British National Formulary
Welcome to BNF 56. We have highlighted below some of the key changes you will find in this edition.
Guidance on the use of lipid-regulating drugs to reduce cardiovascular risk has been updated in BNF 56 (section 2.12) to take account of the recommendations of the NICE guideline: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (May 2008). This guideline describes different approaches depending on whether the patient is being treated for primary or secondary prevention of cardiovascular events; a statin remains the drug of first choice in both situations. In secondary prevention of cardiovascular events only, doses of lipid-regulating drugs may be adjusted if a total cholesterol concentration of less than 4 mmol/litre or a LDL-cholesterol concentration of less than 2 mmol/litre are not reached with initial treatment.
Guidance on the management of atrial fibrillation (section 2.3.1) has been updated for BNF 56. Information is now included on control of ventricular rate with a beta-blocker, diltiazem, verapamil, or digoxin, and on restoration of sinus rhythm, either by electrical cardioversion or pharmacological cardioversion with an intravenous anti-arrhythmic. Treatment of patients with symptomatic paroxysmal or acute-onset atrial fibrillation is also discussed, as well as the importance of assessing all patients for risk of stroke and the need for thromboprophylaxis.
BNF 56 continues to provide guidance on the correct application of topical corticosteroids (section 13.4). Pharmacists should reinforce this advice when counselling patients. If a patient is using topical corticosteroids of different potencies, the patient should be told when to use each corticosteroid. The potency of each topical corticosteroid should be included on the dispensary label together with the directions for use.
From September 2008 routine immunisation with human papilloma virus vaccine will be offered to all 12–13 year old girls to protect them against the two human papilloma virus strains—types 16 and 18—which cause over 70% of cervical cancers. The Immunisation Schedule in BNF 56 (section 14.1) has been updated to reflect this. Details of ‘catch-up’ programmes for the HPV vaccine in England, Wales, Scotland, and Northern Ireland are also included (section 14.4).
In light of further evidence regarding the safety of erythropoietins for the treatment of anaemia associated with cancer (MHRA, Drug Safety Update 2008; 1(12): 10 and 2(1): 3–4), updated prescribing guidance has been included for erythropoietins. Clinical trial data show an unexplained excess mortality and increased risk of tumour progression in patients with anaemia associated with cancer who have been treated with erythropoietins. Many of these trials used erythropoietins outside of the licensed indications (i.e. haemoglobin concentrations were overcorrected or erythropoietins were given to patients who had not received chemotherapy). BNF 56 (section 9.1.3) advises that the decision to use erythropoietins should be based on an assessment of the benefits and risks for individual patients and that blood transfusion may be the preferred treatment for anaemia associated with cancer chemotherapy, particularly in those with a good cancer prognosis.
Evidence suggests that the rate of cross-sensitivity between penicillins and cephalosporins is closer to 0.5–6.5% than the widely quoted rate of 10% (BMJ 2007; 335: 991). BNF 56 advises that patients with a history of immediate hypersensitivity to penicillin should not receive a cephalosporin (section 5.1.2). If a cephalosporin is essential in these patients because a suitable alternative antibacterial is not available, then cefixime, cefotaxime, ceftazidine, ceftriaxone, or cefuroxime can be used with caution; cefaclor, cefadroxil, cefalexin, and cefradine should be avoided. Cephalosporins can be used in patients with a history of a minor rash or a rash that occurs more than 72 hours after penicillin administration (section 5.1.1).
Antiepileptic drugs have been associated with a small increased risk of suicidal thoughts and behaviour; this can occur as early as one week after starting treatment (Drug Safety Update 2008; 2(1): 2). BNF 56 (section 4.8.1) reflects these safety concerns and recommends that patients should seek medical advice if they develop mood changes or suicidal thoughts.
The Management of Acute Asthma table (section 3.1) has been reviewed and updated in the light of the latest BTS/SIGN British Guideline on the Management of Asthma (May 2008; www.brit-thoracic.org.uk). The table continues to include features to assess the severity of each exacerbation, and advice for the management of moderate, severe, and life-threatening acute asthma.
Last edition, the risks associated with using hormone replacement therapy were updated to reflect MHRA and CHM advice (Drug Safety Update 2007; 1(2): 2-6). BNF 56 (section 6.4.1) now presents this information in easy-to-read table format.
Produced in collaboration with Onexamination, this new online revision aid provides a collection of clinically rich questions that will help students improve their knowledge of safe and effective prescribing while using the BNF. Designed to support best prescribing practice, the questions cover topics as diverse as asthma, cardiology, diabetes, infections, medical emergencies, drug interactions, adverse drug reactions, prescribing in pregnancy and much more. Further details about this module can be found at http://bnf.org/bnf/extra/current/450048.htm.
The British Dental Journal recently published A Dentist's Guide to Using the BNF (Br Dental J 2008; 204: 437–9 and Br Dental J 2008; 204: 487–91). This series of articles illustrate how dentists can keep track of the significant changes that occur in a new edition of the BNF and how to navigate to the dental information in it. With the help of clinical scenarios, the authors go on to explain how the BNF can be used as a tool to achieve rational prescribing.
Numerous changes are made for each edition of the BNF. The most significant changes that have been made for BNF 56 can be reviewed by following the links below:
