British National Formulary
Welcome to BNF 62. Some of the appendices in the BNF have been renumbered, although their content remains unchanged; please see appendices for details. We have highlighted below some of the key changes you will find in this new edition.
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.
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.
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 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.
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.
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.
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.
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.
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).
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 latest BNF affect their clinical practice. There are two e-learning programmes: one for pharmacists working in the community and other primary care settings, and another aimed at hospital pharmacists. New modules will be released every 6 months to complement the publication of each new edition of the BNF. 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.
The BNF & BNFC free e-newsletter is issued several times a year. To register for regular updates, case studies, and tips on using these publications effectively, please sign up at bnf.org/newsletter. To visit the e-newsletter archive, go to http://bnf.org/bnf/extra/current/450066.htm.
Numerous changes are made for each edition of the BNF. The most significant changes that have been made for BNF 62 can be reviewed by following the links below:
