Low Na+

The words low Na+ added after some preparations indicate a sodium
content of less than 1 mmol per tablet or 10ml dose.

Infliximab for Crohn’s disease

Infliximab is recommended for Crohn’s disease (with or without fistulae)
when treatment with immunomodulating drugs and corticosteroids has
failed or is not tolerated and when surgery is inappropriate. Treatment may
be repeated if the condition responded to the initial course but relapsed
subsequently. Inflixamab should be prescribed only by a gastroenterologist.

Aminosalicylates (Sulfasalazine)
Blood disorders
Patients receiving aminosalicylates should report any unexplained
bleeding, bruising, purpura, sore throat, fever or malaise that occurs during
treatment. A blood count should be performed and the drug stopped
immediately if there is suspicion of a blood dyscrasia.

Laxative
For children with chronic constipation, it may be necessary to exceed the
licensed doses of some laxatives. Parents and careers of children should
be advised to adjust the dose of laxative given in order to establish a
regular pattern of bowel movements in which stools are soft, well-formed,
and passed without discomfort.

Clopidogrel
Clopidogrel with aspirin appropriate for management of non-ST-segment
elevation acute coronary syndrome in those at moderate to high risk of
myocardial infarction or of death.

Lipid-regulating drugs MUSCLE EFFECTS

The CSM has advised that rhabdomyolsis associated with lipid-regulating
drugs such as the fibrates and statins appears to be rare(apporx. 1 case
every 100 000 treatment years) but may be increased in those with renal
impairement and possibly in those with hypothyroidism. Concomitant
treatment with drugs that increase plasma-statin concentration increase
muscle-toxicity; concomitant treatment with a fibrate and a statin may also
be associated with an increased risk of serious muscle toxicity.
Formoterol and salmeterol
To ensure safe use, the CHM has advised that for the management of
chronic asthma, long-acting beta2 agonists (formoterol and salmeterol)
should:

Be added only if regular use of standard-dose inhaled steroids has failed to control
asthma adequately;
Not be initiated in patients with rapidly deteriorating asthma;
Be introduced at a low dose and the effect properly monitored before considering
dose increase;
Be discontinued in the absence of benefit;
Be reviewed as clinically appropriate;stepping down thereapy should be
considered when good long-term asthma control has been achieved

Aminophylline, Fentanyl, Remifentanil

To avoid excessive dosage in obese patients, dose should be calculated on
the basis of ideal weight for height.

Antipychotics
IM injection of antipychotics can differ from oral dose, im has increased
absorbtion especially if the patient is very active. The dose for antipsychotic
for emergency use should be reviewed at least daily. Injections for depot
must be titrated according to the patients response.

Lithium
Patients on lithium require a lithium card

Hyponatreamia and antidepressant therapy

Hyponatreamia (usually in the elderly and possibly due to inappropriate
secretion of antidiuretic hormones) has been associated with all types of
antidepressants; however, it has been reported more frequently with SSRIs
than with other antidepressants. The CSM has advised that hyponatreamia
should be considered in all patients who develop drowsiness, confusion, or
convulsion while taking an antidepressant.

SSRI’s for children

Not recommended in children as it may provoke suicidal thoughts.
Products unfavourable for under 18’s: citalopram, escitalopram, paroxetine,
sertraline.
Product that is favourable: FLUOXETINE.
Drugs used in status epilepticus
If seizures recur or fail to respond with 30 minutes:
PHENYTOIN, PHENOBARBITAL, FOSPHENYTOIN should be used
If these measures fail to control seizure with 60 minutes, anaesthesia with
thiopental, midazolam, or in adults, a non-barbiturate anaesthetic such as
propofol should be instituted with full intensive care.

Fosphenytoin sodium
Precriptions for fosphenytoin sodium should state the dose in terms of
phenytoin sodium equivalent(PE); fosphenytoin sodium 1.5mg = phenytoin
sodium 1mg

Fibrotic reactions
The CSM has advised that ergot-derived dopamine receptor agonists,
bromocriptine, cabergoline, lisuride[discontinued], and pergolide, have
been associated with pulmonary, retroperitoneal, and pericardial fibrotic
reactions. Before starting treatment with these ergot derivatives it may be
appropriate to measure the erythrocyte sedimentation rate and serum
creatine and to obtain a chest x-ray. Patients should be monitored for
dyspnoea, persistent cough, chest pain, cardiac failure, and abdominal pain
or tenderness. If long-term tests may also be helpful.

Sudden onset of sleep

Excessive daytime sleepiness and sudden onset of sleep can occur
with co-careldopa, co-beneldopa, and dopamine receptor
agonists. Driving warning, drowsiness warning.

Nicotine and bupropion

Only give 2 weeks supply after the stop date, or 3-4 weeks supply of
bupropion. Patients are only allowed to claim NHS supplied smoking
cessation thereapy within 6 months of an unsuccessful cessation attempt.

Bupropion
The CSM has issues a reminder that bupropion is contra-indicated in
patients with a history of seizures or of eating disorders, CNS tumour,
alcohol and benzodiazepine withdrawal. Increases the risk of seizures with
ANTIDEPRESSANTS, ANTIMALARIALS(MEFLOQUINE AND
CHLOROQUINE), ANTIPSYCHOTICS, QUINOLONES, SEDATING
ANTIHISTAMINES, SYSTEMIC CORTICOSTEROIDS, THEOPHYLLINE,
TRAMADOL. And conditions including diabetes, alcohol abuse, head
trauma, and use of stimulated and anorectics.
Methadone and buprenorphine
For opiod dependence, should be administered under supervision for 3
months, until compliance is assured,

Flucloxacillin
Cholestatic jaundice and hepatitis may occur up to several weeks after
treatment with flucloxacillin has been stoppened.Administration for more
than 2 weeks and increasing age and risk factors. CSM has reminded that:

Flucloxacillin should not be used in patients with a history of hepatic dysfunction

associated with flucloxacillin
Flucloxacillin should be used with caution in patients with hepatic impairment;
Careful enquiry should be made about hypersensitivity reactions to beta-lactam
antibacterials

Linezolid
Refer symptoms of visual impairment, and blood disorders

Co-trimoxaole
Drug of choice for:???? Pneumocystis jiroveci (Pneumocystis carinil)
Toxoplasmosis and nocardiasis
If no other alternative consider for:
Acute exacerbations of chronic bronchitis
Urinary tract infections
Acute otitis media in children

Quinonlones (e.g ciprofloxacin)

Tendon damage (including rupture) has been reported in patients receiving
quinolones. Tendon rupture may occur within 48 hours of starting
treatment.

Quinolones are contra-indicated in patients with a history of tendon disorders

related to quinolone use
Elderly patients are more prone to tendonitis
The risk of tendonitis rupture is increased by the concomitant use
of corticosteroids
If tendonitis is suspected, the quinolone should be discontinued immediately

Urineary tract infections

Whenever possible specimen of urine should be collected for culture and
sensitivity testing before starting antibacterial therapy. The antibacterial
chosen should reflect current local bacterial sensitivity to antibacterials.
Itraconazole
Following rare reports of heart failure, the CSM has advised caution when
prescribing itraconazole to patients at high risk of heart failure. Those at
risk include:

Patients receiving high doses and longer treatment courses

Older patients and those with cardiac disease
Patients receiving treatment with negative inotropic drugs, e.g calcium channel
blockers

Inhaled insulin
Not to be used for the routine treatment of type 1 or 3 diabetes. May be
used:

With evidence of poor glycaemic control despite other interventions and

Who require insulin but are unable to use subcutaneous insulin because of either
a diagnosed phobia of injections, or severe or persistent problems with injection
sites.

Treatment should continue beyond 6 months only if there is evidence of

improvement og HBA12.

Insulin glargine
Insulin glargine should be available as an option for patients with type 1
diabetes.
Insuline glargine is not recommended for routine use in patients with type 2
diabetes who require insulin but it may be considered in type 2 diabetes for
those:

Who require assistance with injecting their insulin or

Whose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemia
or
Who would otherwise need twice-daily, basal insulin injections in combination with
oral antidiabetic drugs

Thiazolidinediones
Pioglitazone or rosiglitazone as second-line therapy added to either
metformin or a sulphonylurea is not recommened except for:

Patients who are unable to tolerate metformin and sulphonylurea in combination

therapy, or
Patients in whom either metformin or a sulphonylurea is contra-indicated.

In such case thiazolidinedione should replace whichever drug in the

combination is poorly tolerated or contra-indicated.
Carbimazole
Doctors are reminded of the importance of recognising bone marrow
suppression induced by carbimazzole and the need to stop treatment
promptly.

1. Patient should be asked to report symptoms and signs suggestive of

infection, especially sore throat.
2. A white blood cell count should be performed if there is any clinical
evidence of infection
3. carbimazole should be stopped promptly if there is clinical or
laboratory evidence of neutropenia

Steroid SEs – risk of sever chickenpox/measles, immunosuppression,

adrenal suppression, mood changes, gi affects.

Osteoporosis
Those at risk of osteoporosis should maintain an adequate intake
ofcalcium and vitamin D and any defieciency should be corrected by
increasing dietary intake or taking supplements.

Bisphosphonates (Alendranate, risadronate)

Bisphosphonates are recommended as treatment options for the secondary
prevention of osteoporotic fractures in susceptiblepostmenopausal women.
In women who cannot take a bisphosphonate or who have suffered a
fragility fracture despite treatment for a year and whose bone mineral
density declines below the pre-treatment level, the selective oestrogen
receptor modulatorraloxifene is an alternative. The parathyroid hormone
fragmentteriparatide is recommended for women over 65 years who
cannot take a bisphosphonate (or in whom bisphosphonates has failed to
prevent a fracture) and have:

either an extremely low bone mineral density

or a very low bone mineral density, sufferent more than 2 fractures, and have
other risk factors for fractures (e.g body mass index under 19kg/m2, premature
menopause, prolonged immobility, history of mineral hip fracture under the age of
75 years)

Induction of labour
Dinoprostone is preferable to oxytocin for induction in women with intact
membranes, regardless or parity or cervical favourability.
Parental progesterone-only contraceptive
The CSM has advised that:

in adolescents, medroxyprogesterone acetate (Deop-provera) be under only when

other methods of contraception are inappropriate.
In all women, benfits of using medroxyprogesterone beyond 2 years should be
evaluated again risks.
In women with risk factors for osteoporosis a method of contraception other than
medroxyprogesterone acetate should be considered.

Spermicial contraceptives
Products such as petroleum jelly (Vaseline), baby oil and oil-based vaginal
and rectal preparations are likely to damage condoms and contraceptive
diaphragms made from latex rubber, and may render them less effective as
a barrier method of contraception and as a protection from sexually
transmitted diseases (including HIV).

CRM guildelines on handling cytotoxic drugs:

1. Trained personnel should reconstitute cytotoxics;

2. Reconstitution should be carried out in designated area;
3. Protective clothing (including gloves) should be worn;
4. The eyes should be protected and means of first aid should be
specified;
5. Pregnant staff should not handle cytotoxics
6. Adequate care should be taken in the disposal of waste material,
including syringes, containers, and absorbent material.

Most cytotoxic drugs are teratogenic and all may cause life-threatening
toxicity; administration should, where possible be confined to those
experienced in their use.
Because of the complexity of dosage regimens in the treatment of
malignant disease, dose statements have been omitted from some of the
drug entries in this chapter. In all cases detailed specialist literature should
be consulted.
Presciptions should not be repeated except on the instructions of a
specialist.

Ciclosporin
Because of differences in bioavailability, the brand of oral ciclosporin to be
dispensed should be specified by the prescriber.
Anastrozole
The aromatase inhibitors anastrazole, exemestane, and letrozole, within
their licensed indications, are recommended as options for the adjuvant
treatment of early oestrogen-receptor-postitive invasive breast cancer in
postmenopausal women.

Drugs with definite risk of haemolysis in most G6PD-deficient

individuals (from Afriva, Asia, Oceania,? and from south Europe):
Dapson and other sulphones, Methylthionium chloride, Nitrofurantion,
Pamaquin, Primaquin, Quinolones, Sulphonamides.
Possible risk:
Aspirin, Chloroquine, Menadione, Probenecid, Quinidine, Quinine

Thiamine
Although potentially serious allergic adverse reactions may rarely occur
during, or shortly after, parenteral administration, the CHM has
recommended that:

1. This should not preclude the use of parenteral thiamine in patients

where this route of administration is required, particularly in patients
at risk of Wenicke-Korsakoff syndrome where treatment with thiamine
is essential;
2. Intravenous administration should be by infusion over 30 minutes;
3. Facilities for treating anaphylaxis (including resuscitation facilities)
should be available when parental thiamine is administered.

Pyridoxine Hydrochloride
Pyridoxine is used to treat isoniazid neuropathy. However prolonged use of
pyridoxine in dose of 10mg daily is considered safe but the long-term use
of pyridoxine in a dose of 200mg or more daily has been associated with
neuropathy. The safety of long-term pyroxidine supplements with doses
above 10mg daily has not been established.
NSAIDS and cardiovascular events
COX-2 selective inhibitors are associated with an increased risk of
thrombotic events (e.g MI and stroke) and should not be used in preference
to non-selective NSAIDS except when specifically indicated (i.e for patients
at a particularly high risk of developing gastroduodenal ulceration or
bleeding) and after assessing their cardiovascular risk.
Non-selective NSAIDs may also be associated with a small increased risk
of thrombotic evens particularly when used at high doses and for long-term
treatment. Diclofenac (150mg daily) and ibuprofen (2.4g daily) are
associated with an increased risk of thrombotic events. The increased risk
for diclofenac is similar to that of licensed doses of etoricoxib. Naproxen is
associated with an increased risk of myocardial infarction. A small
increased thrombotic risk cannot be excluded for other NSAIDs.
The lowest effective dose of NSAID or COX-2 selective inhibitor should be
prescribed for the shortest period to control symptoms and that the need for
long-term treatment should be reviewed periodically.

Piroxicam
The CHMP has recommended restrictions on the use of piroxicam because
of the increased risk of gastro-intestinal side effects and serious skin
reactions. The CHMP has advised that

Piroxicam should be initiated only by physicians experienced in treating

inflammatory or degenerative rheumatic diseases
Piroxicam should not be used as first-line treatment
In adults, use of piroxicam should be limited only to the symptomatic relief of
osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis
Piroxicam dose should not exceed 20mg daily
Piroxicam should no longer be used for the treatment of acute painful and
inflammatory conditions
Treatment should be reviewed 2 weeks after initiating piroxicam and periodicallt
therafter
Concomitant administration of a gastro-protective agent should be considered

Topical preparations containing piroxicam are not affected by these

restrictions

Tiaprofenic acid
May cause sever cystisis, stop treatment if symptoms occur.
Methotrexate
In view of reports of dycrasias (including fatalities) and liver cirrhosis with
low-dose methotrexate, the CSM has advised:

Full blood count and renal and liver function tests before starting treatment and
repeated weekly until theraphy stabilised, thereafter patients should be monitored
every 2-3 months
That patients should be advised to report all symptoms and signs suggestive of
infection, especially sore throat.

Treatment with folinic acid(calcium folinate) may be required in acute

toxicity.

The patient must be warned to report immediately the onset of any feature
of blood disorders (e.g sore throat, bruising, and mouth mulcers), liver
toxicity (e.g nausea, vomiting, abdominal discomfort, and dark urine), and
respiratory effects (e.g shortness of breath)

Co-cyprindiol
Venous thromboembolism occurs more frequently in women taking co-
cyprindiol than those taking a low-dose combines oral contraceptive. The
CSM has reminded prescribers that co-cyprindiol is licensed for use in
women with severe acne which has not responded to oral antibacterials
and for moderately severe hirsutism; it should not be used solely for
contraception. It is contra-indicated in those with a personal or close family
history of venous thromboembolism. Women with severe acne or hirsutism
may have an inherently increased risk of cardiovascular disease.
Contra-indicated in pregnancy and a predisposition to thrombosis.

Sun-screen
For optimum photoprotection, sunscreen preparations should be
applied thickly and frequently (approx 2 hourly). In photodermatoses, they
should be used from spring to autumn. As maximum protection from
sunlight is desirable, preparations with the highest SPF should be
prescribed.