Peak 1h post IV dose 9 \200\22318micromol/l (5 \200\22310mg/l); trough <4.2micromol/l (<2mg /l); toxic >12mg/l (22micromol/l); signs of toxicity tinnitus, deafness, nystagmus, vertigo , renal failure (OHCM9 b p766). Will vary with once-daily regimen, check locally. Monitoring gentamicin Glibenclamide see sulphonylureas. Gliclazide see sulphonylureas. Glipizide see sulphonylureas. Glucagon peptide hormone Dose 1mg/PRN IM/SC/slow IV Indication hypoglycaemia, in treatment of B-blocker overdose CI phaeochromocytoma Caution insulinoma, glucagonoma, chronic hypo- g lycaemia SE GI disturbance, dK+, hypotension BNF 6.1.4. OHFP.indb 200 OHFP.indb 200 30/05/2014 16:18 30/05/2014 16:18 201 pharmacopeia Glycerin suppositories see laxatives. Glyceryl trinitrate nitrate see GTN. GTN sublingual/transdermal nitrate Dose 1 \200\2232 sprays/PRN SL; 0.3 \200\2231mg/PRN SL I ndication prophylaxis and treatment of angina, left ventricular failure CI hypotensive cond itions, hypovolaemia, aortic stenosis Caution pregnancy, breastfeeding, hypothyroidism, rec ent MI, head trauma SE postural hypotension, tachycardia, headache Info transdermal patches are available, see BNF \200\223 patients may develop tol- erance (tachyphylaxis) to nitra tes and as such it is suggested to ensure patients have a nitrate-free period for 4 \200 \2238h to prevent this; it is usual to have this period overnight when the eff ects of nitr ates are least likely to be needed BNF 2.6.1. GTN IV infusion nitrate Dose 10 \200\223200micrograms/min IVI GTN eg typical prescription: "50mg in 50ml 0.9% saline, start at 2ml/h and titrate up by 2ml/hr every 10min according to pain and BP; keep systolic BP >90mmHg" Indication left ventricular failure, ongoing ischae mic chest pain refractory to SL nitrates CI hypotensive conditions, hypo- volaemia, aortic stenosis Caution pregnancy, breastfeeding, hypothy- roidism, recent MI, head trauma SE post ural hypotension, tachycardia, headache Info patients may develop tolerance (tachyphylaxis) to nitrates and as such it is suggested to ensure patients have a nitrate-free period for 4 \200\2238h to prevent this; it is usual to have this period overnight when the eff ects o f nitrates are least likely to be needed BNF 2.6.1. Haloperidol antipsychotic (butyrophenone) Dose antiemetic: 0.5 \200\2233mg/8h PO/IV; other: 0.5 \200\22310mg/8h PO/IM/IV Indication schizo- phrenia, agitation, N+V, motor tics, intra ctable hiccups CI comatose/ CNS depres sion Caution pregnancy, breastfeeding, hepatic or re nal impairment, cardi ovascular disease, Parkinson \200\231s, epilepsy SE extrapy- ramidal symptoms, cardiac arrhythmias (QTc prolongation) BNF 4.2.1/4.9.3. Heparin glycosaminoglycan (potentiates antithrombin III) Dose Loading dose: 5000units or 75 units/kg IV; maintenance: 18units/ kg/h IVI (titrate dose to keep APTT within therapeutic r ange); prophy- lactic dose: 5000units/12h SC (seldom used as LMWH have similar ben- efi ts and fewer side eff ects) Indication rapid anticoagulation, treatment and prophylaxis of DVT /PE, ACS CI bleeding disorders, thrombocyto- penia, severe hypertension, recent trauma, his tory of heparin-induced thrombocytopenia (HIT, see b p406) Caution iK+, hepatic or renal im pairment SE hemorrhage, thrombocytopenia, iK+ Interaction NSAIDs increase bleeding risk, ef f ects increased by GTN BNF 2.8.1. Humalog see insulin. _OHFP.indb 201 _OHFP.indb 201 30/05/2014 16:18 30/05/2014 16:18 202 CHAPTER 5 Pharmacopeia Humalin see insulin. Hydralazine vasodilator (arterial>>venous) Dose hyper- tension: 25 \200\22350mg/12h PO; 5 \200\22310mg slow IV titrated to eff ect (can repeat after 30min); h eart failure: 25 \200\22375mg/6h PO Indication hyper- tension, heart failure CI SLE, severe tachycardia, myocardial insuffi - ciency Caution pregnancy, breastfeeding, hepatic or rena l impairment, ischaemic heart disease, cerebrovascular disease SE tachycardia, palpita- tio n, hypotension, SLE-like syndrome after long-term, rebound hyper- tension on stopping thera py, fl uid retention BNF 2.5.1. Hydrocortisone cream see topical corticosteroids. Hydrocortisone IV/PO corticosteroid Dose acute: 100 \200\223500mg/6h IV; chronic: 20 \200 \22330mg/24h PO in divided doses Indication adrenocortical insuffi ciency, acute allergic/i nfl ammatory reactions CI Systemic infection Caution adrenal suppression SE Cushing \200 \231s syndrome, DM, osteoporosis, dyspepsia BNF 6.3.2. Hydroxocobalamin vitamin B12 Dose macrocytic anemia without neurological involvement: initi ally 1mg three times a week IM, after 2 wk 1mg/3mth IM; macrocytic anemia with neurological involve- ment: initially 1mg on alternate days IM until no further improvement, then 1mg/2 mth IM Indication pernicious anemia, other macrocytic anaemias with neurological involvemen t Caution do not give before diagnosis fully established SE N+V, headache, dizziness BNF 9. 1.2. Hyoscine butylbromide anticholinergic Dose 20mg/6h PO (max 80mg/24h in divided doses); 20mg /STAT IV/IM repeated after 30min (max 100mg/24h in divided doses) Indication GI/GU smooth m uscle spasm CI myasthenia gravis Caution pregnancy, glaucoma, GI obstruction, prostatic hyp erplasia, urinary retention SE antimuscarinic eff ects, drowsiness BNF 1.2. Hyoscine hydrobromide anticholinergic Dose antiemetic: 300micrograms/6h PO (max 900microgra ms/24h in divided doses) excessive secretions: 200 \200\223600micrograms/4 \200\2238h SC In dication motion sickness, excessive respiratory secretions CI glau- coma Caution pregnancy, GI obstruction, prostatic hyperplasia, urinary retention SE antimuscarinic eff ects, sedat ive Interaction decreases eff ects of sublingual GTN BNF 4.6/15.1.3. respiratory Ibuprofen NSAID Dose 200 \200\223400mg/6h PO (max 2.4g/24h in divided doses) Indication pai n, infl ammation CI pregnancy, peptic ulcer disease Caution breastfeeding, hepatic or renal impairment, asthma, GI disease SE GI disturbance/bleeding, headache Interaction decreases eff ects of antihypertensives, increases toxicity of methotrexate BNF 10.1.1. OHFP.indb 202 OHFP.indb 202 30/05/2014 16:18 30/05/2014 16:18 203 pharmacopeia Insulatard see insulin. Insulin Dose when starting or changing SC doses liaise with diabe tes team (eg diabetes nurse specialist); infusion see Table 5.16 Indications DM, diabetic k etoacidosis, hyperkalaemia, maintenance of euglycaemia in critical care and post MI CI hypo glycaemia Caution may need dose adjustments in pregnancy, breastfeeding, renal and hepatic impairment, see BNF 6.1.1 SE hypoglycaemia, local reactions and fat hypertrophy at injectio n site, rarely allergic reactions Info Table 5.15 is not an exhaus- tive list of insulins. In addition to these single preparations of insulin, so called biphasic mixtures of two dif f erent insulins are also used and often consist of a rapid or short acting insulin and a l onger acting insulin (in dif- ferent proportions) BNF 6.1.1. Table 5.15 Properties of common subcutaneous insulins BNF 6.1.1 Type of insulin Example Onset Peak Max Duration Rapid-acting Novorapid 15 \200\22330min Humalog 15 \200\22330min Apidra 15 \200\22330min Aspart Lispro Glulisine 0.5 \200\2231.25h 0.5 \200\2231.25h 0.5 \200\2231.25h 4 \200\2236h 4 \200\2236h 4 \200\2236h Short-acting Actrapid Soluble 30 \200\22360min 2 \200\2233h 6 \200\2238h Intermediate and long-acting Isophane Glargine Detemir Insulatard Lantus Levemir 2 \200\2234h 3 \200\2234h 3 \200\2234h 6 \200\22310h 8 \200\22316h 6 \200\2238h 14 \200\22318h 20 \200\22324h 720h Table 5.16 IV infusions of insulins Indication Hyperkalaemia (b p385) 50ml of 50% glucose with 10units soluble insulin (eg Actrapid ) IVI over 10min 50ml of 0.9 % saline with 50units soluble insulin (eg Actrapid ), often infused at 0 \200\2237ml/h dep ending upon the patient \200\231s blood sugar Sliding scale (b p327) Ipratropium anticholinergic Dose Chronic: 20 \200\22340micrograms/6h INH (max 80micrograms/ 6h) Acute: 250 \200\223500micrograms/4 \200\2236h NEB Indication bronchospasm; chronic and acute Caution glaucoma, pros- tatic hyperplasia SE minimal antimuscarinic eff ects BNF 3.1. 2. Iron see ferrous preparations. ISMN nitrate see isosorbide mononitrate. ISMO nitrate see isosorbide mononitrate. _OHFP.indb 203 _OHFP.indb 203 30/05/2014 16:18 30/05/2014 16:18 204 CHAPTER 5 Pharmacopeia Isoket nitrate see isosorbide dinitrate. Isosorbide dinitrate IV infusion nitrate Dose 2 \200\22310mg/h IVI Indication left ventricular failure, ischaemic chest pain CI hypotensive con- ditions, hypovolaemia, aortic stenosis Caution pregnancy, breastfeeding, hypothyroidi sm, recent MI, head trauma SE postural hypotension, tachy- cardia, headache Info patients m ay develop tolerance (tachyphylaxis) to nitrates if infused for prolonged periods, though t here are obvious risks about stopping a nitrate infusion; consult senior BNF 2.6.1. Isosorbide mononitrate nitrate Dose initially: 20mg break- fast and lunchtime PO then: 40mg breakfast and lunchtime PO (max 120mg/24h in divided doses) Indication prophylaxis of angi na, adjunct in congestive heart failure Caution as GTN SE postural hypotension, tachycardia , headache Info patients may develop tolerance (tachyphy- laxis) to nitrates and as such it is suggested to ensure patients have a nitrate-free period for 4 \200\2238h to prevent thi s; it is usual to have this period overnight when the eff ects of nitrates are least likely to be needed, hence prescribing them to be given at breakfast and lunchtime rather than 8a m and 8pm BNF 2.6.1. Istin see calcium-channel blockers. Lactulose see laxative. Lamotrigine antiepileptic Dose initially: 25mg/24h PO for 14d then: 50mg/24h PO for 14d, in crease by max 50 \200\223100mg/24h every 7 \200\22314d until seizures controlled (max 500mg /24h) Indication epilepsy Caution requires close monitoring of serum levels, pregnancy, bre ast- feeding, hepatic or renal impairment, avoid rapid withdrawal SE rash/ severe skin reac tions, cerebellar symptoms, cytopenias BNF 4.8.1. Lansoprazole proton pump inhibitor Dose 30mg/24h PO for 4 \200\2238wk, 15mg/24h PO maintena nce Indication prophylaxis and treat- ment of peptic ulcers, GORD, H. pylori eradication, Z ollinger \200\223Ellison syndrome CI pregnancy Caution breastfeeding, hepatic impairment, g astric cancer SE GI disturbance, headache Interaction proton pump inhibitors may reduce eff ectiveness of clopidogrel Info also available as a FasTab which dissolves in the mouth a nd is useful in patients who are NBM BNF 1.3.5. OHFP.indb 204 OHFP.indb 204 30/05/2014 16:18 30/05/2014 16:18 205 pharmacopeia Laxative Dose see Table 5.17 Indications treatment and prophylaxis of constipation (see b p 310) Caution confi rm the patient is consti- pated and consider causes of constipation SE s ee Table 5.17 Info chronic use of laxatives can lead to electrolyte imbalances and gut dys- motility. Ensure adequate water intake and increase fi bre intake where possible. Always c onsider fecal impaction and other causes of obstruc- tion before commencing oral laxatives. Combinations of laxatives from diff erent groups can be used in severe constipation (eg la ctulose and senna) BNF 1.6. Table 5.17 Laxative BNF 1.6 Classi \201 cation eg Fybogel , Normacol CI diffi culty in swallowing, intestinal obstruction, colonic aton y, fecal impaction SE diarrhea, fl atulence, abdominal distension, gastrointestinal obstruc tion 1 sachet or two 5ml spoons in water/12h PO Bulk-forming laxatives BNF 1.6.1 Fybogel eg bisacodyl, docusate, glycerol, senna CI intestinal obstruction, acute surgical abdomens, active infl ammatory bowel disease, dehydration SE diarrhea, hypokalaemia, abdominal pain, N+V Info co-danthramer should only be used in the terminally ill as potentially carcinogen ic 5 \200\22310mg/nocte PO or 10mg/mane PR 1 \200\2232 capsules/nocte PO Stimulant laxatives BNF 1.6.2 Bisacodyl Co-danthramer Docusate sodium 200mg/12h PO (max 500mg/24h PO in divided doses) Glycerin supps Senna 1 suppository/PRN PR, max 4 in 24h 2 tablets/nocte PO or 10ml/nocte PO eg arachis oil, liquid paraffi n Info infrequently used CI peanut allergy eg lactulose, Mov icol , magnesium salts, rectal phosphates (eg Fleet enema), rectal sodium citrate (eg Mi crolette ) CI intestinal obstruction, colonic atony SE diarrhea, fl atulence, abdominal di stension and discomfort, nausea; local irritation with rectal preparations 10 \200\22315ml/ 12h PO 1 \200\2233 sachets/24h PO Fecal softeners BNF 1.6.3 Osmotic laxatives BNF 1.6.4 Lactulose Movicol Phosphate enemas 1/PRN PR, max 2 in 24h Microlette 1/PRN PR, max 2 in 24h Levothyroxine typically 50 \200\223200micrograms/24h PO at breakfast Indication hypothyroid ism CI thy- rotoxicosis Caution pregnancy, breastfeeding, panhypopituitarism, adrenal insuf fi ciency, cardiovascular disorders, DM SE hyperthyroid-like symptoms; GI disturbance, trem ors, restlessness, fl ushing Interaction increases eff ects of TCAs and warfarin, decreases eff ects of propranolol BNF 6.2.1. thyroid hormone (T4) Dose _OHFP.indb 205 _OHFP.indb 205 30/05/2014 16:18 30/05/2014 16:18 206 CHAPTER 5 Pharmacopeia Lidocaine local anesthetic (amide) Dose local anesthesia: 1/2/4% solution SC (max 3mg/kg [m ax total dose 200mg]) anti- arrhythmic: see BNF Indication local anesthesia, ventricular ar rhythmias (alternative to amiodarone) CI myocardial depression, atrioventricular block, sin oatrial node disorders Caution pregnancy, hepatic or renal impairment, epilepsy, severe hyp oxia/hypovolaemia SE dizziness, drowsi- ness, confusion, tinnitus Interaction increased myo cardial depression with B-blockers and other anti-arrhythmics, increased risk of arrhythmia s with antipsychotics BNF 15.2. Lignocaine local anesthetic (amide) see lidocaine. Lisinopril see ACEi. Lithium lithium salt (mood stabilizer) Dose see BNF Indication mania, bipolar disorder CI p regnancy, breastfeeding, untreated hypothy- roidism, Addison \200\231s disease Caution thyr oid disease, myasthenia gravis SE GI upset, thirst, polyuria Interaction diuretics, NSAIDs Info lithium citrate and lithium carbonate doses are not simply interchangeable d/w senior/ pharmacist; on stable regiments monitor level every 3mth. The NPSA have published guidance on the \200\230safer use of lithium \200\231 and this should be consulted before commencin g lithium therapy1 BNF 4.2.3. Optimum sampling time 4 \200\2237d after commencing treatment 12h post dose 0.4 \200\2231mm ol/l; early signs of toxicity (Li+ >1.5mmol/l) tremor, agitation, twitching, thirst, polyur ia, N+V; late signs of toxicity (Li+ >2mmol/l) spasms, coma, fi ts, arrhythmias, renal fail ure (OHAM3 b p716) Monitoring lithium Loperamide opioid (antimotility) Dose 4mg PO initially then 2mg PO following every loose st ool (max 16mg/24h in divided doses) Indication diarrhea, control of high output stoma CI pr egnancy, IBD, any condition where peristalsis should not be stopped; constipation, ileus, m egacolon Caution hepatic impairment, can promote fl uid and electrolyte depletion in the yo ung SE abdominal cramps, constipation, dizziness Info loperamide should not be used in infe ctive diarrhoeas or diarrhea associated with IBD BNF 1.4.2. Loratadine H1-antagonist see antihistamine. Lorazepam benzodiazepine Dose sedation/anxiety: 1 \200\2234mg/24h PO/IM/IV seizures: 4mg sl ow IV (repeated once after 10min if needed) Indication sedation, seizures, status epileptic us CI respiratory depres- sion, sleep apnoea, unstable myasthenia gravis, severe hepatic im pairment Caution pregnancy, breastfeeding, history of drug abuse, respiratory disease, musc le weakness, renal impairment SE drowsiness, confusion, muscle weakness BNF 4.1.2/4.8.2. 1 (cid:27)www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=65426 OHFP.indb 206 OHFP.indb 206 30/05/2014 16:18 30/05/2014 16:18 207 pharmacopeia Losartan see AT II antagonists. Magnesium sulfate magnesium salt Dose 2 \200\2234g IV over 5 \200\22315min often followed b y an infusion (see BNF) Indication arrhythmias, MI, acute severe asthma, pre-eclampsia/ecla mpsia, dMg2+ Caution preg- nancy, monitor BP, RR, urinary output, hepatic or renal impairme nt SE N+V, hypotension, thirst, fl ushed skin Interaction risk of hypotension with calcium- channel blockers Info magnesium sulfate 1g equivalent to approximately 4mmol BNF 9.5.1.3. Levels should be checked every 6h whilst on IV therapy or more urgently if indicated therap eutic range 1.7 \200\2233.5mmol/l Normal plasma range Therapeutic range ECG changes (QRS wi dens) Reduction in tendon refl exes Loss of deep tendon refl exes Heart block, respiratory paralysis, CNS depression Cardiac arrest Monitoring magnesium 0.7 \200\2231.0mmol/l 1.7 \200\2233.5mmol/l 2.5 \200\2235.0mmol/l 4.0 \200\2235.0mmol/l >5.0mmol/l >7.5mmol/l >12mmol/l Maxolon antiemetic (dopamine antagonist) see metoclo- pramide. Mannitol polyol (osmotic diuretic) Dose 0.25 \200\2232g/kg/4 \200\2238h over 30 \200\22360m in IVI (max 3 doses) Indication cerebral oedema, glaucoma CI pulmonary oedema, cardiac fail ure Caution pregnancy, breastfeeding, renal impairment SE hypotension, fl uid and electroly te imbalance BNF 2.2.5. Mebeverine antispasmodic (antimuscarinic) Dose 135 \200\223 150mg/8h PO (20min before food) Indication GI smooth muscle cramps; IBS/diverticulitis CI paralytic ileus Caution pregnanc y, acute porphyria SE very rarely rash, urticaria BNF 1.2. Meropenem carbapenem antibiotic Dose 500 \200\2231000mg/8h IV (dose doubled in severe infec tions) Indication aerobic and anaer- obic Gram-positive and Gram-negative infections Cautio n pregnancy, breastfeeding, hepatic or renal impairment, sensitivity to beta-lactams SE GI disturbance including antibiotic associated colitis, headache, deranged LFTs BNF 5.1.2.2. Mesalazine aminosalicylate Dose depends upon formulation, consult BNF; PO and PR preparatio ns available Indication mild/mod- erate active ulcerative colitis and maintenance of remiss ion CI salicylate allergy, coagulopathies Caution pregnancy, breastfeeding, hepatic or rena l impairment SE GI upset, bleeding disorders BNF 1.5.1. Metformin biguanide Dose initially: 500mg/24h PO with breakfast; after 1wk: 500mg/12h PO; a fter further 1wk: 500mg/8h PO if required (max 2g/24 in divided doses) Indication type 2 DM , polycystic ovarian syndrome CI hepatic or renal impairment Caution ketoacidosis, poten- t ial increased risk of lactic acidosis, iodine-containing contrast, general anesthesia SE GI disturbance, metallic taste BNF 6.1.2.2. _OHFP.indb 207 _OHFP.indb 207 30/05/2014 16:18 30/05/2014 16:18 208 CHAPTER 5 Pharmacopeia Methadone opioid Dose usual range 60 \200\223120mg/24h PO; should not be given more frequen tly than 12h if on prolonged use; establish the patient \200\231s dose from the usual dispe nsing drugstore, the patient may not tell you accurate information Indication aid in withdr awal from opioid dependence, chronic pain CI acute respiratory depression, paralytic ileus, raised ICP/head trauma, comatose patients, phaeochromocytoma Caution pregnancy (especially delivery), arrhythmias, hepatic or renal impairment SE N+V, constipation, respiratory depr ession, dry mouth Interaction MAOI within 2wk BNF 4.10.3. Methotrexate dihydrofolate reductase inhibitor Dose 2.5 \200\223 10mg/wk PO (max 25mg/wk) I ndication rheumatoid arthritis, Crohn \200\231s disease, psoriasis, ALL, non-Hodgkin \200 \231s lymphoma CI pregnancy, breast- feeding, hepatic or renal impairment, active infection , immunodefi cient syndromes Caution blood disorders, eff usions (especially ascites), pept ic ulcer, ulcerative colitis SE GI disturbance/mucositis, pulmonary fi brosis, pneumonitis, myelosuppression Interaction NSAIDs, co-tri- moxazole, trimethoprim Info patients usually also prescribed folic acid during treatment with methotrexate BNF 1.5.3/10.1.3. Methylprednisolone corticosteroid Dose 2 \200\22340mg/24h PO; 10 \200\223500mg/24h IV/IM (e xceptionally, up to 1g/24h for up to 3d) Indication acute infl ammatory disease, cerebral o edema (associated with malignancy), graft rejection CI systemic infection Caution adrenal s uppression SE Cushing \200\231s syndrome, DM, osteoporosis Interaction duration decreased b y rifampicin, car bamazepine, phenytoin; duration of action increased by erythromycin, keto conazole, ciclosporin BNF 6.3.2. Metoclopramide dopamine antagonist see antiemetic. Metoprolol see beta-blockers. Metronidazole antibiotic Dose 400mg/8h PO; 500mg/8h IV Indication anaerobic and protozoal i nfections, abdominal sepsis, Clostridium diffi cile diarrhea Caution pregnancy, breastfeedi ng, hepatic impairment, alcohol use SE GI disturbance, metallic taste, oral mucositis Inter action can increase lithium and phenytoin levels, increases eff ects of warfarin BNF 5.1.11 . Midazolam benzodiazepine Dose 1 \200\22310mg IV titrated to eff ect Indication conscious se dation, sedation in anesthesia CI breastfeeding, respiratory depression, sleep apnoea, unst able myasthenia gravis Caution pregnancy, hepatic or renal impairment, history of drug abus e, respiratory disease, muscle weakness SE drowsiness, confusion, muscle weakness BNF 15.1. 4.1. Misoprostol prostaglandin E1 analog Dose treat- ment: 800micrograms/24h PO in divided dose; prophylaxis: 200micrograms/6 \200\22312h PO Indication prophylaxis and treatment of peptic ulcers CI pregnancy, breastfeeding Caution cardiovascular/cer- ebrovascular disease SE dia rrhea BNF 1.3.4. OHFP.indb 208 OHFP.indb 208 30/05/2014 16:18 30/05/2014 16:18 209 pharmacopeia Mixtard see insulin. Montelukast leukotriene receptor antagonist Dose 10mg/24h PO in even ing Indication chronic asthma (BTS guidelines), allergic rhinitis Caution pregnancy, breast feeding SE abdominal pain, headache, rarely Churg \200\223Strauss syndrome BNF 3.3.2. Morph ine opioid Dose 2.5 \200\22310mg/4h IV titrated to eff ect; 5 \200\22310mg/4h IM/SC Indicat ion acute severe pain, chronic pain, acute MI, acute LVF CI acute respiratory depression, p aralytic ileus, raised ICP/head trauma, comatose patients Caution pregnancy (especially del ivery), COPD, asthma, arrhythmias, renal impairment, hepatic impairment SE N+V, constipatio n, respiratory depression, dry mouth Info co-prescribe laxatives if using opioids for >24h BNF 4.7.2. MST Continus opioid see oral morphine. Mupirocin antibacterial Dose apply to s kin up to 3 times/24h Indication bacterial skin infections Caution pregnancy, breastfeeding , renal impairment SE local reactions; urticarial, pruritus, burning sensa- tion, rash BNF 13.10.1.1. N-acetylcysteine amino acid derivative see acetylcysteine. Naloxone opioid recep tor antagonist Dose 0.4 \200\2232.0mg IV/IM/ SC, repeat after 2min if needed (max 10mg) Ind ication opioid reversal during OD/overtreatment Caution pregnancy, physical dependence on o pioids, cardiovascular disease SE N+V, hypotension BNF Emergency treatment of poisoning. Na rcan opioid receptor antagonist Narcan is a brand name for naloxone that is no longer u sed. See naloxone for opioid overdose or reversal of narcosis. Nefopam centrally-acting non -opioid analgesic Dose 30 \200\22360mg/8h PO (max 90mg/8h PO) Indication moderate pain CI c onvulsive disorders Caution pregnancy, breastfeeding, hepatic or renal impairment, elderly, urinary retention SE N+V, nervousness, urinary retention, dry mouth, lightheadedness, may color urine pink BNF 4.7.1. Nicorandil potassium channel activator Dose 5 \200\22310mg/12h PO (max 30mg/12h in divided doses) Indication angina prophylaxis and treatment (not 1st lin e) CI breastfeeding, hypotension, LVF with low fi lling pressures Caution pregnancy, hypovo laemia, acute pulmonary oedema, MI SE headache, fl ushing, GI disturbance BNF 2.6.3. Nifedi pine see calcium-channel blockers. Nitrofurantoin antibiotic Dose 50 \200\223100mg/6h PO; t ake with food Indication urinary tract infections CI pregnancy, breastfeeding, renal impair ment, G6PD defi ciency, infants <3mth, acute porphyria Caution hepatic impairment, anemia, DM, electrolyte imbalance, vitamin B12/ folate defi ciency, lung disease SE anorexia, GI di sturbance, acute and chronic pulmonary reactions BNF 5.1.13. _OHFP.indb 209 _OHFP.indb 209 30/05/2014 16:18 30/05/2014 16:18 210 CHAPTER 5 Pharmacopeia Nurofen NSAID see ibuprofen. Nystatin polyene antifungal Dose 100 000 units (1ml)/6h PO; topical gel PRN Indication candidiasis; oral, skin Caution GI absorbance minimal SE GI dist urbance (at high doses), oral irritation, rash BNF 12.3.2. Omeprazole proton pump inhibitor Dose 10 \200\22340mg/24h PO; IV preparation available for endoscopically proven bleeding u lcers (consult BNF/local guidelines) Indication prophylaxis and treatment of peptic ulcers, GORD, H. pylori eradication Caution hepatic impairment (no more than 20mg/24h), can mask g astric cancer SE GI disturbance, headache, dizziness Interaction proton pump inhibitors may reduce eff ectiveness of clopidogrel BNF 1.3.5. Ondansetron see antiemetics (5HT3 receptor antagonist). Oral morphine opioid Dose oral solu tion 5 \200\22320mg/4h PO; tablets: 5 \200\22320mg/4h PO; 12h slow release preparations: 10 \200\22330mg/12h PO, adjust to response (larger dose tablets available; seek senior/spe- c ialist advice) Indication severe pain, chronic pain CI acute respiratory depression, paraly tic ileus, raised ICP/head trauma, comatose patients, phaeochromocytoma Caution pregnancy ( especially delivery), COPD, asthma, arrhythmias, renal impairment, hepatic impairment SE N+ V, constipation, respiratory depression, dry mouth Info co-prescribe laxa- tives if using o pioids for >24h BNF 4.7.2. Oramorph opioid see oral morphine. Oseltamivir (Tami \202 u ) antiviral Dose treatment of infl uenza 75mg/12h PO for 5d; prevention of infl uenza 75mg/ 24h PO for 10d Indication treatment of infl uenza if started within 48h of the onset of sym ptoms, post-exposure prophylaxis of infl uenza Caution renal impairment, pregnancy and brea stfeeding (use only if potential benefi t outweighs risk (eg during a pandemic)) SE GI dist urbances, headache, arrhythmias, convulsions, thrombocytopenia BNF 5.3.4. Oxybutynin antimuscarinic Dose 5mg/8 \200\22312h PO, increase if required (max 20mg/24h in divided doses); modifi ed release prepara- tions also available Indication detrusor instabi lity; urinary frequency, urgency and incontinence CI pregnancy, breastfeeding, bladder outf l ow/ GI obstruction, myasthenia gravis Caution hepatic or renal impairment, prostatic hype rplasia, autonomic neuropathy SE antimuscarinic eff ects, GI disturbance BNF 7.4.2. Oxycodone opioid Dose 5mg/4 \200\2236h PO (max 400mg/24h); 1 \200\22310mg/4h IV/SC titrated to eff ect Indication pain; moderate to severe CI acute respiratory depression, paralytic ileus, chronic constipa- tion, acute abdomen, raised ICP/head trauma, hepatic or renal impa ir- ment if severe, acute porphyria, cor pulmonale, comatose patients Caution pregnancy, CO PD, asthma, arrhythmias, renal impairment, hepatic impairment SE N+V, constipation, respira tory depression, dry mouth Info 2mg PO \200\2231mg IV Info co-prescribe laxatives if usin g opioids for >24h BNF 4.7.2. OxyContin opioid see oxycodone. OHFP.indb 210 OHFP.indb 210 30/05/2014 16:18 30/05/2014 16:18 211 pharmacopeia OxyNorm opioid see oxycodone. Oxytetracycline tetracycline antibiotic Dose 250 \200\22350 0mg/6h PO Indication acne vulgaris, rosacea CI pregnancy, breastfeeding, renal impairment, age <12yr (irreversibly stains growing teeth and bones) Caution myasthenia gravis may worse n, exacerbates SLE SE GI disturbance including, dysphagia/oesophageal irritation Interactio n decreased absorption with dairy products, decreases eff ects of oral con- traceptive pill , mildly increases eff ects of warfarin BNF 5.1.3. Pabrinex see thiamine. Pantoprazole pr oton pump inhibitor Dose 20 \200\22380mg/24h PO; IV preparation available for endoscopicall y proven bleeding ulcers (consult BNF/local guidelines) Indication prophylaxis and treatmen t of peptic ulcers, GORD, H. pylori eradication Caution hepatic impairment (max 20mg/24h), renal impairment (max oral dose 40mg/24h), can mask gastric cancer SE GI disturbance, heada che, dizziness Interaction proton pump inhibitors may reduce eff ectiveness of clopidogrel BNF 1.3.5. Paracetamol simple analgesic Dose 0.5 \200\2231g/4 \200\2236h PO/IV (max 4g/24h in divided doses) Indication pain; mild to moderate, pyrexia Caution alcohol dependence, hepatic impai rment SE rare; rash, hypo- glycaemia, blood disorders, hepatic impairment Interaction prolo nged use can potentiate warfarin BNF 4.7.1. Paroxetine selective serotonin re-uptake inhibitor Dose 20 \200\22340mg/24h PO (max 50 \200 \22360/24h) Indication major depression, obsessive-compulsive disorder, panic disorder, pos t-traumatic stress disorder Caution pregnancy, epilepsy, cardiac disease, DM SE GI dis- tur bance, anorexia, weight loss, dNa+, agitation; increased incidence of antimuscarinic, extra pyramidal and withdrawal eff ects compared with fl uoxetine BNF 4.3.3. Penicillin G beta-lactam see benzylpenicillin. Penicillin V beta-lactam see phenoxymethylpenicillin. Pentasa aminosalicylate see mesalaz ine. Peppermint oil antispasmodic Dose 1 \200\2232 capsules/8h PO before meals Indication a bdominal colic and distension especially in IBS Caution sensitivity to menthol SE heartburn , perianal irritation BNF 1.2. Perindopril see ACEi. Pethidine opioid Dose 25 \200\223100mg/4h SC/IM; 25 \200\22350mg/4h slow IV Indication pain ; moderate to severe, obstetric, post-op CI acute respira- tory depression, paralytic ileus , raised ICP/head trauma, comatose patients Caution pregnancy (especially delivery), COPD, asthma, arrhythmias, renal impairment, hepatic impairment SE N+V, less constipation than mo rphine, respiratory depression, dry mouth BNF 4.7.2. _OHFP.indb 211 _OHFP.indb 211 30/05/2014 16:18 30/05/2014 16:18 212 CHAPTER 5 Pharmacopeia Phenobarbital barbiturate Dose epilepsy (not 1st line): 60 \200\223180mg/24h PO at night; s tatus epilepticus: 10mg/kg at max 100mg/min (max 1g) IV (see BNF 4.8.2) Indication epilepsy , status epilepticus CI pregnancy, breast- feeding, hepatic impairment Caution renal impair ment, acute porphyria SE respi ratory depression, hypotension, sedation BNF 4.8.1. Trough 60 \200\223180micromol/l (15 \200\22340mg/l); toxic >180micromol/l (>40mg/l) Monitoring phenobarbital Phenoxymethylepenicillin (penicillin V) beta-lactam Dose 0.5 \200\2231g/6h PO Indication or al infections, post-splenectomy (prophy- laxis) CI penicillin allergy Caution history of al lergy SE diarrhea Interaction decrease eff ects of oral contraceptive pill, allopurinol inc reases risk of rash BNF 5.1.1.1. Phenytoin antiepileptic Dose epilepsy: 3 \200\2234mg/kg/24h PO increased gradually as neces sary; status epilepticus: loading dose = 20mg/kg IV at no more than 50mg/min with ECG monit oring, main- tenance = 100mg/6 \200\2238h thereafter IV (see BNF 4.8.2); monitor level (see box) Indication epilepsy, status epilepticus CI pregnancy, breast- feeding, sinus hypotens ion Caution hepatic impairment, avoid abrupt withdrawal, acute porphyria; monitor blood cou nt SE drowsiness, cer- ebellar eff ects, hypotension, arrhythmias, purple glove syndrome, b lood disorders; chronic use: coarse facies, hirsutism, gum hypertrophy Info as drug highly protein bound, may need to adjust monitored levels for low albumin (consult pharmacist) BNF 4.8.1. Trough 40 \200\22380micromol/l (10 \200\22320mg/l); toxic >80micromol/l (>20mg/l); signs of toxicity ataxia, nystagmus, dysarthria, diplopia Monitoring phenytoin Phosphate enema see laxatives. Phytomenadione vitamin K1 Dose 1 \200\22310mg/STAT PO/IV dep ending upon indication \200\224consult BNF and/or d/w hematologist Indication bleeding and/ or over-anticoagulation with warfarin Caution pregnancy, give IV slowly BNF 9.6.6. Picolax see laxatives. Piperacillin with tazobactam beta-lactam with tazobactam Dose 4.5g/6 \200 \2238h IV Indication severe infection, infection in neutropenic patients (in combination wi th aminoglycoside) CI penicillin allergy Caution pregnancy, breastfeeding, renal impairment , history of penicillin allergy SE diarrhea BNF 5.1.1.4. Piriton antihistamine (H1-antago nist) see chlorphenamine. Plavix antiplatelet see clopidogrel. OHFP.indb 212 OHFP.indb 212 30/05/2014 16:18 30/05/2014 16:18 213 pharmacopeia Potassium oral supplement potassium salt Dose potassium chloride: 2 \200\2234g/24h PO (two tablets/8 \200\22312h) Indication potassium loss CI serum potassium >5mmol/l Caution renal impairment, elderly, intestinal strictures, history of peptic ulcer SE GI disturbance, uppe r GI ulceration Info check serum Mg2+ as this is also likely to be low in dK+ BNF 9.2.1.1. Pravastatin HMG CoA reductase inhibitor see statin. Prednisolone corticosteroid Dose initially: 10 \200\22320mg/24h mane PO though often 30 \200\22340mg/24 PO in severe disease (up to 60mg/24h); maintenance: 2.5 \200\22315mg/24h PO Indication suppression of infl amma- tory and allergic disorders (eg IBD, asthma, COPD), i mmunosuppres- sion CI systemic infection without antibiotic cover Caution adrenal suppressi on SE peptic ulceration, Cushing \200\231s syndrome, DM, osteo- porosis Interaction duratio n of action decreased by rifampicin, car- bamazepine, phenytoin; duration of action increas ed by erythromycin, ketoconazole, ciclosporin Info consider bone and GI protection strate- gies when using long-term corticosteroids; see b p177 BNF 6.3.2. Pregabalin antiepileptic D ose epilepsy: 25mg/12h PO increased every 7d by 50mg to 100 \200\223150mg/8 \200\22312h (ma x 600mg/24h in divided doses) pain/anxiety: 75mg/12h increased every 3 \200\2237d up to max 600mg/24h in divided doses Indication epilepsy, neuropathic pain, generalized anxiety diso rder CI pregnancy, breastfeeding Caution renal impairment, severe congestive heart failure, avoid abrupt withdrawal SE GI disturbance, dry mouth, dizziness, drowsiness BNF 4.8.1. Prochlorperazine phenothiazine see antiemetics. Procyclidine anticholinergic Dose 2.5mg/8h PO increased every 3d up to max 30mg/24h in divi ded doses; acute dystonia: 5 \200\22310mg IM/ IV Indication parkinsonism; drug-induced extr apyramidal symptoms CI urinary retention, glaucoma, myasthenia gravis Caution pregnancy, br eastfeeding, hepatic or renal impairment, cardiovascular disease, pros- tatic hyperplasia, tardive dyskinesia SE antimuscarinic eff ects BNF 4.9.2. Propranolol see beta-blockers. Protamine heparin antagonist Dose 1mg IV neutralizes 80 \200\223100units heparin IV in last 15min (max 50mg at rate <5mg/min); 1mg IV neutralizes 100units heparin SC (max 50mg at rat e <5mg/min) Indication heparin OD, bleeding in patient on heparin therapy Caution risk of a llergy increased post-vasectomy, or in infertile men, fi sh allergy SE GI disturbance, fl u shing, hypotension, dyspnoea Info Protamine can also be used to help reverse the eff ects o f LMWH but it is much less eff ective at this than for heparin BNF 2.8.3. Prozac selectiv e serotonin re-uptake inhibitor see fl uoxetine. Pulmicort corticosteroid see budesonide. _OHFP.indb 213 _OHFP.indb 213 30/05/2014 16:18 30/05/2014 16:18 214 CHAPTER 5 Pharmacopeia Quinine plant alkaloid Dose nocturnal leg cramps 200 \200\223300mg/24h (nocte) PO; treatmen t of malaria see BNF 5.4.1 Indication nocturnal leg cramps, treatment and prophylaxis of ma laria CI haemoglobinuria, myasthenia gravis, optic neuritis, tinnitus Caution pregnancy (te ra- togenic in 1st trimester), breastfeeding, hepatic or renal impairment, cardiac disease (AF, conduction defects, heart block), elderly, G6PD defi ciency SE cinchonism (tinnitus, h eadache, hot and fl ushed skin, nausea, abdominal pain, rashes, visual disturbances (includ ing temporary blindness), confusion), acute renal failure, photosensitivity BNF 5.4.1 and 1 0.2.2. Ramipril see ACEi. Ranitidine antihistamine (H2-antagonist) Dose 150mg/12h PO; IV preparati on available (see BNF) Indication peptic ulcers, GORD Caution pregnancy, breastfeeding, ren al impairment, acute porphyria, may mask symptoms of gastric cancer SE GI upset, confusion, fatigue BNF 1.3.1. Reteplase plasminogen activator see fi brinolytic. Rifampicin antibiotic Dose tuberculosis: consult BNF; meningitis prophylaxis: 600mg/12h PO for 2d; other serious infections: 600mg/12h IV (usually after microbiology advice) Indicati on tuberculosis, N. meningitidis/H. infl uenza meningitis prophylaxis, serious staphylococc al infections CI jaundice Caution pregnancy, hepatic or renal impairment, alcohol dependenc e, acute porphyria SE GI disturbance, headache, drowsiness, hepatotoxicity, turns body secr etions orange Interaction induces p450, decreases eff ects of warfarin BNF 5.1.9. Rosuvastatin HMG CoA reductase inhibitor see statin. (r)tPA plasminogen activator see fi brinolytic. Salbutamol B2 agonist Dose airways disease 100 \200\223200micrograms aerosol/200 \200\223400micrograms powder INH PRN (max 400 \200 \223800micrograms/24h in divided doses); 2.5 \200\2235mg/4h NEB; status asthmaticus 2.5 \200\2235mg/PRN NEB; 250micrograms/STAT (diluted to 50micrograms/ml) slow IV, followed by m aintenance infusion of 3 \200\22320micrograms/min (3 \200\22324ml/h of the 50micrograms/ml solution), titrated to heart-rate Indication asthma; chronic and acute, other reversible ai rway obstruction eg COPD, iK+ Caution cardiovascular disease, DM, hyperthyroidism SE fi ne tremor, nervous tension, head- ache, palpitation, muscle cramps BNF 3.1.1.1. Salmeterol lon g-acting B2 agonist Dose 50 \200\223100micrograms/12h INH Indication chronic asthma, revers ible airway obstruction Caution cardiovascular disease, DM, hyperthyroidism SE fi ne tremor , nervous tension, headache, palpitation, muscle cramps BNF 3.1.1.1. Sando-K potassium sa lt see potassium oral supplement. Senna see laxatives. chronic OHFP.indb 214 OHFP.indb 214 30/05/2014 16:18 30/05/2014 16:18 215 pharmacopeia Seretide long-acting B2 agonist with corticosteroid Dose 25 \200\22350micrograms salmeter ol with 50 \200\223500micrograms fl uticasone/12 \200\223 24h INH (depends upon inhaler dev ice, see BNF) Indication asthma (see b p273) Caution cardiovascular disease, DM, hyperthyro idism, TB SE fi ne tremor, nervous tension, headache, palpitation, muscle cramps, oral cand idiasis, hoarse voice, paradoxical bronchospasm (rare) Interaction see salmeterol and fl ut icasone BNF 3.2. Sertraline selective serotonin re-uptake inhibitors Dose 50mg/24h PO increased by 50mg incr ements at intervals of at least 1wk until desired eff ect (max 200mg/24h) Indication depres sion, OCD, panic disorder CI hepatic or renal impairment, active mania Caution pregnancy, e pilepsy, cardiac disease, DM SE GI disturbance, anorexia, weight loss Interaction MAOI with in 2wk, inhibits p450 enzymes BNF 4.3.3. Sevredol opioid see oral morphine. Simvastatin H MG CoA reductase inhibitor see statin. Slow-K potassium salt see potassium oral supplemen t. Sodium valproate antiepileptic see valproate. Sotalol see beta-blockers. Spironolactone potassium-sparing diuretic (aldosterone antagonist) Dose 100 \200\223200mg/2 4h PO (max 400mg/24h) Indication oedema/ascites in cirrhosis/malignancy, nephritic syndrome , con- gestive heart failure CI pregnancy, breastfeeding, hyperkalaemia, hyponatraemia, Add ison \200\231s disease Caution renal impairment, porphyria SE GI disturbance, impotence, gy naecomastia, menstrual irregularities Interaction increases digoxin and lithium levels; ris k of iK+ when used with ACEi or AT II receptor antagonists BNF 2.2.3.