole. A combination of oral vancomycin and intravenous metronidazole can be used for infection not responding to oral vancomycin alone or for life-threatening infection. For further information click on Clostridium difficile
Hospital-acquired pneumonia
Guidance on the treatment of hospital-acquired pneumonia has been updated to take into account the recommendations of a Working Party of the British Society for Antimicrobial Chemotherapy (J Antimicrob Chemother 2008; 62: 5–34). Patients with early-onset infection can be treated with either co-amoxiclav or cefuroxime. More broad-spectrum antibacterials are recommended for patients with late-onset infection that occurs more than 5 days after admission to hospital, for those with a history of recent antibacterial treatment, for life-threatening infection, or if resistant organisms are suspected. For further information click on pneumonia
Atrial flutter, paroxysmal supraventricular tachycardia, and ventricular tachycardia
If you are looking for a quick refresher on the management of these arrhythmias then the revised prescribing notes in BNF 58 are well worth a read. Treatment options are discussed, including selection of drug treatment and indications for direct current cardioversion, pacing, and catheter ablation. For further information click on arrhythmias
Nutrition
New tables on ACBS-approved enteral feeds, nutritional supplements, and special feeds will make it easier to compare and select products for patients with different nutritional requirements. Tables on enteral feeds and nutritional supplements are separated according to their energy and protein content. For further information click on Appendix 7
Other changes
To review other changes in BNF 58, click on changes
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| BNF CASE STUDY |
To help you put BNF advice on adjusting drug doses in chronic kidney disease into practice, please follow this link to a BNF case study.
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| TIPS ON USING THE BNF EFFECTIVELY |
Where can I find online calculators for creatinine clearance and paracetamol poisoning?
Simply go to the Resources section of the BNF website and click on Calculators.
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| LEARNING WITH THE BNF |
BNF e-learning modules for pharmacists
BNF Update is an e-learning programme developed in collaboration with the Centre for Pharmacy Postgraduate Education (CPPE). Using a series of clinical case studies, the programme enables pharmacists to identify and assess how significant changes in the BNF affect their clinical practice. The first module (BNF 57 Update) was launched in April 2009 for pharmacists working in the community and other primary care settings. A new module will be released every 6 months to complement the publication of each new edition of the BNF. From autumn 2009, there will be an additional e-learning programme based on BNF 58 that is aimed at hospital pharmacists. Recognised as an essential component of every pharmacist's continuing professional development, BNF Update can be accessed free of charge by pharmacists and pre-registration pharmacists in England at http://www.cppe.ac.uk
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| FEEDBACK ON OUR E-NEWSLETTER |
Please let us know if there are any issues that you would like us to address in e-newsletters. We welcome your feedback, if you have any comments or suggestions please let us know at enewsletter@bnf.org.
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