Dear colleague,
BNF 62 has now published. Our e-newsletter provides insight into the most significant changes made for BNF 62 including new guidance on rebound acid hypersecretion with proton pump inhibitors, the management of haemorrhage in patients taking warfarin, and the risk of bladder cancer with pioglitazone. You'll note that some of the appendices in the BNF have been renumbered, although their content remains unchanged; please see appendices for details.
Our case study reviews the differences between antipsychotic drugs in their ability to cause extrapyramidal and metabolic side-effects.
Also look out for details of how to purchase BNF in a variety formats.
Thank you for your ongoing interest and support
BNF Team |
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| BNF update on significant changes |
Rebound acid hypersecretion with proton pump inhibitors
The safety of proton pump inhibitors came under scrutiny when the results of a trial suggested that discontinuation of this therapy may cause or aggravate the acid-related symptoms they are used to treat (Reimer C et al. Proton Pump Inhibitor Therapy Induces Acid-Related Symptoms in Healthy Volunteers after Withdrawal of Therapy. Gastroenterology 2009; 137: 80- 87). BNF 62 (section 1.3.5) states that rebound acid hypersecretion and protracted dyspepsia may occur after stopping prolonged treatment with a proton pump inhibitor. Healthcare professionals are reminded to prescribe proton pump inhibitors for appropriate indications at the lowest effective dose for the shortest period, and that the need for long-term treatment should be reviewed periodically. For further information click on Proton Pump Inhibitors.
Management of haemorrhage in patients taking warfarin
Guidance for the reversal of the anticoagulant effects of warfarin has been updated in section 2.8.2, to take into account the recommendations of the British Committee for Standards in Haematology: Guidelines on Oral Anticoagulation with Warfarin - fourth edition (2011). Advice is given on the management of patients with a raised INR and either major, minor, or no bleeding. For further information click on Warfarin.
Pioglitazone and bladder cancer
The European Medicines Agency has advised that there is a small increased risk of bladder cancer associated with pioglitazone use; however, in patients who respond adequately to treatment, the benefits of pioglitazone continue to outweigh the risks. BNF 62 (section 6.1.2.3) has been updated to reflect the European Medicines Agency's advice on assessment of patients for risk factors of bladder cancer before initiation of treatment with pioglitazone and when to review patients already receiving treatment. Patients receiving treatment with pioglitazone should be advised to report any haematuria, dysuria, or urinary urgency during treatment. For further information click on Pioglitazone.
Treatment of high-severity community-acquired pneumonia
Concerns were raised that the British Thoracic Society recommendations for high-severity community-acquired pneumonia may lead to overprescribing of broad-spectrum antibacterials with consequences such as antibacterial resistance and Clostridium difficile infection (Dryden M et al. Antibiotics for Community-Acquired Pneumonia. J Antimic Chemotherapy 2009; 64: 1123-25). BNF 62 (Table 1, section 5.1) recommends benzylpenicillin with either clarithromycin or doxycycline for the treatment of most patients with high-severity community-acquired pneumonia; the more broad-spectrum combinations such as co-amoxiclav + clarithromycin are reserved for patients with life-threatening infection or co-morbidities, for those living in long-term residential or nursing homes, or if Gram-negative infection is suspected. For further information click on Community-acquired Pneumonia.
Antiepileptic medication and breast-feeding
Guidance on the use of antiepileptic medication and breast-feeding has been reviewed and updated in section 4.8.1. Women taking antiepileptic monotherapy should generally be encouraged to breast-feed. Infants should be monitored for sedation, feeding difficulties, adequate weight gain, developmental milestones, and adverse effects associated with antiepileptic therapy. If suspected adverse effects develop in infants, plasma-drug concentrations should be measured and it may be necessary to introduce formula feeds. For further information click on Antiepileptics.
Starting and switching combined oral contraceptives
Guidance on the initiation of combined oral contraceptives and on switching to and from combined oral contraceptives, has been updated in section 7.3.1 to take into account the recommendations of the Medicines and Healthcare products Regulatory Agency (MHRA) and the Faculty of Sexual and Reproductive Health (May 2011). A combined oral contraceptive (except Qlaira®, see below) can now be initiated on day 1-5 of the cycle without the need for additional contraceptive precautions. If the woman is switching from another hormonal method of contraception to a combined oral contraceptive and the previous method has been used correctly, or pregnancy can reasonably be excluded, the new brand may be started immediately (without the need for additional contraception). The advice on the initiation of, and switching to and from, Qlaira® remains unchanged because of limited clinical experience with this brand. For further information click on Combined Hormonal Contraceptives.
Antipsychotics
For BNF 62, section 4.2.1 has been fully updated. The prescribing
notes have been expanded to describe the role of first-generation and second-generation (or 'atypical') antipsychotics in the management of schizophrenia. Guidance is provided on the choice of antipsychotic drug, monitoring requirements, and the side-effects associated with specific antipsychotic drugs. For further information click on Antipsychotics and see also the BNF case study.
Bisphosphonates and atypical femoral fractures
BNF 62 includes guidance on the risk of atypical femoral fractures with bisphosphonate treatment (section 6.6.2) in light of advice from the Medicines and Healthcare products Regulatory Agency (MHRA). Atypical femoral fractures have been reported rarely with bisphosphonates, mainly in patients receiving long-term treatment for osteoporosis. The need to continue bisphosphonate treatment for osteoporosis should be re-evaluated periodically, particularly after 5 or more years of use. Patients should be advised to report any thigh, hip, or groin pain during treatment with a bisphosphonate, and discontinuation of treatment should be considered for patients suspected to have an atypical femoral fracture, after an assessment of the benefits and risks of continued treatment. For further information click on Bisphosphonates.
Noradrenaline/Norepinephrine base
Manufacturers are now required to express the strength of all noradrenaline preparations as noradrenaline base. While this is being implemented, for a period of time preparations on the UK market may be described as either noradrenaline base or noradrenaline acid tartrate. Doses in BNF 62 are expressed as noradrenaline base (section 2.7.2). For further information click on Noradrenaline.
Controlled Drug symbols
Preparations of Controlled Drugs in Schedules 2, 3, 4 (Part I), and 4 (Part II) of the Misuse of Drugs Regulations 2001 (and subsequent amendments) are now identified throughout the BNF using symbols to indicate the Schedule to which they belong. A key to the new symbols can be found in the Controlled Drugs and Drug Dependence section in General Guidance. For further information click on Controlled Drugs.
Other changes
To view other changes in BNF 62, click on changes. return to top |
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| Clarification - BNFC 2011–2012 |
 Paracetamol intravenous infusion dose in BNF for Children 2011–2012
The intravenous infusion dose for paracetamol was amended for BNF for Children 2011–2012. Unfortunately, this significant change was not highlighted in the dose change section on page xviii of BNF for Children 2011–2012.
The change in dose was recommended and agreed by our expert advisers and was also agreed by our Paediatric Formulary Committee in November 2010. The neonatal doses are lower than those recommended in the Neonatal Formulary 6th Edition.
The recommendation to change the intravenous paracetamol dose for neonates and children under 10kg body-weight was based on an article,1 which points out that many experienced clinicians are using doses of IV paracetamol that are more in line with pharmacokinetic data than that previously recommended in BNF for Children.
1. Wilson-Smith EM, Morton NS. Survey of I.V. paracetamol (acetaminophen) use in neonates and infants under 1 year of age by UK anaesthetists. Paediatr. Anaesth. 2009 April; 19(4):329-337
For further information click on Paracetamol.
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| BNF Case Study |
 To help you put BNF advice on the differences between antipsychotic drugs in their ability to cause extrapyramidal and metabolic side-effects into practice, please follow this link to a BNF case study.
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| BNF e-learning modules for pharmacists |
BNF Update is an e-learning programme developed in collaboration with the Centre for Pharmacy Postgraduate Education (CPPE); there are two modules: one for pharmacists working in the community and other primary care settings, and another aimed at hospital pharmacists. BNF 62 Update will be released in September 2011 and can be accessed free of charge by pharmacists and pre-registration pharmacists in England at http://www.cppe.ac.uk.
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| BNF to power New Zealand medicines formulary |
As supporters of the BNF, we thought you'd be interested to know that BNF content has been chosen to form the basis of a New Zealand-specific medicines information resource.
Now widely regarded as an international gold standard in medicines information, the BNF will sit alongside content from BNF for Children and Stockley's Drug Interactions. All content and updates will be modified to suit the New Zealand environment.
The product is a result of a collaboration between the publishers, Best Practice Advocacy Centre New Zealand (bpacnz) and Best Practice Advocacy Centre Incorporated (BPAC Inc) and is expected to be rolled out in the next 12 months.
For more information, please contact Guy Simpson, International Business Development Manager, Royal Pharmaceutical Society.
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