British National Formulary
Welcome to BNF 57. We have highlighted below some of the key changes you will find in this new edition.
Guidance on the treatment of irritable bowel syndrome has been updated for BNF 57 (section 1.5). The fibre intake of patients with irritable bowel syndrome should be reviewed, and if an increase in dietary fibre is required, soluble fibre (e.g. ispaghula husk, sterculia, or oats) is recommended; bran should be avoided. An osmotic laxative, such as a macrogol, is preferred for the treatment of constipation. Low doses of a tricyclic antidepressant can be used to treat abdominal pain or discomfort in patients who have not responded to laxatives, loperamide, or antispasmodics. A selective serotonin re-uptake inhibitor may be considered in those who do not respond to a tricyclic antidepressant.
Guidance on the emergency use of oxygen has been updated in BNF 57 (section 3.6) to take account of the recommendations of the BTS guideline: Emergency oxygen use in adult patients (October 2008). This guideline recommends aiming to achieve normal or near-normal oxygen saturation in most acutely ill patients except those at risk of hypercapnic respiratory failure, in whom a lower target oxygen saturation should be aimed for. The guideline recommends that patients who have had an episode of hypercapnic respiratory failure should be given an oxygen alert card including the oxygen saturations required during previous exacerbations (BNF 57, section 3.1).
Guidance on the treatment of HIV infection has been updated for BNF 57 (section 5.3.1) to take account of the recommendations of the British HIV Association (HIV Medicine 2008; 9: 563–608). Treatment is initiated with 2 nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor. Regimens containing a boosted protease inhibitor are reserved for patients with resistance to first-line regimens, women wishing to become pregnant, or patients with psychiatric illness. Advice on reducing the cardiovascular risk of patients receiving antiretrovirals has been expanded to include information on monitoring plasma lipids and blood glucose. BNF 57 also addresses the differences between protease inhibitors in their ability to cause dyslipidaemia and impair glucose tolerance.
Guidance on the use of oral antidiabetic drugs for the treatment of type 2 diabetes during pregnancy and breast-feeding, has been updated in BNF 57 (section 6.1.2) to incorporate some of the recommendations of the NICE guideline: Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period (March 2008, reissued July 2008). BNF 57 now advises that metformin may be used to treat type 2 diabetes during pregnancy for women with either pre-existing or gestational diabetes. Metformin can be continued during breast-feeding for those with pre-existing diabetes. Other oral hypoglycaemic drugs, including sulphonylureas, continue to be contra-indicated in pregnancy and breast-feeding.
BNF 57 (section 6.6) includes updated advice on the primary and secondary prevention of osteoporotic fractures in postmenopausal women from the NICE technology appraisals:
Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (October 2008). Alendronate is recommended as a treatment option for the primary prevention of osteoporotic fractures in postmenopausal women with confirmed osteoporosis who are:
Alternative treatments, etidronate, risedronate, or strontium ranelate, are recommended if other options are contra-indicated or not tolerated, and if particular combinations of bone mineral density measurement, age, and independent risk factors for fracture apply. Raloxifene is not recommended as a treatment option in postmenopausal women for primary prevention of osteoporotic fractures.
Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (October 2008). In postmenopausal women with confirmed osteoporosis who have also sustained a clinically apparent osteoporotic fracture, alendronate is recommended as a treatment option for the secondary prevention of osteoporotic fractures. Alternative treatments, etidronate, risedronate, raloxifene, strontium ranelate, and teriparatide, are recommended if other options are contra-indicated or not tolerated, and if particular combinations of bone mineral density measurement, age, and independent risk factors for fracture apply.
The European Medicines Agency has recommended new warnings and contra-indications for ergot-derived dopamine agonists (bromocriptine, cabergoline, and pergolide) because of the risk of fibrosis associated with chronic use. Furthermore, the maximum licensed doses of these drugs have been reduced. BNF 57 (section 4.9.1 and section 6.7.1) has been updated to reflect MHRA and CHM advice (Drug Safety Update 2008; 1(12): 9 and 2(3): 2).
Tendon damage is a rare, but well recognised side-effect of quinolones. The factors that predispose patients to this side-effect have been revised in BNF 57 (section 5.1.12). The risk of tendon damage is increased in patients over 60 years of age, in recipients of kidney, heart, or lung transplants, and in those receiving concomitant treatment with corticosteroids. While tendon rupture may occur within 48 hours of starting treatment, cases have also been reported several months after stopping a quinolone.
The information in BNF 57, the chapter on Immunological products and vaccines, has been updated and reformatted as follows:
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Numerous changes are made for each edition of the BNF. The most significant changes that have been made for BNF 57 can be reviewed by following the links below:
