189 pharmacopeia Betamethasone cream see topical corticosteroid. Beza \201 brate \201 brate Dose 200mg/8h PO; modifi ed release prepara- tions available, check BNF Indication hyperlipidaemias unre sponsive to diet and other measures CI hypoalbuminaemia, primary biliary cirrhosis, gall bl adder disease, nephrotic syndrome, pregnancy and breastfeeding Caution renal impairment (se e BNF for reduced dosing), hepatic impair- ment, hypothyroidism SE GI disturbance, anorexia , cholestasis BNF 2.12. Bisoprolol see beta-blockers. Bowel cleansing preparations laxative Dose consult BNF 1.6.5 or local guideline Indications prior to surgery, colonoscopy or radio- logical examination CI bowel obstruction, toxic me gacolon Caution elderly, children, dehydration SE N+V, abdominal pain and distension, dehyd ration, electrolyte disturbance Info these agents should not be used in the treatment of co nstipation (see also laxatives) BNF 1.6.5. Bricanyl B2 agonist see terbutaline. Buccastem see antiemetics (phenothiazine). Budesonide corticosteroid Dose 100 \200\223800microgram s/12h INH; 1 \200\2232mg/12h NEB Indication chronic asthma (step 2 BTS guidelines) Caution TB SE oral candidiasis, hoarse voice, paradoxical bronchos- pasm (rare) BNF 3.2. Bupropion (Zyban ) treatment of nicotine dependence Dose commence 1 \200\2232 wk before target smoki ng cessation date, ini- tially 150mg/24h PO for 6d, then 150mg/12h PO (max single dose 150m g; max total daily dose 300mg) Indication smoking cessation CI acute alcohol or benzodiazep ine withdrawal, severe hepatic cirrhosis, CNS tumor, history of seizures Caution hepatic im pairment, renal impairment, pregnancy and breastfeeding SE dry mouth, GI disturbances, tast e distur- bance, agitation, anxiety BNF 4.10.2. Buscopan antimuscarinic see hyoscine buty lbromide. Calcichew /Calcichew D3 calcium salt see calcium carbonate. Calcium carbonate calcium salt Dose see BNF Indication osteoporosis, dCa2+ CI iCa2+ (urine/serum) eg malignan cy Caution history of renal stones, sarcoid, renal impairment SE GI disturbance, dHR, arrhy thmias BNF 9.5.1. _OHFP.indb 189 _OHFP.indb 189 30/05/2014 16:18 30/05/2014 16:18 190 CHAPTER 5 Pharmacopeia Calcium-channel blockers dihydropyridines Dose see Table 5.9 Indications iBP, prophylaxis o f angina CI unstable angina, cardiogenic shock, signifi cant aortic stenosis, acute porphyr ia Caution pregnancy, breastfeeding, heart failure SE abdominal pain, N+V, fl ushing, palpi tations, dBP, oedema, headache, sleep disturbance, fatigue Info the dihydropyridines relax smooth muscle and dilate both coronary and peripheral arteries. Nimodipine prefer- entially acts upon cerebral vascular smooth muscle and is used in the preven- tion and treatment of ischaemic neurological defi cits following aneurysmal subarachnoid hemorrhage BNF 2.6.2. Table 5.9 Calcium-channel blockers (dihydropyridines) BNF 2.6.2 Amlodipine Dose initially 5mg/24h PO up to max 10mg/24h PO Felodipine Dose initially 5mg/24 h PO up to max 10 \200\22320mg/24h PO Nifedipine Dose depends upon preparation. Always spec ify specifi c brand for modifi ed release (MR) preparations; consult BNF 2.6.2 Nimodipine Dose 60mg/4h PO starting within 4d of subarachnoid hemorrhage and continue for 21d; IV preparation available, consult BNF 2.6.2 Calcium-channel blockers verapamil, diltiazem Dose see Table 5.10 Indications iBP, prophyla xis of angina; verapamil is also used in the management of tachyarrhythmias CI left ventric ular failure, brady- cardia, 2nd- or 3rd-degree AV dissociation, sick sinus syndrome Cautio n pregnancy, patients taking B-blockers or other negatively chronotropic drugs, 1st-degree AV dissociation, acute phase of MI SE bradycardia, dBP, heart block, dizziness, fl ushing, headache, oedema, GI disturbance Interactions unlike the dihydropyridines diltiazem and ver apamil are negatively chronotropic and inotropic and should not generally be used in conjun ction with B-blockers or other negatively chronotropic drugs BNF 2.6.2. Table 5.10 Calcium-channel blockers (verapamil, diltiazem) BNF 2.6.2 Diltiazem Dose depends upon preparation; consult. Always specify specifi c brand for modifi ed release (MR) preparations; consult BNF 2.6.2 Verapamil Dose typically 40 \200\223120mg/8h PO for SVT; 80 \200\223120mg/8h PO for angina prophylaxis; 80 \200\223160mg/8h PO for iBP; 5 \200\22310mg over 5min IV with EC G monitoring for treatment of acute SVT (seek senior help before giving IV inotropes/chrono tropes) Calcium chloride calcium salt Dose 10ml of 10%; give 1ml/min IV Indication Emergency manage ment of dCa2+ CI iCa2+ Caution history of renal stones, sarcoid, renal impairment SE periph eral vasodilatation, dBP, injection-site reactions; more irritant than calcium gluconate BN F 9.5.1. Calcium gluconate calcium salt Dose 10ml of 10%; give over 3min IV Indication Emergency man agement of dCa2+, iK+ CI iCa2+ Caution history of renal stones, sarcoid, renal impairment S E periph- eral vasodilatation, dBP, injection-site reactions BNF 9.5.1. OHFP.indb 190 OHFP.indb 190 30/05/2014 16:18 30/05/2014 16:18 191 pharmacopeia Calcium Resonium calcium salt Dose 15g/6-8h PO; PR prepa- rations also available (see BNF ) Indication iK+ (mild to moderate) Caution pregnancy, breastfeeding SE GI disturbance Info monitor K+ BNF 9.2.1.1. Calpol simple analgesic see paracetamol. Candesartan see AT II a ntagonists. Canesten imidazole anti-fungal see clotrimazole. Captopril see ACEi. Carbamazepine antiepileptic Dose Initially: 100mg/12h PO; Increase to max 2g/24h in divided doses; PR preparations available (see BNF) Indication anti-epileptic; generalized tonic-cl onic, chronic pain, eg trigeminal neuralgia (see BNF for dosing) CI AV conduction abnormali ties, history of bone marrow depression, acute porphyria Caution pregnancy, breastfeeding, cardiac disease, Hong Kong Chinese/Thai origin, history of skin conditions SE N+V, dizzines s, drowsiness, headache, ataxia, visual disturbance, cytopenias, hepatic dysfunction, skin disorders Interaction enzyme inducer BNF 4.8.1. random sample 20 \200\22350micromol/l (4 \200\22312mg/l); toxic >50micromol/l (>12mg/l) Monitoring carbamazepine Carbimazole antithyroid Dose Initially: 15 \200\22340mg/24h PO; Once euthyroid: 5 \200\2231 5mg/24h PO as maintenance dose usually given for 12 \200\22318mth Indication hyperthyroidis m CI severe blood disorders Caution pregnancy, breastfeeding, hepatic impairment SE N+V, pr uritus, rash, agranulocytosis BNF 6.2.2. Carvedilol see beta-blockers. Cefaclor see cephalosporin. Cefalexin see cephalosporin. Cefo taxime see cephalosporin. Cefradine see cephalosporin. Ceftazidime see cephalosporin. Ceftr iaxone see cephalosporin. Cefuroxime see cephalosporin. Celecoxib (Celebrex ) NSAID/COX2 i nhibitor Dose 100 \200\223 200mg/12h PO (max 400mg/24h in divided doses) Indication pain an d infl ammation; osteoarthritis, rheumatoid arthritis and ankylosing spondylitis CI IHD, CV D, HF, allergy to any NSAID Caution pregnancy, breastfeeding, hepatic impairment, renal imp airment SE GI disturbance/ bleeding, headache, dizziness Interaction decreases eff ects of antihy- pertensives, increases toxicity of methotrexate, increased risk of renal impairment with ACEi, AT II antagonists or ciclosporin BNF 10.1.1. _OHFP.indb 191 _OHFP.indb 191 30/05/2014 16:18 30/05/2014 16:18 192 CHAPTER 5 Pharmacopeia Cephalosporin Dose see Table 5.11 Indications infections [with known or suspected antimicro bial sensitivity (consult local guidelines)], surgical prophylaxis, other prophylaxis Cauti on not known to be harmful in pregnancy, present in breast-milk in low concentration; 0.5 \200\2236.5% of patients who are penicillin-allergic will display allergy to cephalosporins as cephalosporins contain a beta-lactam ring as do the penicillins and carbap- enems SE di arrhea (rarely antibiotic-associated colitis), N+V, abdominal discomfort, headache, allergi c reactions Info cephalosporins are amongst the antibiotics which are most likely to result in Clostridium diffi cile diar- rhoea, the others being quinolones and clindamycin. As wit h all antibiotics, it is important to consult local guidelines as infectious agents have di ff ering susceptibility depending upon geographical location BNF 5.1.2.1. Table 5.11 Cephalosporins BNF 5.1.2.1 (consult local guidelines) First generation Dose 500mg (250 \200\223500mg) 8h PO Indications UTIs, respiratory tract infections, otitis media, sinusitis, skin and soft tissue infections Dose; 500mg (250 \200\223500mg) 6h PO In dications surgical prophylaxis but generally not used widely now Cefalexin Cefradine Second generation Cefuroxime Dose 750mg (750 \200\2231500mg) 8h IV, 500mg (250 \200\223500mg) 12h PO; Indications Gram-p ositive and Gram-negative bacteria; surgical prophylaxis Third generation Dose 1g (1 \200\2232g) 12h IV Indications better Gram-negative activity, but poorer coverag e against Gram-positive bacteria than cefuroxime; penetrates the CSF Dose 1g (1 \200\2234g) 24h IV Indications better Gram-negative activity, but poorer coverage against Gram-positiv e bacteria than cefuroxime; penetrates the CSF Dose 1g (1-2g) 8h IV or 2g/12h IV; Indicatio ns better Gram-negative activity, but poorer coverage against Gram- positive bacteria than cefuroxime; good activity against Pseudomonas Cefotaxime Ceftriaxone Ceftazidime Cetirizine H1-antagonist see antihistamine. Chloramphenicol; eye drops antibiotic Dose 1 dr op 0.5%/2h TOP; reduce frequency as infection is controlled. Continue for 48h after symptom s resolve Indication conjunctivitis, corneal abrasions, post eye surgery SE transient sting ing BNF 11.3.1. OHFP.indb 192 OHFP.indb 192 30/05/2014 16:18 30/05/2014 16:18 193 pharmacopeia Chlordiazepoxide benzodiazepine Dose see Table 5.12 Indications acute alcohol withdrawal tr eatment/prophylaxis Caution pregnancy, breastfeeding, liver disease, renal impairment, resp iratory disease (sleep apnoea, respiratory failure), reduce dose in the elderly, avoid abru pt with- drawal SE respiratory depression, drowsiness, confusion, ataxia, amnesia, dependen ce Info symptoms of acute alcohol withdrawal tend to occur 12 \200\22348h after the last al coholic drink and usually subside 5 \200\2237d after the last drink. A reducing dose of chl ordiazepoxide acts as a surrogate CNS depres- sant (which is the eff ect alcohol has upon t he CNS) and it is uncommon for physical symptoms of withdrawal to present if patients are t reated with this sort of regimen; always consider vitamin supplementation in these patients (b p103); consult local guidelines BNF 4.1.2. Table 5.12 Chlordiazepoxide regimen for alcohol withdrawal Day 1 Day 2 Day 3 Day 4 20mg/6h PO 20mg/8h PO 10mg/6h PO 10mg/8h PO Day 5 Day 6 Day 7 Day 8 5mg/6h PO 5mg/8h PO 5mg/12h PO STOP Local guidelines may diff er from this suggested regimen Chlorhexidine antiseptic Indication skin preparation prior to surgery or other invasive pro cedures (eg vascular access, spinal/epidural anesthesia), surgical hand scrub, oral hygiene , antiseptic lubricant (eg Hibitane ) CI avoid contact with eyes, brain, meninges, middle ear and other body cavities SE sensitivity, mucosal irritation BNF 13.11.2/12.3.3. Chlorphe namine (H1-antagonist) see antihistamine. Cimetidine antihistamine (H2-antagonist) see rani tidine. Cipro \202 oxacin quinolone Dose 500 \200\223750mg/12h PO; 400mg/12h IV Indication infections: GI, respiratory, urinary CI pregnancy, breast- feeding, allergy to quinolones Caution myasthenia gravis, seizures (reduced seizure threshold), adolescents/children, rena l impairment SE N+V, diarrhea, tendonitis (including tendon rupture) Interaction NSAIDs inc rease risk of seizure, increase levels of theophyllines, increase nephrotoxicity of ciclosp orin, increase eff ect of warfarin BNF 5.1.12. Citalopram selective serotonin re-uptake inh ibitor Dose 20mg/24h PO (max 40mg/24h) Indication depression, panic disorder CI active mani a, QT interval prolongation Caution pregnancy, epilepsy, cardiac disease, DM SE GI disturba nce, anorexia, weight loss, dNa+, agitation Interaction MAOI within 2wk BNF 4.3.3. Clarithr omycin macrolide antibiotic Dose 250 \200\223500mg/12h PO/IV Indication atypical pneumonias , H. pylori CI allergy Caution pregnancy, breastfeeding, hepatic or renal impairment, conco mitant use with statins SE GI upset, irritant to veins BNF 5.1.5. _OHFP.indb 193 _OHFP.indb 193 30/05/2014 16:18 30/05/2014 16:18 194 CHAPTER 5 Pharmacopeia Clindamycin antibiotic Dose 150 \200\223450mg/6h PO; up to 4.8g/24h IV in 2 \200\2234 doses for life-threatening infections (consult BNF) Indication Gram-positive cocci and anaerobes ; osteomyelitis, intra-abdominal infec- tions, MRSA CI diarrhea Caution breastfeeding, acut e porphyria SE GI disturbance, antibiotic-associated colitis (namely C. diff ), hepatotox- icity, arthralgia; discontinue drug if patient develops new onset diarrhea Interaction incr eases neuromuscular blockade BNF 5.1.6. Clobetasol propionate cream see topical corticoster oids. Clopidogrel antiplatelet Dose Loading: 300mg/STAT PO. Maintenance: 75mg/24h PO Indica tion prevention of atherothrom- botic events following MI/ACS/CVA CI pregnancy, breastfeedi ng, active bleeding Caution hepatic impairment, increased risk of bleeding, recent trauma/s urgery SE GI disturbance, bleeding disorders Interaction increased risk of bleeding with NS AIDs and anticoagulants; proton pump inhibitors may reduce eff ectiveness of clopidogrel BN F 2.9. Clotrimazole imidazole anti-fungal Dose 1% cream 2 \200\2233 applications/24h Indica tion fungal skin infections, vaginal candidiasis Caution avoid contact with eyes and mucous membranes, can damage condoms and diaphragms SE local irritation BNF 13.10.2. Co-amoxiclav beta-lactam with clavulanic acid Dose 375 \200\223 625mg/8h PO; 1.2g/8h IV Indication infe ction; where amoxicillin alone is not appropriate CI penicillin allergy Caution renal impai rment, glandular fever, CMV infection, ALL/CLL SE N+V, diarrhea, rash BNF 5.1.1.3. Co-benel dopa levodopa and dopa-decarboxylase inhibitor (benserazide) Dose initially 50mg/6-8h PO, i ncreased to 100mg/24h or 100mg/twice a week according to response; usual maintenance dose 4 00-800mg/day in divided doses Indication Parkinson s disease Caution severe pulmonary or ca rdiovascular disease, psychiatric illness, endocrine disorders, pregnancy and breastfeeding SE GI disturbances, taste disturbances, dry mouth, anorexia, arrhythmias and palpitations, pos- tural hypotension, drowsiness, dystonia, dyskinesia BNF 4.9.1. Co-careldopa levodopa and dopa-decarboxylase inhib- itor (carbidopa) Dose depends upon preparation, consult BNF I ndication Parkinson s disease Caution severe pulmonary or cardiovas- cular disease, psychia tric illness, endocrine disorders, pregnancy and breast- feeding SE GI disturbances, taste disturbances, dry mouth, anorexia, arrhythmias and palpitations, postural hypotension, drow siness, dys- tonia, dyskinesia BNF 4.9.1. Co-codamol weak opioids with paracetamol Dose 8/500mg two tablets/4 \200\2236h PO (max eigh t tablets/24h in divided doses); 30/500mg two tablets/4 \200\2236h PO (max eight tablets/24 h in divided doses) Indication pain CI acute respiratory depression, paralytic ileus; codei ne containing medicines should not be used in children under 12yr, or in any patient under the age of 18yr who undergoes removal of tonsils or adenoids for the treatment of sleep apn oea Caution pregnancy (especially delivery), COPD, asthma, renal impairment, hepatic impair ment SE N+V, constipa- tion Info co-prescribe laxatives if using opioids for >24h BNF 4.7.1 . OHFP.indb 194 OHFP.indb 194 30/05/2014 16:18 30/05/2014 16:18 195 pharmacopeia Codeine phosphate weak opioid Dose 30 \200\22360mg/4h PO/IM (max 240mg/24h in divided doses ) Indication pain CI acute respira- tory depression, paralytic ileus; codeine containing me dicines should not be used in children under 12yr, or in any patient under the age of 18yr who undergoes removal of tonsils or adenoids for the treatment of sleep apnoea Caution preg nancy (especially delivery), COPD, asthma, renal impairment, hepatic impairment; never give codeine phosphate IV SE N+V, constipation Info co-prescribe laxatives if using opioids for >24h BNF 4.7.2. Combivent antimuscarinic with \2372 agonist Dose 500micro- grams ipratr opium bromide with 2.5mg salbutamol/PRN NEB Indication asthma and other reversible airway o bstruction, COPD Caution prostatic hyperplasia, glaucoma SE antimuscarinic eff ects (common ly dry mouth), fi ne tremor, tension headaches, arrhythmias BNF 3.1.4. Corsodyl antisepti c see chlorhexidine. Cyclizine antihistamine (H1 antagonist) see antiemetics. Dalteparin lo w-molecular-weight heparin Dose consult BNF Indication DVT/PE treatment and prophylaxis, AC S CI bleeding disor- ders, thrombocytopenia, severe hypertension, recent trauma Caution hyp erkalaemia, hepatic or renal impairment SE hemorrhage, thrombo- cytopenia, hyperkalaemia In teraction NSAIDs increase bleeding risk, eff ects increased by GTN BNF 2.8.1. Desloratadine antihistamine (H1 antagonist) see antihistamines. Dexamethasone corticosteroid Dose see BN F Indication cer- ebral oedema (malignancy), suppression of infl ammation/allergic dis- ord ers, diagnosis of Cushing \200\231s disease, chemotherapy induced N+V CI systemic infection Caution adrenal suppression, may precipitate tumor lysis syndrome in patients with some he matological malignancies SE Cushing \200\231s syndrome, DM, osteoporosis, psychiatric react ions, raised WCC (specifi cally neutrophilia) BNF 6.3.2. Diamorphine opioid Dose 2.5 \200\2235mg/4h SC/IM/IV Indication severe pain, ACS/acute MI, a cute pulmonary oedema, palliative care CI respiratory depression, paralytic ileus, raised I CP/head trauma, comatose patients, phaeochromocytoma Caution pregnancy (espe- cially delive ry), COPD, asthma, renal impairment, hepatic impairment SE N+V, constipation, respiratory d epression, dry mouth Interaction MAOI Info co-prescribe laxatives if using opioids for >24h BNF 4.7.2. Diazepam benzodiazepine Dose status epilepticus: 5 \200\22310mg over 10min IV (max 20mg) or 10 \200\22340mg PR; other short-term usage: 2mg/8h PO (max 30mg/24h in divided doses) Indi cation seizures, status epi- lepticus; short term: anxiety, alcohol withdrawal, muscle spas ms CI res- piratory depression, sleep apnoea, unstable myasthenia gravis, hepatic impairmen t Caution pregnancy, breastfeeding, history of drug abuse, respiratory disease, muscle weak ness, renal impairment SE drowsiness, confusion, muscle weakness BNF 4.1.2/4.8.2. _OHFP.indb 195 _OHFP.indb 195 30/05/2014 16:18 30/05/2014 16:18 196 CHAPTER 5 Pharmacopeia Diclofenac NSAID Dose 50mg/8h PO/PR (max 150mg/24h in divided doses) Indication pain, infl ammation CI pregnancy, peptic ulcer disease, hepatic impairment, congestive heart failure, ischaemic heart disease, peripheral arterial disease, cerebrovascular disease Caution breas tfeeding, renal impairment, asthma, GI disease, patients with signifi - cant risk factors f or cardiovascular events (eg iBP, ilipids, DM, smoking) SE GI disturbance/bleeding, headach e, dizziness Info Arthrotec is a preparation of diclofenac with misoprostol and may reduc e GI side eff ects BNF 10.1.1. Digoxin cardiac glycoside Emergency IV loading dose 0.75 \200\2231mg over at least 2h IV Ra pid oral loading dose 0.75 \200\2231.5mg over 24h in 3 divided doses PO (typically 500micro grams PO initially, followed by 250micrograms PO 6h later, and further 250micrograms PO 12h later if still tachycardic Maintenance dose 62.5 \200\223125micrograms/24h PO Indications often 2nd-line agent in supraventricular tachyarrhythmias (commonly AF and atrial fl utter) , heart failure CI 2nd- or 3rd-degree AV dissociation, accessory conducting pathways (eg WP W) Caution pregnancy, recent MI, sick sinus syndrome, renal impairment, elderly patients, d K+, dMg2+ or iCa2+ SE N+V, diarrhea, bradyarrhythmias, tachyarrhythmias, dizziness, blurred or yellow vision Therapeutic monitoring (see Table 5.13) should be under- taken if toxicit y is considered (usually presents with N+V) or if rate control is poor Info digoxin is now rarely used for rapid rate control, with other agents often being used in preference (b p25 0) or DC cardioversion (b p532). Digoxin is most often used in the chronic rate control of supraven- tricular tachyarrhythmias and in heart failure. Digoxin does not restore sinus rh ythm, it merely slows conduction at the atrio-ventricular node, limiting the number of impu lses passing from the atria through to the ventricles thus controlling ventricular rate. It also acts as a positive inotrope, increasing the force of ventricular contraction If rate not adequately controlled after loading with digoxin, discuss with senior or cardiologist B NF 2.1.1. Optimum sampling time 6 \200\22312h post oral dose 1 \200\2232.6nmol/l (0.8 \200\2232microg /l); typically takes 7d to get to steady state toxic >2.6nmol/l (>2microg/l). Toxicity can occur at levels <1.3nmol/l if patient has dK+ signs of toxicity (see Table 5.13 and OHAM3 b p708) Monitoring digoxin Table 5.13 Digoxin toxicity Symptoms Bloods N+V, confusion, diarrhea, yellow and blurred vision Toxicity precipitated by renal failure, dK+, dMg2+ and dT4 Check digoxin level (b see box); toxic if >2.6nmol/l (>2microg/l) Tachy - and bradyarrhythmias. ST depression/T-wave inversion ECG Complications iK+, cardiac dysrhythmias (tachy- and bradyarrhythmias) Management Airway, breathing, and circulation Continuous ECG monitoring Treat arrhythmias Consider dig oxin-binding antibody fragments (DigiFab , BNF 2.1.1) if known or suspected digoxin overdo se OHFP.indb 196 OHFP.indb 196 30/05/2014 16:18 30/05/2014 16:18 197 pharmacopeia Dihydrocodeine weak opioid Dose 30mg/4 \200\2236h PO (max 240mg/24h in divided doses); 50mg /4 \200\2236h IM Indication pain CI acute respiratory depression, paralytic ileus Caution p regnancy (especially delivery), COPD, asthma, renal impairment, hepatic impairment; never g ive dihydrocodeine IV SE N+V, constipation Info co-prescribe laxatives if using opioids for >24h BNF 4.7.2. Diltiazem see calcium-channel blockers. Dipyridamole antiplatelet Dose 200mg modifi ed release/12h PO (max 600mg/24h in divided dos es), non-modifi ed release preparations also available (see BNF) Indication secondary preve ntion of ischaemic stroke and TIA, adjunct to oral anticoagulation for prophylaxis of throm boembo- lism associated with prosthetic heart valves Caution breastfeeding, aortic stenosis , unstable angina, recent MI SE GI disturbance, dizziness, headache, myalgia Interaction in creases eff ect of warfarin, decreases eff ect of cho- linesterase inhibitors BNF 2.9. Docu sate sodium see laxatives. Doxazosin A1 antagonist Dose 1mg/24h PO; increase gradually to 2 \200\2234mg/24h (max 16mg/24h) Indication benign prostatic hyperplasia, hypertension CI br eastfeeding, hypotension Caution pregnancy, hepatic impairment SE postural hypotension, hea dache, dizziness, urinary incon- tinence Interaction increases eff ects of antihypertensive s BNF 2.5.4. Doxycycline tetracycline Dose 100 \200\223200mg 12 \200\22324h PO (consult BNF ) Indication respiratory tract infections, GU infections, anthrax, malaria prophylaxis CI p regnancy, breastfeeding, renal impairment, age <12yr (stains growing teeth and bones) Cauti on myasthenia gravis may worsen, exacerbates SLE SE GI disturbance including, dysphagia/ oe sophageal irritation, photosensitivity Interaction decreased absorp- tion with milk, decrea ses eff ects of oral contraceptive pill, mildly increases eff ects of warfarin BNF 5.1.3. E nalapril see ACEi. Enoxaparin low-molecular-weight heparin Dose DVT/PE proph- ylaxis: 20 \200\22340mg/24h SC (see b p407); DVT/PE treatment: 1.5mg/kg/24h SC; ACS treatment: 1mg/kg/ 12h Indication DVT/PE treatment and prophylaxis, ACS CI bleeding disorders, thrombocytopeni a, severe hyper- tension, recent trauma Caution hyperkalaemia, hepatic or renal impair- men t SE hemorrhage, thrombocytopenia, hyperkalaemia Interaction NSAIDs increase bleeding risk, eff ects increased by GTN BNF 2.8.1. Epilim antiepileptic see valproate. Erythromycin ma crolide antibiotic Dose 500 \200\2231000mg/6h PO; 50mg/kg/24h IV in divided dose (typically 500 \200\2231000mg/6h IV) Indication infection; atypical pneumonias. Commonly used in pati ents allergic to penicillins CI allergy Caution pregnancy, breastfeeding, hepatic or renal impairment, concomitant use with statins SE GI upset, irritant to veins BNF 5.1.5. _OHFP.indb 197 _OHFP.indb 197 30/05/2014 16:18 30/05/2014 16:18 198 CHAPTER 5 Pharmacopeia Esomeprazole proton pump inhibitor Dose 20 \200\22340mg/24h PO Indication PUD, GORD, H. pyl ori eradication CI breastfeeding Caution pregnancy, hepatic impairment, gastric cancer SE G I disturbance, head- ache Interaction proton pump inhibitors may reduce eff ectiveness of c lopidogrel BNF 1.3.5. Felodipine see calcium-channel blockers. Ferrous fumarate iron supple ment Dose consult BNF as depends upon formulation Indication iron defi ciency anemia SE GI disturbance, dark stools BNF 9.1.1.1. Ferrous gluconate iron supplement Dose 600mg/8h PO (s ee BNF) Indication iron defi ciency anemia SE GI disturbance, dark stools BNF 9.1.1.1. Ferr ous sulfate iron supplement Dose 200mg/8h PO Indication iron defi ciency anemia SE GI distu rbance, dark stools BNF 9.1.1.1. Fibrinolytic drugs plasminogen activator Dose & Indication s depends upon specifi c agent, see Table 5.14 (see also b p536) CI recent hemorrhage, trau ma or surgery, coagulopathies, aortic dissection, aneurysm, coma, history of cerebrovasular disease, peptic ulceration, menorrhagia, hepatic impairment; streptokinase should not be u sed again beyond 4d of fi rst administration due to antibody formation and risk of allergic reactions Caution pregnancy, following external chest compression, old age, hypertension S E N+V, bleeding, hypotension BNF 2.10.2. Table 5.14 Fibrinolytic drugs BNF 2.10.2 In acute STEMI, fi brinolytic drugs should be used where primary cutaneous intervention (PCI) is not immediately available Indications acute MI, massive PE, acute ischaemic stroke Dose consult BNF; given as an IV b olus followed by an IV infusion, followed by heparin infusion Indications acute MI Dose con sult BNF; given as two IV boluses 30min apart, followed by heparin infusion Alteplase Reteplase Streptokinase Indications acute MI, DVT, PE, acute arterial thromboembolism, central retinal venous or arterial thrombosis Dose consult BNF; typically 1.5million units in 100ml 0.9% saline over 1h IV. Do not repeat administration after 4d of initial dose due to risk of allergic reaction Indications acute MI Dose consult BNF; given as an IV bolus, followed by heparin infusion Indications thromboembolic occlusive vascular disease; DVT, PE and peripheral vascular occlusion; occluded intravenous catheters and cann ulae blocked by fi brin clot Dose consult BNF Tenecteplase Urokinase OHFP.indb 198 OHFP.indb 198 30/05/2014 16:18 30/05/2014 16:18 199 pharmacopeia Finasteride antiandrogen Dose BPH: 5mg/24h PO; male-pattern baldness: 1mg/24h PO Indication BPH, male-pattern baldness CI females and adolescents Caution prostate cancer, urinary tra ct obstruction SE gynaecomastia, testicular pain, sexual dysfunction BNF 6.4.2/13.9. Flagyl antibiotic see metronidazole. Flecainide class Ic antiarrhythmic Dose initially: 100mg/1 2h PO; reduce to lowest eff ective dose over 3 \200\2235d; 2mg/kg over 10 \200\22330min slo w IV (max 150mg) Indication VT, SVT CI HF, history of MI, heart block, bundle branch block Caution patients with pacemakers, AF SE GI disturbance, dizziness, oedema, fatigue Interact ion duration of action increased by amiodarone, fl uoxetine, quinine; myocardial depres- si on with B-blockers/verapamil BNF 2.3.2. Flixotide corticosteroid see fl uticasone. Fluclo xacillin beta-lactam Dose 250 \200\223500mg/6h PO; 250 \200\2232000mg/6h IV Indication peni cillin sensitive infections, endocarditis, osteomyelitis CI history of fl ucloxacillin-rela ted jaundice, penicillin allergy SE diarrhea, abdominal pain Caution renal impairment Inter action decrease eff ects of oral contraceptive pill, allopurinol increases risk of rash BNF 5.1.1.2. Fluconazole triazole antifungal Dose 50 \200\223400mg/24h PO/IV dependent on indi cation Indication fungal meningitis, candidiasis, fungal prophylaxis CI pregnancy, acute po rphyria Caution breastfeeding, hepatic or renal impairment SE GI disturbance BNF 5.2. Fludr ocortisone mineralocorticoid Dose 50 \200\223300micrograms/24h PO Indication Addison \200 \231s disease, other adrenal insuffi ciency, postural hypotension CI systemic infection wit hout antibiotic cover Caution adrenal suppression SE sodium and water retention, hypertensi on BNF 6.3.1. Flumazenil benzodiazepine antagonist Dose 200micrograms/ STAT IV, followed by 100micrograms/1min if required (max 1mg) Indication benzodiazepine OD/toxicity CI conditio ns dependent on benzodiazepines, eg status epilepticus Caution benzodiazepine depend- ence, mixed OD SE N+V, dizziness, arrhythmias BNF 15.1.7. Fluoxetine selective serotonin re-upta ke inhibitor Dose 20mg/24h PO (max 60mg/24h) Indication depression, bulimia nervosa and OCD CI active mania Caution pregnancy, epilepsy, cardiac disease, DM, bleeding disorders, glau coma SE GI disturbance, anorexia, weight loss, dNa+, agitation Interaction MAOI within 2wk BNF 4.3.3. Fluticasone corticosteroid Dose 100 \200\223500micrograms/12h INH (consult BNF) Indication chronic asthma (step 2 BTS guidelines) Caution TB SE oral candidiasis, hoarse vo ice, paradoxical bronchos- pasm (rare) BNF 3.2. Folic acid vitamin B9 Dose 400micrograms/24 h PO before con- ception and until week 12 of pregnancy; 5mg/wk for preventing metho- trexa te side eff ects Indication pregnancy, folate defi cient megaloblastic anemia, long-term me thotrexate CI malignancy Caution never give alone for pernicious anemia; can cause degenera tion of spinal cord, undiagnosed megaloblastic anemia SE GI disturbance BNF 9.1.2. _OHFP.indb 199 _OHFP.indb 199 30/05/2014 16:18 30/05/2014 16:18 200 CHAPTER 5 Pharmacopeia Fondaparinux factor Xa inhibitor Dose 2.5mg/24h SC (2.5mg loading dose 6h post-op) Indicati on VTE prophylaxis and treatment, ACS CI active bleeding, bacterial endocarditis Caution pr egnancy, breastfeeding, bleeding disorders, active PUD, recent surgery, epidural/ spinal an esthesia, hepatic or renal impairment SE bleeding, purpura, anemia, thrombocytopenia BNF 2. 8.1. Frusemide loop diuretic see furosemide. Furosemide loop diuretic Dose typically 20 \200\22380mg/24h PO/IV Indication oedema (LVF, pulmonary oedema), resistant hypertension CI severe dK+ and dNa+, hypovolaemia, renal impairment Caution hypotension SE GI disturbance, hypotension, electrolyte disturbances (dK+, dNa+, dMg2+) Interaction increases toxicity of gentamicin, digoxin, NSAIDs Info IV doses >80mg should be infused at <4mg/min (risk of dea fness) BNF 2.2.2. Fusidic acid antibiotic Dose 2% topical cream 3 \200\2234 applications/24 h; oral and IV preparations available (see BNF) Indication staphylococcal skin infections; IV treatment osteomyelitis, penicillin-resistant staphylo- coccal infections Caution pregna ncy, breastfeeding, monitor LFTs SE GI disturbance, reversible jaundice BNF 5.1.7/13.10.1.2 . Fybogel see laxatives. Gabapentin antiepileptic Dose day 1: 300mg/24h PO; continued: in crease by 300mg/24h PO up to max 3.6g/24h in 3 divided doses Indication epilepsy, neuropath ic pain Caution pregnancy, breast- feeding, renal impairment, DM, avoid abrupt withdrawal S E GI distur- bance, headache, sleep disturbance Interaction eff ects decreased by antidepre ssants BNF 4.8.1. Gentamicin aminoglycoside Dose Once daily: 5 \200\2237mg/kg/24h IV adjust to serum concentr ation; other dosing regimens may be used (consult local guidelines) Indication infection; s epsis, meningitis, endo- carditis CI myasthenia gravis Caution pregnancy, breastfeeding, re nal impairment SE ototoxic, nephrotoxic Interaction eff ects increased by loop diuretics, i ncreases eff ects of warfarin BNF 5.1.4. 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)