BNF 85 (British National Formulary) March-September 2023 PDF

BNF 85 Copyright © 2023. Pharmaceutical Press. All rights reserved. March – September 2023 Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. Published jointly by BMJ Tavistock Square London WC1H 9JP UK and Pharmaceutical Press 66-68 East Smithﬁeld London E1W 1AW UK Pharmaceutical Press is the publishing division of the Royal Pharmaceutical Society. Copyright © BMJ Publishing Group Ltd and the Royal Pharmaceutical Society of Great Britain 2023. BNF 85 ISBN: 978 0 85711 458 7 BNF 85 ISBN: 978 0 85711 459 4 (ePDF) Printed by GGP Media GmbH, Pößneck, Germany Typeset by Data Standards Ltd, UK Text design by Peter Burgess A catalogue record for this book is available from the British Library. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, without the prior written permission of the copyright holder. Copyright © 2023. Pharmaceutical Press. All rights reserved. Material published in the British National Formulary may not be used for any form of advertising, sales or publicity without prior written permission. Each of the classiﬁcation and the text are protected by copyright and/or database right. Requesting copies of BNF Publications Paper copies may be obtained through any bookseller or direct from: Pharmaceutical Press c/o Macmillan Distribution (MDL) Hampshire International Business Park Lime Tree Way Basingstoke Hampshire RG24 8YJ Tel: +44 (0) 1256 302 699 Fax: +44 (0) 1256 812 521 [email protected] BNF, please call (0)1268 495 609 or email: [email protected]. In Scotland, email: [email protected] In Wales, email: [email protected] In Northern Ireland: Primary care: contact the Business Services Organisation Secondary care: contact your local Trust pharmacy department About BNF content The BNF is designed as a digest for rapid reference and it may not always include all the information necessary for prescribing and dispensing. Also, less detail is given on areas such as obstetrics, malignant disease, and anaesthesia since it is expected that those undertaking treatment will have specialist knowledge and access to specialist literature. BNF for Children should be consulted for detailed information on the use of medicines in children. The BNF should be interpreted in the light of professional knowledge and supplemented as necessary by specialised publications and by reference to the product literature. Information is also available from Medicines Information Services. Please refer to digital versions of BNF for the most up-todate content. BNF is published in print but interim updates are issued and published in the digital versions of BNF. The publishers work to ensure that the information is as accurate and up-to-date as possible at the date of publication, but knowledge and best practice in this ﬁeld change regularly. BNF’s accuracy and currency cannot be guaranteed and neither the publishers nor the authors accept any responsibility for errors or omissions. While considerable efforts have been made to check the material in this publication, it should be treated as a guide only. Prescribers, pharmacists and other healthcare professionals are advised to check www.bnf.org/ for information about key updates and corrections. Pharmaid Numerous requests have been received from developing countries for BNFs. The Pharmaid scheme of the Commonwealth Pharmacists Association will dispatch old BNFs to certain Commonwealth countries. For more information on this scheme see commonwealthpharmacy.org/what-we-do/pharmaid/. If you would like to donate your copy email: [email protected] or via our website www.pharmpress.com/ For all bulk orders of more than 20 copies: Tel: +44 (0) 207 572 2266 [email protected] The BNF is available as a mobile app, online (bnf.nice.org.uk/) and also through MedicinesComplete. In addition, BNF content can be integrated into a local formulary by using BNF on FormularyComplete; see www.bnf.org for details. Distribution of printed BNFs In England, NICE purchases print editions of the BNF (September editions only) for distribution within the NHS. For details of who is eligible to receive a copy and further contact details, please refer to the NICE website: www.nice.org.uk/about/what-we-do/evidence-services/britishnational-formulary. If you are entitled to a shared copy of the Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. iii BNF 85 Copyright © 2023. Pharmaceutical Press. All rights reserved. Preface The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. It is published under the authority of a Joint Formulary Committee which comprises representatives of the two professional bodies, the UK Health Departments, the Medicines and Healthcare products Regulatory Agency, and a national guideline producer. The Dental Advisory Group oversees the preparation of advice on the drug management of dental and oral conditions; the Group includes representatives of the British Dental Association and a representative from the UK Health Departments. The Nurse Prescribers’ Advisory Group advises on the content relevant to nurses and includes representatives from different parts of the nursing community and from the UK Health Departments. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines. The BNF includes key information on the selection, prescribing, dispensing and administration of medicines. Medicines generally prescribed in the UK are covered and those considered less suitable for prescribing are clearly identiﬁed. Little or no information is included on medicines promoted for purchase by the public. Information on drugs is drawn from the manufacturers’ product literature, medical and pharmaceutical literature, UK health departments, regulatory authorities, and professional bodies. Advice is constructed from clinical literature and reﬂects, as far as possible, an evaluation of the evidence from diverse sources. The BNF also takes account of authoritative national guidelines and emerging safety concerns. In addition, the editorial team receives advice on all therapeutic areas from expert clinicians; this ensures that the BNF’s recommendations are relevant to practice. The BNF is designed as a digest for rapid reference and it may not always include all the information necessary for prescribing and dispensing. Also, less detail is given on areas such as obstetrics, malignant disease, and anaesthesia since it is expected that those undertaking treatment will have specialist knowledge and access to specialist literature. Similarly, little or no information is included on medicines for very rare conditions. BNF for Children should be consulted for detailed information on the use of medicines in children. The BNF should be interpreted in the light of professional knowledge and supplemented as necessary by specialised publications and by reference to the product literature. Information is also available from medicines information services, see Medicines Information Services (see inside front cover). It is important to use the most recent BNF information for making clinical decisions. The print edition of the BNF is updated in March and September each year. Monthly updates are provided online via MedicinesComplete and NICE (www.nice.org.uk). The more important changes listed under Changes p. xvi are cumulative (from one print edition to the next), and can be printed off each month to show the main changes since the last print edition as an aide memoire for those using print copies. The BNF Publications website (www.bnf.org) includes additional information of relevance to healthcare professionals. Other digital formats of the BNF—including versions for mobile devices and integration into local formularies—are also available. BNF Publications welcomes comments from healthcare professionals. Comments and constructive criticism should be sent to: British National Formulary Royal Pharmaceutical Society 66–68 East Smithﬁeld London E1W 1AW [email protected] The contact email for manufacturers or pharmaceutical companies wishing to contact BNF Publications is [email protected] Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. iv BNF 85 Contents page iii v viii x xvi 1 4 6 7 10 14 16 17 19 20 20 24 24 25 29 31 31 NOTES ON DRUGS AND PREPARATIONS 1 Gastro-intestinal system 2 Cardiovascular system 3 Respiratory system 4 Nervous system 5 Infection 6 Endocrine system 7 Genito-urinary system 8 Immune system and malignant disease 9 Blood and nutrition 10 Musculoskeletal system 11 Eye 12 Ear, nose and oropharynx 13 Skin 14 Vaccines 15 Anaesthesia 16 Emergency treatment of poisoning page 37 106 256 328 546 730 848 914 1114 1208 1272 1310 1338 1410 1466 1500 APPENDICES AND INDICES Appendix 1 Interactions 1515 Appendix 2 1760 Borderline substances Appendix 3 Cautionary and advisory labels for dispensed medicines 1802 Appendix 4 Wound management products and elasticated garments 1805 Dental Practitioners’ Formulary 1828 Nurse Prescribers’ Formulary 1830 Non-medical prescribing 1835 Index of manufacturers 1836 Special-order Manufacturers 1841 Index 1843 Medical emergencies in the community 1884 Life support algorithm inside back cover Copyright © 2023. Pharmaceutical Press. All rights reserved. Preface Acknowledgements How BNF publications are constructed How to use BNF Publications in print Changes Guidance on Prescribing Prescription writing Emergency supply of medicines Controlled drugs and drug dependence Adverse reactions to drugs Guidance on intravenous infusions Medicines optimisation Antimicrobial stewardship Prescribing for children Prescribing in hepatic impairment Prescribing in renal impairment Prescribing in pregnancy Prescribing in breast-feeding Prescribing in palliative care Prescribing for the elderly Drugs and sport Prescribing in dental practice Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. BNF 85 Acknowledgements The Joint Formulary Committee is grateful to individuals and organisations that have provided advice and information to the BNF. Contributors for this update were: K.W. Ah-See, A.K. Bahl, D. Bilton, M.F. Bultitude, I.F. Burgess, C.E. Dearden, D.W. Denning, D.A.C. Elliman, P. Emery, A. Freyer, N.J.L. Gittoes, M. Gupta, T.L. Hawkins, S.P. Higgins, T.H. Lee, A. Lekkas, D.N.J. Lockwood, A.M. Lovering, M.G. Lucas, P.D. Mason, D.A. McArthur, L.M. Melvin, R.M. Mirakian, P. Morrison, S.M.S. Nasser, C. Nelson-Piercy, D.J. Nutt, R. Patel, A.B. Provan, A.S.C. Rice, D.J. Rowbotham, S.E. Slater, J. Soar, M.D. Stewart, S. Thomas, A.D. Weeks, A. Wilcock. Expert advice on the management of oral and dental conditions was kindly provided by A. Crighton, C. Scully, R.A. Seymour, and R. Welbury. S. Kaur provided valuable advice on dental prescribing policy. Valuable advice has been provided by the following expert groups: Advisory Committee on Malaria Prevention, Association of British Neurologists, British Association of Dermatologists’ Therapy & Guidelines Sub-committee, British Geriatrics Society, British Menopause Society, British Oncology Pharmacy Association, British Pain Society, British Society for Allergy & Clinical Immunology, British Society for Antimicrobial Chemotherapy, British Society of Gastroenterology, British Society of Rheumatology, College of Mental Health Pharmacy, ENT UK, Faculty of Sexual and Reproductive Healthcare, National Poisons Information Service & TOXBASE, Public Health England, Renal Association, Royal College of Anaesthetists, Royal College of Obstetricians and Gynaecologists, Royal College of Ophthalmologists, Royal College of Pathologists, Royal College of Physicians, Royal College of Psychiatrists, Society for Endocrinology, UK Teratology Information Service, Vascular Society. The MHRA have provided valuable assistance. Correspondents in the pharmaceutical industry have provided information on new products and commented on products in the BNF. Copyright © 2023. Pharmaceutical Press. All rights reserved. Numerous doctors, pharmacists, nurses, and others have sent comments and suggestions. The BNF team are grateful for the support and access to inhouse expertise at Pharmaceutical Press and acknowledge the assistance of K. Baxter, A. Chester, A. Naylor, N. Potter, D. Wright and their teams. A. Devanand, S. Khan, C. Lam, and T. Tahmasi provided considerable assistance during the production of this update of the BNF. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. v vi BNF 85 BNF Staff ASSOCIATE CONTENT DIRECTOR (BNF PUBLICATIONS) Kate Towers BPharm (AU), GCClinPharm (AU) SENIOR EDITORIAL STAFF Kiri Aikman BPharm (NZ), PGDipClinPharm (NZ), ARPharmS Mahinaz Harrison BPharm, DipPharmPract, IP, MRPharmS Rosalind Barker BMus, MA Emily Henderson BPharm (NZ), PGCertClinPharm (NZ) Alison Brayﬁeld BPharm, MRPharmS Jean MacKershan BSc, PgDip Robert Buckingham BSc, SRPharmS Angela McFarlane BSc, DipClinPharm Catherine Cadart BPharm (AU), BA(Hons), GradDipHospPharm (AU), MRPharmS Anna McLachlan BPharm (NZ), PGCertClinPharm (NZ) Claire Preston BPharm, PGDipMedMan, MRPharmS Darren Chan BSc, MSc EDITORIAL STAFF Natasha Bell-Asher BPharm (NZ), PGDipClinPharm (NZ) Banisha Morar BPharm (NZ) Adam Brelsford MPharm, PhD Liliana Moreira Vilas Boas MPharm(PT), PGDipHPS(PT), PGCertHSDM(PT), PGCertGPP, MRPharmS Lucía Camañas Sáez MPharm (ESP), PGDipClinPharm, PGCertPsychTherap, MRPharmS Nalwenga Mutambo MPharm Kim Chan MPharm, MRPharmS Barbara Okpala MPharm, PGDipHospPharm Rochelle Chin BPharm (AU) Heenaben Patel MPharm, PGDipClinPharm, MRPharmS Kathleen Eager BPharm Laura Pham BPharm(Hons) (AU) Georgina Fell MPharm, PGDip Catherine Pitt MPharm, PGDipClinPharm, MRPharmS Sue Ho BPharm (AU), MRPharmS Leah Richardson BPharm (NZ) Emma Jones MPharm Sharyl Rodrigues BPharm (NZ), PGDipClinPharm (NZ) Elizabeth King MAPharmT Beejal Shah MPharm, PGDipClinPharm, IP Julia Lacey BPharm, PGDipClinPharm, PharmD India Smith MPharm David Lipanovic BPharm (NZ), PGCertClinPharm (NZ) Punam Solanki MPharm, PGCertClinPharm Deirdre McGuirk BComm, MPharm Renee Spriggs BPharm (NZ), PGCertClinPharm (NZ) Lona Mehta MPharm, MRPharmS Jodie-Anne Swatton BSc(Hons) Navpreet Mittal MPharm, PGCert, MRPharmS Harpreet Takhar MPharm, MRPharmS Copyright © 2023. Pharmaceutical Press. All rights reserved. SUPPORT STAFF Libby Achilles BSc(Hons) Shaunagh Lee BPharm(Hons) (AU) Allegra Chan BSc(Hons) Rebecca Luckhurst BSc(Hons), MSc Lauren Cheetham BA(Hons) Olivia Maskill BSc(Hons) Charlotte Clark MPharm Faye Morley MPharm Melanie Eustace Hang Nguyen BSc(Hons) Rebecca Harwood BSc(Hons) Carina Redig de Campos Nick Judd BA(Hons), MA Jannah Ryan BSc(Hons) Moriam Kolapo MPharm Paula Sutton BPharm (NZ), PGCertPharm (NZ) Philip Lee BSc, PhD Jessica Tang BSc(Hons) Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. vii Copyright © 2023. Pharmaceutical Press. All rights reserved. BNF 85 Joint Formulary Committee Dental Advisory Group CHAIR CHAIR Fraz A. Mir BSc, MA, MBBS, FRCP Sarah Manton BDS, FDSRCS Ed, FHEA, PhD, FDFTEd COMMITTEE MEMBERS COMMITTEE MEMBERS Andy Burman (lay member) CMgr, FCMI, FRSA, FIAM Daniel Burrage MRCP, MSc, PhD, FHEA Rima Chauhan MPharm (Hons), MSc, IP, MRPharmS Jo Lyn Chooi BMedSc, BM BS, FRCA Carmel M. Darcy BSc, MSc, IP, MPSNI, MRPharmS Sue Faulding BPharm, MSc, FRPharmS Daniel Greenwood MPharm(Hons), PgCertMedEd, PgDip(ClinPharm), PhD Tracy Hall BSc, MSc, RN, DN, NIP, Dip N, Cert N, QN Lynn Haygarth BPharm, MEd, FFRPS, FRPharmS, FCMHP Simon Hurding MB, ChB, MRCGP Valerie Joynson BSc, PGCE, PGCert Sandeep Kapur BSc(Hons), MB BS, MRCGP(Dist) Mark P. Lythgoe MB BS, MRPharmS Louise Picton BSc, DipCommPharm, MSc, MRPharmS Bernadette Rae Pg Cert Ed, Fellow HEA, MSc Nursing, Pg CertANP, BSc(Hons), Grad Cert NMP, RGN Fiona Raje (lay member) DPhil, MSc, BA, FRGS Muhammad Magdi Yaqoob MD, FRCP Elaine Boylan (observer) PhD Andrew K. Brewer BSc, BchD, MFDS (Glas) Rochelle Chin BPharm (AU) Alexander Crighton BDS, MB, ChB, FDS, OM Angela McFarlane BSc, DipClinPharm Monica Neil BDS, MFDS RCS, MSc, MPaed Dent RCS, FDS RCS, MBA Suzanne Sykes BDS (Hons), MSc Adv HCP (Open), MFGDP (UK) MJDF, PG Cert Dental Sedation and Pain Management (UCL), Dip FMS (FMS), Dip Spec Care Dent RCSEd Adrian Thorp BDS, LLB (Hons), MFDS RCS (Eng), M Surg Dent RCS (Eng), MAcadMEd, FDS RCSEd, FDTFEd, FFGDP (UK), FCGDent, PG Cert Kate Towers BPharm (AU), GCClinPharm (AU) ADVICE ON DENTAL PRACTICE The British Dental Association has contributed to the advice on medicines for dental practice through its representatives on the Dental Advisory Group. Nurse Prescribers’Advisory Group CHAIR Molly Courtenay PhD, MSc, Cert Ed, BSc, RGN COMMITTEE MEMBERS Penny M. Franklin RN, RCN, RSCPHN(HV), MA, PGCE Matt Grifﬁths BA(Hons), FAETC, RGN, Cert A&E, NISP, PHECC Tracy Hall BSc, MSc, RN, DN, NIP, Dip N, Cert N, QN Sue Ho BPharm (AU), MRPharmS Angela McFarlane BSc, DipClinPharm Joan Myers MSc, BSc, RGN, RSCN, Dip DN Fiona Peniston-Bird BSc(Hons), NIP, RHV, RGN Kathy Radley BSc, RGN Kate Towers BPharm (AU), GCClinPharm (AU) Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. viii BNF 85 How BNF Publications are constructed Overview The BNF is an independent professional publication that addresses the day-to-day prescribing information needs of healthcare professionals. Use of this resource throughout the health service helps to ensure that medicines are used safely, effectively, and appropriately. Hundreds of changes are made between print editions, and are published monthly in a number of digital formats. The most clinically signiﬁcant updates are listed under Changes p. xvi. The BNF is unique in bringing together authoritative, independent guidance on best practice with clinically validated drug information. Validation of information follows a standardised process, reviewing emerging evidence, best-practice guidelines, and advice from a network of clinical experts. Where the evidence base is weak, further validation may be undertaken through a process of peer review. The process and its governance are outlined in greater detail in the sections that follow. Joint Formulary Committee The Joint Formulary Committee (JFC) is responsible for the content of the BNF. The JFC includes pharmacy, medical, nursing, and lay representatives; there are also representatives from the Medicines and Healthcare products Regulatory Agency (MHRA), the UK Health Departments, and a national guideline producer. The JFC decides on matters of policy and reviews amendments to the BNF in the light of new complex or contentious evidence and expert advice. Dental Advisory Group The Dental Advisory Group oversees the preparation of advice on the drug management of dental and oral conditions; the group includes representatives from the British Dental Association and a representative from the UK Health Departments. Nurse Prescribers’ Advisory Group The Nurse Prescribers’ Advisory Group oversees the list of drugs approved for inclusion in the Nurse Prescribers’ Formulary; the group includes representatives from a range of nursing disciplines and stakeholder organisations. Copyright © 2023. Pharmaceutical Press. All rights reserved. Expert advisers The BNF uses representatives from expert groups (professional societies and advisory bodies) to provide expert advice on clinical content. These expert advisers are practice-based healthcare professionals (including doctors, pharmacists, nurses, and dentists), and are regarded as specialists in their ﬁeld. The role of these expert advisers is to provide independent advice on their area of expertise by reviewing existing text and commenting on amendments drafted by the clinical writers. These clinical experts help to ensure that the BNF remains reliable by:. commenting on the relevance of the text in the context of best clinical practice in the UK;. checking draft amendments for appropriate interpretation of any new evidence;. providing expert opinion in areas of controversy or when reliable evidence is lacking. The BNF may also call on other clinical specialists for speciﬁc developments when particular expertise is required. The BNF works closely with a number of expert bodies that produce clinical guidelines. Drafts or pre-publication copies of guidelines are often received for comment and assimilation into the BNF. Editorial team BNF clinical writers have worked as pharmacists or possess a pharmacy degree and many have a further, relevant post-graduate qualiﬁcation; they therefore have a sound understanding of how drugs are used in clinical practice. As a team, the clinical writers are responsible for editing, maintaining, and updating BNF content. They follow a systematic prioritisation process in response to updates to the evidence base in order to ensure the most clinically important topics are reviewed as quickly as possible. In addition, review of content is carried out proactively, with the aim of considering all recommendations for review every 3 to 4 years. Amendments to the text are drafted when the clinical writers are satisﬁed that any new information is reliable and relevant. A set of standard criteria deﬁnes when content is referred to expert advisers, the Joint Formulary Committee or other advisory groups, or submitted for peer review. Clinical writers prepare the text for publication and undertake a number of validation checks at various stages of the content creation process. Sources of BNF information The BNF uses a variety of sources for its information; the main ones are shown below. Summaries of product characteristics The BNF reviews summaries of product characteristics (SPCs) of all new products as well as revised SPCs for existing products. The SPCs are the principal source of product information and are carefully processed. Such processing involves:. verifying the approved names of all relevant ingredients including ‘non-active’ ingredients (the BNF is committed to using approved names and descriptions as laid down by the Human Medicine Regulations 2012);. comparing the indications, cautions, contra-indications, and side-effects with similar existing drugs. Where these are different from the expected pattern, justiﬁcation is sought for their inclusion or exclusion;. seeking independent data on the use of drugs in pregnancy and breast-feeding;. incorporating the information into the BNF using established criteria for the presentation and inclusion of the data;. checking interpretation of the information by a second clinical writer before submitting to a content approver; changes relating to doses receive a further check;. identifying potential clinical problems or omissions and seeking further information from manufacturers or from expert advisers;. constructing, with the help of expert advisers, a comment on the role of the drug in the context of similar drugs. Much of this processing is applicable to the following sources as well. Literature Clinical writers monitor and process various sources of information on a regular basis. When a difference between the advice in the BNF and the source is noted, the new information is assessed for reliability (using tools based on SIGN methodology if appropriate) and relevance to UK clinical practice. If necessary, new text is drafted and discussed with expert advisers and the Joint Formulary Committee. The BNF enjoys a close working relationship with a number of national information providers. In addition to the routine process, which is used to identify ‘triggers’ for changing the content, systematic literature searches are used to identify the best quality evidence available to inform an update. Clinical writers receive training in critical appraisal, literature evaluation, and search strategies. Consensus guidelines The advice in the BNF is checked against consensus guidelines produced by expert bodies. The quality of the guidelines is assessed using adapted versions of the AGREE II tool. A number of bodies make drafts or pre-publication copies of the guidelines available to the BNF; it is therefore possible to ensure that a consistent message is disseminated. The BNF routinely processes guidelines from the National Institute for Health and Care Excellence (NICE), the All Wales Medicines Strategy Group (AWMSG), the Scottish Medicines Consortium (SMC), and the Scottish Intercollegiate Guidelines Network (SIGN). Reference sources Textbooks and reference sources are used to provide background information for the review of existing text or for the construction of new text. The BNF team works closely with the editorial team that produces Martindale: The Complete Drug Reference. The BNF has access to Martindale information resources and each team Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. ix BNF 85 keeps the other informed of signiﬁcant developments and shifts in the trends of drug usage. Peer review Although every effort is made to identify the most robust data available, inevitably there are areas where the evidence base is weak or contradictory. While the BNF has the valuable support of expert advisers and the Joint Formulary Committee, the recommendations made may be subject to a further level of scrutiny through peer review to ensure they reﬂect best practice. Content for open peer review is posted on bnf.org and interested parties are notiﬁed via a number of channels, including the BNF e-newsletter. Statutory information The BNF routinely processes relevant information from various Government bodies including Statutory Instruments and regulations affecting the Prescription Only Medicines Order. Ofﬁcial compendia such as the British Pharmacopoeia and its addenda are processed routinely to ensure that the BNF complies with the relevant sections of the Human Medicines Regulations 2012. The BNF maintains close links with the Home Ofﬁce (in relation to controlled drug regulations) and the Medicines and Healthcare products Regulatory Agency (including the British Pharmacopoeia Commission). Safety warnings issued by the Commission on Human Medicines (CHM) and guidelines on drug use issued by the UK health departments are processed as a matter of routine. Relevant professional statements issued by the Royal Pharmaceutical Society are included in the BNF as are guidelines from bodies such as the Royal College of General Practitioners. Medicines and devices NHS Prescription Services (from the NHS Business Services Authority) provides non-clinical, categorical information (including prices) on the medicines and devices included in the BNF. Comments from readers Readers of the BNF are invited to send in comments. Numerous letters and emails are received by the BNF team. Such feedback helps to ensure that the BNF provides practical and clinically relevant information. Many changes in the presentation and scope of the BNF have resulted from comments sent in by users. Copyright © 2023. Pharmaceutical Press. All rights reserved. Comments from industry Close scrutiny of BNF by the manufacturers provides an additional check and allows them an opportunity to raise issues about BNF’s presentation of the role of various drugs; this is yet another check on the balance of BNF’s advice. All comments are looked at with care and, where necessary, additional information and expert advice are sought. Market research Market research is conducted at regular intervals to gather feedback on speciﬁc areas of development. Assessing the evidence From January 2016, recommendations made in the BNF have been evidence graded to reﬂect the strength of the recommendation. The addition of evidence grading is to support clinical decision-making based on the best available evidence. Recommendations from summaries of product characteristics Recommendations from summaries of product characteristics (SPCs) and other product literature are either preceded by “manufacturer advises” or have the symbol M (manufacturer information) displayed next to the recommendation within the text. Grading system The BNF has adopted a ﬁve-level grading system from A to E, based on the former SIGN grading system. This grade is displayed next to the recommendation within the text. Evidence used to make a recommendation is assessed for validity using standardised methodology tools based on AGREE II or SIGN and then assigned a level of evidence. The recommendation is given a grade that is extrapolated from the level of evidence, and an assessment of the body of evidence and its applicability. Evidence assigned a level 1- or 2- score has an unacceptable level of bias or confounding and is not used to form recommendations. Levels of evidence. Level 1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias.. Level 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.. Level 1– Meta-analyses, systematic reviews, or RCTs with a high risk of bias.. Level 2++ High quality systematic reviews of case control or cohort studies; or high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.. Level 2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.. Level 2– Case control or cohort studies with a high risk of confounding or bias and a signiﬁcant risk that the relationship is not causal.. Level 3 Non-analytic studies, e.g. case reports, case series.. Level 4 Expert advice or clinical experience from respected authorities. Grades of recommendation. Grade A: High strength NICE-accredited guidelines; or other guidelines, assessed using AGREE II, that meet the grade A threshold; or at least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results.. Grade B: Moderate strength Guidelines, assessed using AGREE II, that meet the grade B threshold; or a body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+.. Grade C: Low strength Guidelines, assessed using AGREE II, that meet the grade C threshold; or a body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++.. Grade D: Very low strength Guidelines, assessed using AGREE II, that meet the grade D threshold; or evidence level 3; or extrapolated evidence from studies rated as 2+; or tertiary reference source created by a transparent, deﬁned methodology, where the basis for recommendation is clear.. Grade E: Practice point Evidence level 4. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. x BNF 85 How to use BNF Publications in print How to use the BNF This edition of the BNF continues to display the fundamental change to the structure of the content that was ﬁrst shown in BNF 70. The changes were made to bring consistency and clarity to BNF content, and to the way that the content is arranged within print and digital products, increasing the ease with which information can be found. For reference, the most notable changes to the structure of the content include:. Drug monographs – where possible, all information that relates to a single drug is contained within its drug monograph, moving information previously contained in the prescribing notes. Drug monographs have also changed structurally: additional sections have been added, ensuring greater regularity around where information is located within the publication.. Drug class monographs – where substantial amounts of information are common to all drugs within a drug class (e.g. macrolides p. 590), a drug class monograph has been created to contain the common information.. Medicinal forms – categorical information about marketed medicines, such as price and pack size, continues to be sourced directly from the Dictionary of Medicines and Devices provided by the NHS Business Services Authority. However, clinical information curated by the BNF team has been clearly separated from the categorical pricing and pack size information and is included in the relevant section of the drug monograph.. Section numbering – the BNF section numbering has been removed. This section numbering tied the content to a rigid structure and enforced the retention of defunct classiﬁcations, such as mercurial diuretics, and hindered the relocation of drugs where therapeutic use had altered. It also caused constraints between the BNF and BNF for Children, where drugs had different therapeutic uses in children.. Appendix 4 – the content has been moved to individual drug monographs. The introductory notes have been replaced with a new guidance section, Guidance on intravenous infusions p. 14. Copyright © 2023. Pharmaceutical Press. All rights reserved. Introduction In order to achieve the safe, effective, and appropriate use of medicines, healthcare professionals must be able to use the BNF effectively, and keep up to date with signiﬁcant changes in the BNF that are relevant to their clinical practice. This How to Use the BNF is key in reinforcing the details of the new structure of the BNF to all healthcare professionals involved with prescribing, monitoring, supplying, and administering medicines, as well as supporting the learning of students training to join these professions. Structure of the BNF This BNF edition continues to broadly follows the high-level structure of earlier editions of the BNF (i.e. those published before BNF 70): Front matter, comprising information on how to use the BNF, the signiﬁcant content changes in each edition, and guidance on various prescribing matters (e.g. prescription writing, the use of intravenous drugs, particular considerations for special patient populations). Chapters, containing drug monographs describing the uses, doses, safety issues and other considerations involved in the use of drugs; drug class monographs; and treatment summaries, covering guidance on the selection of drugs. Monographs and treatment summaries are divided into chapters based on speciﬁc aspects of medical care, such as Chapter 5, Infections, or Chapter 16, Emergency treatment of poisoning; or drug use related to a particular system of the body, such as Chapter 2, Cardiovascular. Within each chapter, content is organised alphabetically by therapeutic use (e.g. Airways disease, obstructive), with the treatment summaries ﬁrst, (e.g. asthma), followed by the monographs of the drugs used to manage the conditions discussed in the treatment summary. Within each therapeutic use, the drugs are organised alphabetically by classiﬁcation (e.g. Antimuscarinics, Beta2-agonist bronchodilators) and then alphabetically within each classiﬁcation (e.g. Aclidinium bromide, Glycopyrronium bromide, Ipratropium bromide). Appendices, covering interactions, borderline substances, cautionary and advisory labels, and woundcare. Back matter, covering the lists of medicines approved by the NHS for Dental and Nurse Practitioner prescribing, proprietary and specials manufacturers’ contact details, and the index. Quick reference guides for life support and key drug doses in medical emergencies are also included, for ease of access. Navigating the BNF The contents page provides the high-level layout of information within the BNF; and in addition, each chapter begins with a small contents section, describing the therapeutic uses covered within that chapter. Once in a chapter, location is guided by the side of the page showing the chapter number (the thumbnail), alongside the chapter title. The top of the page includes the therapeutic use (the running head) alongside the page number. Once on a page, visual cues aid navigation: treatment summary information is in black type, with therapeutic use titles similarly styled in black, whereas the use of colour indicates drug-related information, including drug classiﬁcation titles, drug class monographs, and drug monographs. Although navigation is possible by browsing, primarily access to the information is via the index, which covers the titles of drug class monographs, drug monographs, and treatment summaries. The index also includes the names of branded medicines and other topics of relevance, such as abbreviations, guidance sections, tables, and images. Content types Treatment summaries Treatment summaries are of three main types;. an overview of delivering a drug to a particular body system (e.g. Skin conditions, management p. 1338). a comparison between a group or groups of drugs (e.g. Beta-adrenoceptor blocking drugs p. 163). an overview of the drug management or prophylaxis of common conditions intended to facilitate rapid appraisal of options (e.g. Hypertension p. 156, or Malaria, prophylaxis p. 669). In order to select safe and effective medicines for individual patients, information in the treatment summaries must be used in conjunction with other prescribing details about the drugs and knowledge of the patient’s medical and drug history. Monographs Overview In earlier editions (i.e. before BNF 70), a systemically administered drug with indications for use in different body systems was split across the chapters relating to those body systems. So, for example, codeine phosphate p. 492 was found in chapter 1, for its antimotility effects and chapter 4 for its analgesic effects. However, the monograph in chapter 1 contained only the dose and some selected safety precautions. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xi BNF 85 Now, all of the information for the systemic use of a drug is contained within one monograph, so codeine phosphate p. 492 is now included in chapter 4. This carries the advantage of providing all of the information in one place, so the user does not need to ﬂick back and forth across several pages to ﬁnd all of the relevant information for that drug. Cross references are included in chapter 1, where the management of diarrhoea is discussed, to the drug monograph to assist navigation. Where drugs have systemic and local uses, for example, chloramphenicol, and the considerations around drug use are markedly different according to the route of administration, the monograph is split, as with earlier editions, into the relevant chapters. This means that the majority of drugs are still placed in the same chapters and sections as earlier editions, and although there may be some variation in order, all of the relevant information will be easier to locate. One of the most signiﬁcant changes to the monograph structure is the increased granularity, with a move from around 9 sections to over 20 sections; sections are only included when relevant information has been identiﬁed. The following information describes these sections and their uses in more detail. The dose panel also contains, where known, an indication of pharmacokinetic considerations that may affect the choice of dose, and dose equivalence information, which may aid the selection of dose when switching between drugs or preparations. The BNF includes unlicensed use of medicines when the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience. When the BNF recommends an unlicensed medicine or the ‘off-label’ use of a licensed medicine, this is shown below the indication and dose panel in the unlicensed use section. Nomenclature Minimising harm and drug safety Monograph titles follow the convention of recommended international non-proprietary names (rINNs), or, in the absence of a rINN, British Approved Names. Relevant synonyms are included below the title and, in some instances a brief description of the drug action is included. Over future editions these drug action statements will be rolled out for all drugs. In some monographs, immediately below the nomenclature or drug action, there are a number of cross references or ﬂags used to signpost the user to any additional information they need to consider about a drug. This is most common for drugs formulated in combinations, where users will be signposted to the monographs for the individual ingredients (e.g. senna with ispaghula husk p. 65) or for drugs that are related to a drug class monograph (see Drug class monographs, below). Copyright © 2023. Pharmaceutical Press. All rights reserved. Indication and dose User feedback has highlighted that one of the main uses of the BNF is identifying indications and doses of drugs. Therefore, indication and dose information has been promoted to the top of the monograph and highlighted by a coloured panel to aid quick reference. The indication and dose section is more highly structured than in earlier editions, giving greater clarity around which doses should be used for which indications and by which route. In addition, if the dose varies with a speciﬁc preparation or formulation, that dosing information has been moved out of the preparations section and in to the indication and dose panel, under a heading of the preparation name. Doses are either expressed in terms of a deﬁnite frequency (e.g. 1 g 4 times daily) or in the total daily dose format (e.g. 6 g daily in 3 divided doses); the total daily dose should be divided into individual doses (in the second example, the patient should receive 2 g 3 times daily). Doses for speciﬁc patient groups (e.g. the elderly) may be included if they are different to the standard dose. Doses for children can be identiﬁed by the relevant age range and may vary according to their age or body-weight. In earlier editions of the BNF, age ranges and weight ranges overlapped. For clarity and to aid selection of the correct dose, wherever possible these age and weight ranges now do not overlap. When interpreting age ranges it is important to understand that a patient is considered to be 64 up until the point of their 65th birthday, meaning that an age range of adult 18 to 64 is applicable to a patient from the day of their 18th birthday until the day before their 65th birthday. All age ranges should be interpreted in this way. Similarly, when interpreting weight ranges, it should be understood that a weight of up to 30 kg is applicable to a patient up to, but not including, the point that they tip the scales at 30 kg and a weight range of 35 to 59 kg is applicable to a patient as soon as they tip the scales at 35 kg right up until, but not including, the point that they tip the scales at 60 kg. All weight ranges should be interpreted in this way. In all circumstances, it is important to consider the patient in question and their physical condition, and select the dose most appropriate for the individual. Other information relevant to Indication and dose The drug chosen to treat a particular condition should minimise the patient’s susceptibility to adverse effects and, where co-morbidities exist, have minimal detrimental effects on the patient’s other diseases. To achieve this, the Contraindications, Cautions and Side-effects of the relevant drug should be reviewed. The information under Cautions can be used to assess the risks of using a drug in a patient who has co-morbidities that are also included in the Cautions for that drug—if a safer alternative cannot be found, the drug may be prescribed while monitoring the patient for adverse-effects or deterioration in the co-morbidity. Contra-indications are far more restrictive than Cautions and mean that the drug should be avoided in a patient with a condition that is contra-indicated. The impact that potential side-effects may have on a patient’s quality of life should also be assessed. For instance, in a patient who has difﬁculty sleeping, it may be preferable to avoid a drug that frequently causes insomnia. The Important safety advice section in the BNF, delineated by a coloured outline box, highlights important safety concerns, often those raised by regulatory authorities or guideline producers. Safety warnings issued by the Commission on Human Medicines (CHM) or Medicines and Healthcare products Regulatory Agency (MHRA) are found here. Drug selection should aim to minimise drug interactions. If it is necessary to prescribe a potentially serious combination of drugs, patients should be monitored appropriately. The mechanisms underlying drug interactions are explained in Appendix 1, followed by details of drug interactions. Use of drugs in specific patient populations Drug selection should aim to minimise the potential for drug accumulation, adverse drug reactions, and exacerbation of pre-existing hepatic or renal disease. If it is necessary to prescribe drugs whose effect is altered by hepatic or renal disease, appropriate drug dose adjustments should be made, and patients should be monitored adequately. The general principles for prescribing are outlined under Prescribing in hepatic impairment p. 20, and Prescribing in renal impairment p. 20. Information about drugs that should be avoided or used with caution in hepatic disease or renal impairment can be found in drug monographs under Hepatic impairment and Renal impairment (e.g. ﬂuconazole p. 657). Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xii BNF 85 Typical layout of a monograph and associated medicinal forms * 1 Class Monographs and drug monographs In most cases, all information that relates to an individual drug is contained in its drug monograph and there is no symbol. Class monographs have been created where substantial amounts of information are common to all drugs within a drug class, these are indicated by a flag symbol in a circle: f Class monograph * 1 CLASSIFICATION * 2 Drug monograph * 1 Drug monographs with a corresponding class monograph are indicated by a tab with a flag symbol: ! F 1234 The page number of the corresponding class monograph is indicated within the tab. For further information, see How to use BNF Publications eiii F 1234i * 3 01-Jun-2016 (Synonym) another name by which a drug may be known l DRUG ACTION how a drug exerts its effect in the body l INDICATIONS AND DOSE Indications are the clinical reasons a drug is used. The dose of a drug will often depend on the indications Indication * 2 Drug classifications Used to inform users of the class of a drug and to assist in finding other drugs of the same class. May be based on pharmacological class (e.g. opioids) but can also be associated with the use of the drug (e.g. cough suppressants) ▶ ROUTE ▶ Age groups: [Child/Adult/Elderly] Dose and frequency of administration (max. dose) SPECIFIC PREPARATION NAME * 4 Indication * 3 Review date ▶ ROUTE ▶ Age groups: The date of last review of the content [Child/Adult/Elderly] Dose and frequency of administration (max. dose) DOSE ADJUSTMENTS DUE TO INTERACTIONS dosing information when used concurrently with other drugs DOSES AT EXTREMES OF BODY-WEIGHT dosing information for patients who are overweight or underweight DOSE EQUIVALENCE AND CONVERSION information around the bioequivalence between formulations of the same drug, or equivalent doses of drugs that are members of the same class PHARMACOKINETICS how the body affects a drug (absorption, distribution, metabolism, and excretion) POTENCY a measure of drug activity expressed in terms of the concentration required to produce an effect of given intensity * 4 Specific preparation name If the dose varies with a specific preparation or formulation it appears under a heading of the preparation name l Copyright © 2023. Pharmaceutical Press. All rights reserved. f UNLICENSED USE describes the use of medicines outside the terms of their UK licence (off-label use), or use of medicines that have no licence for use in the UK IMPORTANT SAFETY INFORMATION Information produced and disseminated by drug regulators often highlights serious risks associated with the use of a drug, and may include advice that is mandatory l l l l l l CONTRA-INDICATIONS circumstances when a drug should be avoided CAUTIONS details of precautions required INTERACTIONS when one drug changes the effects of another drug; the mechanisms underlying drug interactions are explained in Appendix 1 SIDE-EFFECTS listed in order of frequency, where known, and arranged alphabetically ALLERGY AND CROSS-SENSITIVITY for drugs that carry an increased risk of hypersensitivity reactions CONCEPTION AND CONTRACEPTION potential for a drug to have harmful effects on an unborn child when prescribing for a woman of childbearing age or for a man trying to father a child; information on the effect of drugs on the efﬁcacy of latex condoms or diaphragms Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xiii BNF 85 l l l l l l l l l l l l l l Copyright © 2023. Pharmaceutical Press. All rights reserved. l l l PREGNANCY advice on the use of a drug during pregnancy BREAST FEEDING g advice on the use of a drug during breast feeding h * 5 HEPATIC IMPAIRMENT advice on the use of a drug in hepatic impairment RENAL IMPAIRMENT advice on the use of a drug in renal impairment PRE-TREATMENT SCREENING covers one off tests required to assess the suitability of a patient for a particular drug MONITORING REQUIREMENTS speciﬁes any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow therapeutic index EFFECTS ON LABORATORY TESTS for drugs that can interfere with the accuracy of seemingly unrelated laboratory tests TREATMENT CESSATION speciﬁes whether further monitoring or precautions are advised when the drug is withdrawn DIRECTIONS FOR ADMINISTRATION practical information on the preparation of intravenous drug infusions; general advice relevant to other routes of administration PRESCRIBING AND DISPENSING INFORMATION practical information around how a drug can be prescribed and dispensed including details of when brand prescribing is necessary HANDLING AND STORAGE includes information on drugs that can cause adverse effects to those who handle them before they are taken by, or administered to, a patient; advice on storage conditions PATIENT AND CARER ADVICE for drugs with a special need for counselling PROFESSION SPECIFIC INFORMATION provides details of the restrictions certain professions such as dental practitioners or nurse prescribers need to be aware of when prescribing on the NHS NATIONAL FUNDING/ACCESS DECISIONS references to NICE Technology Appraisals, SMC advice and AWMSG advice LESS SUITABLE FOR PRESCRIBING preparations that are considered by the Joint Formulary Committee to be less suitable for prescribing EXCEPTION TO LEGAL CATEGORY advice and information on drugs which may be sold without a prescription under speciﬁc conditions * 5 Evidence grading Evidence grading to reflect the strengths of recommendations will be applied as content goes through the revalidation process. A five level evidence grading system based on the former SIGN grading system has been adopted. The grades h i j k l are displayed next to the recommendations within the text, and are preceded by the symbol: g The symbol M indicates manufacturer information For further information, see How BNF Publications are constructed * 6 Legal categories P This symbol has been placed against those preparations that are available only on a prescription issued by an appropriate practitioner. For more detailed information see Medicines, Ethics and Practice, London, Pharmaceutical Press (always consult latest edition) a b c d e m These symbols indicate that the preparations are subject to the prescription requirements of the Misuse of Drugs Act For regulations governing prescriptions for such preparations, see Controlled Drugs and Drug Dependence Not all monographs include all possible sections; sections are only included when relevant information has been identified MEDICINAL FORMS Form CAUTIONARY AND ADVISORY LABELS if applicable EXCIPIENTS clinically important but not comprehensive [consult manufacturer information for full details] ELECTROLYTES if clinically signiﬁcant quantities occur ▶ Preparation name (Manufacturer/Non-proprietary) Drug name and strength pack sizes P * 6 Prices Combinations available this indicates a combination preparation is available and a cross reference page number is provided to locate this preparation Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xiv Similarly, drug selection should aim to minimise harm to the fetus, nursing infant, and mother. The infant should be monitored for potential side-effects of drugs used by the mother during pregnancy or breast-feeding. The general principles for prescribing are outlined under Prescribing in pregnancy p. 24 and Prescribing in breast-feeding p. 24. The Treatment Summaries provide guidance on the drug treatment of common conditions that can occur during pregnancy or breast-feeding (e.g. Venous thromboembolism p. 126). Information about the use of speciﬁc drugs during pregnancy and breast-feeding can be found in their drug monographs under Pregnancy, and Breast-feeding (e.g. ﬂuconazole p. 657). A section, Conception and contraception, containing information around considerations for females of childbearing potential or men who might father a child (e.g. isotretinoin p. 1392) has been included. The prescriber and the patient should agree on the health outcomes that the patient desires and on the strategy for achieving them. Taking the time to explain to the patient (and carers) the rationale and the potential adverse effects of treatment may improve adherence. For some medicines there is a special need for counselling (e.g. appropriate posture during administration of doxycycline p. 623); this is shown in Patient and carer advice. Other information contained in the latter half of the monograph also helps prescribers and those dispensing medicines choose medicinal forms (by indicating information such as ﬂavour or when branded products may not be interchangeable (e.g. diltiazem hydrochloride p. 174), assess the suitability of a drug for prescribing, understand the NHS funding status for a drug (e.g. sildenaﬁl p. 891), or assess when a patient may be able to purchase a drug without prescription (e.g. loperamide hydrochloride p. 69). In earlier editions, when a particular preparation had safety information, dose advice or other clinical information speciﬁc to the product, it was contained within the preparations section. This information has been moved to the relevant section in the main body of the monograph under a heading of the name of the speciﬁc medicinal form (e.g. peppermint oil p. 49). The medicinal forms (formerly preparations) section provides information on the type of formulation (e.g. tablet), the amount of active drug in a solid dosage form, and the concentration of active drug in a liquid dosage form. The legal status is shown for prescription-only medicines and controlled drugs, as well as pharmacy medicines and medicines on the general sales list. Practitioners are reminded, by a statement under the heading of “Medicinal Forms” that not all products containing a speciﬁc drug ingredient may be similarly licensed. To be clear on the precise licensing status of speciﬁc medicinal forms, practitioners should check the product literature for the particular product being prescribed or dispensed. Details of all medicinal forms available on the dm+d for each drug in BNF Publications appears online on MedicinesComplete. In print editions, due to space constraints, only certain branded products are included in detail. Where medicinal forms are listed they should not be inferred as equivalent to the other brands listed under the same form heading. For example, all the products listed under a heading of “Modiﬁed release capsule” will be available as modiﬁed release capsules, however, the brands listed under that form heading may have different release proﬁles, the available strengths may vary and/or the products may have different licensing information. As with earlier editions of the BNF, practitioners must ensure that the particular product being prescribed or dispensed is appropriate. As medicinal forms are derived from dm+d data, some drugs may appear under names derived from that data; this may vary slightly from those in previous BNF versions, e.g. sodium acid phosphate, is now sodium dihydrogen phosphate anhydrous. Patients should be prescribed a preparation that complements their daily routine, and that provides the right dose of drug for the right indication and route of administration. When dispensing liquid preparations, a sugar-free preparation should always be used in preference to one containing sugar. Patients receiving medicines containing cariogenic sugars should be advised of appropriate dental hygiene measures to prevent caries. In earlier editions, the BNF only included excipients and electrolyte information for proprietary medicines. This information is now covered at the level of the dose form (e.g. tablet). It is not possible to keep abreast of all of the generic products available on the UK market, and so this information serves as a reminder to the healthcare professional that, if the presence of a particular excipient is of concern, they should check the product literature for the particular product being prescribed or dispensed. Cautionary and advisory labels that pharmacists are recommended to add when dispensing are included in the medicinal forms section. Details of these labels can be found in Appendix 3, Guidance for cautionary and advisory labels p. 1802. As these labels have now been applied at the level of the dose form, a full list of medicinal products with their relevant labels would be extensive. This list has therefore been removed, but the information is retained within the monograph. In the case of compound preparations, the prescribing information for all constituents should be taken into account. Medicinal forms Prices in the BNF Administration and monitoring Copyright © 2023. Pharmaceutical Press. All rights reserved. BNF 85 When selecting the most appropriate drug, it may be necessary to screen the patient for certain genetic markers or metabolic states. This information is included within a section called Pre-treatment screening (e.g. abacavir p. 711). This section covers one-off tests required to assess the suitability of a patient for a particular drug. Once the drug has been selected, it needs to be given in the most appropriate manner. A Directions for administration section contains the information about intravenous administration previously located in Appendix 4. This provides practical information on the preparation of intravenous drug infusions, including compatibility of drugs with standard intravenous infusion ﬂuids, method of dilution or reconstitution, and administration rates. In addition, general advice relevant to other routes of administration is provided within this section (e.g. fentanyl p. 495). After selecting and administering the most appropriate drug by the most appropriate route, patients should be monitored to ensure they are achieving the expected beneﬁts from drug treatment without any unwanted sideeffects. The Monitoring section speciﬁes any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow therapeutic index (e.g. theophylline p. 299). Monitoring may, in certain cases, be affected by the impact of a drug on laboratory tests (e.g. hydroxocobalamin p. 1133), and this information is included in Effects on laboratory tests. In some cases, when a drug is withdrawn, further monitoring or precautions may be advised (e.g. clonidine hydrochloride p. 162): these are covered under Treatment cessation. Choice and supply In the BNF, preparations follow immediately after the monograph for the drug that is their main ingredient. Basic NHS net prices are given in the BNF to provide an indication of relative cost. Where there is a choice of suitable Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xv BNF 85 Copyright © 2023. Pharmaceutical Press. All rights reserved. preparations for a particular disease or condition the relative cost may be used in making a selection. Cost-effective prescribing must, however, take into account other factors (such as dose frequency and duration of treatment) that affect the total cost. The use of more expensive drugs is justiﬁed if it will result in better treatment of the patient, or a reduction of the length of an illness, or the time spent in hospital. Prices are regularly updated using the Drug Tariff and proprietary price information published by the NHS dictionary of medicines and devices (dm+d, www.nhsbsa.nhs. uk/pharmacies-gp-practices-and-appliance-contractors/ dictionary-medicines-and-devices-dmd). The weekly updated dm+d data (including prices) can be accessed using the dm+d browser of the NHS Business Services Authority (services. nhsbsa.nhs.uk/dmd-browser/). Prices have been calculated from the net cost used in pricing NHS prescriptions and generally reﬂect whole dispensing packs. Prices for extemporaneously prepared preparations are not provided in the BNF as prices vary between different manufacturers. In Appendix 4, prices stated are per dressing or bandage. BNF prices are not suitable for quoting to patients seeking private prescriptions or contemplating over-the-counter purchases because they do not take into account VAT, professional fees, and other overheads. A fuller explanation of costs to the NHS may be obtained from the Drug Tariff. Separate drug tariffs are applicable to England and Wales (www.nhsbsa.nhs.uk/pharmacies-gppractices-and-appliance-contractors/drug-tariff), Scotland (www. isdscotland.org/Health-Topics/Prescribing-and-Medicines/ Scottish-Drug-Tariff/), and Northern Ireland (www.hscbusiness. hscni.net/services/2034.htm); prices in the different tariffs may vary. Drug class monographs In earlier editions of the BNF, information relating to a class of drugs sharing the same properties (e.g. tetracyclines p. 623), was contained within the prescribing notes. In the updated structure, drug class monographs have been created to contain the common information; this ensures such information is easier to ﬁnd, and has a more regularised structure. For consistency and ease of use, the class monograph follows the same structure as a drug monograph. Class monographs are indicated by the presence of a ﬂag f (e.g. beta-adrenoceptor blockers (systemic) p. 165). If a drug monograph has a corresponding class monograph, that needs to be considered in tandem, in order to understand the full information about a drug, the monograph is also indicated by a ﬂag eiii F 1234 i (e.g. metoprolol tartrate p. 171). Within this ﬂag, the page number of the drug class monograph is provided (e.g. 1234), to help navigate the user to this information. This is particularly useful where occasionally, due to differences in therapeutic use, the drug monograph may not directly follow the drug class monograph (e.g. sotalol hydrochloride p. 117). Advanced wound contact dressings have been classiﬁed in order of increasing absorbency. Other useful information Finding significant changes in the BNF. Changes, provides a list of signiﬁcant changes, dose changes, classiﬁcation changes, new names, and new preparations that have been incorporated into the BNF, as well as a list of preparations that have been discontinued and removed from the BNF. Changes listed online are cumulative (from one print edition to the next), and can be printed off each month to show the main changes since the last print edition as an aide memoire for those using print copies. So many changes are made for each update of the BNF, that not all of them can be accommodated in the Changes section. We encourage healthcare professionals to regularly review the prescribing information on drugs that they encounter frequently;. Changes to the Dental Practioners’ Formulary, are located at the end of the Dental List;. E-newsletter, the BNF & BNF for Children e-newsletter service is available free of charge. It alerts healthcare professionals to details of signiﬁcant changes in the clinical content of these publications and to the way that this information is delivered. Newsletters also review clinical case studies, provide tips on using these publications effectively, and highlight forthcoming changes to the publications. To sign up for e-newsletters go to www.bnf.org. Using other sources for medicines information The BNF is designed as a digest for rapid reference. Less detail is given on areas such as obstetrics, malignant disease, and anaesthesia since it is expected that those undertaking treatment will have specialist knowledge and access to specialist literature. BNF for Children should be consulted for detailed information on the use of medicines in children. The BNF should be interpreted in the light of professional knowledge and supplemented as necessary by specialised publications and by reference to the product literature. Information is also available from medicines information services. Other content Nutrition Appendix 2, Borderline substances p. 1760, includes tables of ACBS-approved enteral feeds and nutritional supplements based on their energy and protein content. There are separate tables for specialised formulae for speciﬁc clinical conditions. Classiﬁed sections on foods for special diets and nutritional supplements for metabolic diseases are also included. Wound dressings A table on wound dressings in Appendix 4, Wound management products and elasticated garments p. 1805, allows an appropriate dressing to be selected based on the appearance and condition of the wound. Further information about the dressing can be found by following the crossreference to the relevant classiﬁed section in the Appendix. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xvi BNF 85 Changes Monthly updates are provided online via Medicines Complete and the NICE BNF website. The changes listed below are cumulative (from one print edition to the next). Copyright © 2023. Pharmaceutical Press. All rights reserved. Significant changes Signiﬁcant changes that appear in the print edition of BNF 85 (March — September 2023):. Anagrelide p. 1140: risk of thrombosis, including cerebral infarction, if treatment discontinued abruptly [MHRA/CHM advice].. Antibacterials, use for prophylaxis p. 548: updated guidance for the prevention of secondary cases of diphtheria, and addition of guidance for the prevention of intra-uterine infection in preterm prelabour rupture of membranes.. Contraceptives, interactions p. 870: updated guidance.. Controlled drugs and drug dependence p. 7: updated guidance on the prescribing of drugs associated with dependence and withdrawal.. COVID-19 vaccines p. 1423: updated guidance for immunisation.. Cystic ﬁbrosis transmembrane conductance regulator modulators: update to hepatic impairment advice (see example in ivacaftor p. 321).. Daratumumab p. 952 (Darzalex ®): updated pregnancy advice.. Denosumab p. 744 (Prolia ®): should not be used in patients under 18 years due to the risk of serious hypercalcaemia [MHRA/CHM advice].. Depression p. 395: updated guidance on management.. Dexmedetomidine p. 1486: clinical trial ﬁnds increased risk of mortality in intensive care unit (ICU) patients aged 65 years or younger [MHRA/CHM advice].. Diphtheria vaccine p. 1425: updated guidance for immunisation.. Epilepsy p. 333: updated guidance on management.. Gout p. 1235: updated guidance on management.. Herpesvirus infections p. 694: updated guidance for postexposure prophylaxis.. Hydrocortisone p. 754: addition of children’s dosing for adrenal crisis.. Hypertension p. 156: updated guidance for the management of patients with type 1 diabetes.. Immunisation schedule p. 1420: updated guidance for immunisation against inﬂuenza.. Inﬂuenza vaccine p. 1431: updated guidance for immunisation (updated September 2022).. Inﬂuenza vaccine p. 1431: updated guidance for immunisation (updated October 2022).. Meropenem with vaborbactam p. 572 [update to how dose is expressed].. Metformin hydrochloride p. 771: reduced vitamin B12 levels and new advice for monitoring patients at risk [MHRA/CHM advice].. Methylphenidate hydrochloride p. 383 long-acting (modiﬁed-release) preparations: caution if switching between products due to differences in formulations [MHRA/CHM advice].. Multiple sclerosis p. 928: updated guidance on management.. Nebulised asthma rescue therapy in children: home use of nebulisers in paediatric asthma should be initiated and managed only by specialists [MHRA/CHM advice] (advice in ipratropium bromide, salbutamol, terbutaline sulfate; see example in ipratropium bromide p. 268).. Obstetrics p. 900: updated guidance for preterm labour.. Ozanimod p. 936 (Zeposia ®): new indication for ulcerative colitis.. Rucaparib p. 1108 (Rubraca ®): withdrawal of third-line treatment indication [MHRA/CHM advice].. Tacrolimus p. 920: updated pregnancy, breast-feeding and monitoring advice.. Tezacaftor with ivacaftor and elexacaftor: name change to ivacaftor with tezacaftor and elexacaftor p. 321.. Topiramate p. 365 (Topamax ®): start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities in children with prenatal exposure [MHRA/CHM advice].. Type 1 diabetes p. 762: inclusion of continuous glucose monitoring in aims of treatment.. Type 2 diabetes p. 765: updated guidance for the use of non-insulin antidiabetic drugs.. Valaciclovir p. 698 [update to indication and doses in line with UK Health Security Agency recommendations on post-exposure prophylaxis for chickenpox and shingles]. Dose changes Changes in dose statements that appear in the print edition of BNF 85 (March — September 2023):. Abilify Maintena ® (aripiprazole p. 433) [addition of alternative initiation dosing].. Aciclovir p. 696 [update to indication and doses in line with UK Health Security Agency recommendations on post-exposure prophylaxis for chickenpox and shingles].. Benlysta ® (belimumab p. 924) [addition of subcutaneous dosing].. Budesonide p. 1324 [update to dosing for intranasal administration for rhinitis and nasal polyps].. Buprenorphine p. 486 [update to indications and dose for transdermal patches].. Cimzia ® (certolizumab pegol p. 1228) [update to dosing for ankylosing spondylitis].. Colecalciferol p. 1200 [update to dosing for primary prevention and treatment of Vitamin D deﬁciency].. Cyanocobalamin p. 1133 [update to indications and dose].. Empagliﬂozin p. 786 [update to indication and dose (age ranges and heart failure indication amended), and advice on use and dosing in renal impairment].. Ergocalciferol p. 1203 [update to dosing for primary prevention and treatment of Vitamin D deﬁciency].. Jorveza ® (budesonide p. 45) [update to dosing for eosinophilic oesophagitis].. Lacosamide p. 347 [update to age range for monotherapy and adjunctive treatment of focal seizures with or without secondary generalisation].. Melatonin p. 528 [update to dosing for jet lag].. Procyclidine hydrochloride p. 450 [update to dosing for parkinsonism and drug-induced extrapyramidal symptoms].. Sotrovimab p. 684 [update to indications and dose to remove body-weight from dose statement]. New monographs New monographs that appear in the print edition of BNF 85 (March — September 2023):. Aklief ® [trifarotene p. 1394].. Brukinsa ® [zanubrutinib p. 1104].. Bylvay ® [odevixibat p. 96].. Drovelis ® [drospirenone with estetrol p. 874].. Ducressa ® [dexamethasone with levoﬂoxacin p. 1293].. Exkivity ® [mobocertinib p. 1084].. Gavreto ® [pralsetinib p. 1092].. Giapreza ® [angiotensin II p. 204].. Hepcludex ® [bulevirtide p. 694].. Imcivree ® [setmelanotide p. 99].. Kapruvia ® [difelikefalin p. 1386].. Kerendia ® [ﬁnerenone p. 900].. Kimmtrak ® [tebentafusp p. 1110].. Magnesium citrate p. 1163.. Netildex ® [dexamethasone with netilmicin p. 1278]. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. BNF 85. Nettacin ® [netilmicin p. 1285].. NovoThirteen ® [factor XIII A-subunit (recombinant) p. 122].. Oxbryta ® [voxelotor p. 1125].. Padcev ® [enfortumab vedotin p. 956].. Palforzia ® [peanut protein p. 314].. Qinlock ® [ripretinib p. 1094].. Scemblix ® [asciminib p. 1059].. Sibnayal ® [potassium citrate with potassium bicarbonate p. 1146].. Tavneos ® [avacopan p. 923].. Tenkasi ® [oritavancin p. 585].. Vabysmo ® [faricimab p. 1306].. Vydura ® [rimegepant p. 516].. Vyepti ® [eptinezumab p. 514].. Welireg ® [belzutifan p. 1105].. Xerava ® [eravacycline p. 625]. New preparations New preparations that appear in the print edition of BNF 85 (March — September 2023):. Actimorph ® [morphine p. 500].. Aloﬂute ®, Avenor ®, Seffalair Spiromax ®, Sereﬂo Ciphaler ®, Stalpex ® [ﬂuticasone with salmeterol p. 287].. Dailiport ® [tacrolimus p. 920].. Efmody ® [hydrocortisone p. 754].. Nuvaxovid ® [COVID-19 vaccine p. 1452].. Ogluo ® [glucagon p. 804].. Orobalin ® [cyanocobalamin p. 1133].. Trimbow 172/5/9 ® [beclometasone with formoterol and glycopyrronium p. 282].. Uxil ® [dasatinib p. 1069].. WockAIR ® [budesonide with formoterol p. 283]. Deleted preparations Copyright © 2023. Pharmaceutical Press. All rights reserved. Deleted preparations since the print edition of BNF 84 (September 2022 — March 2023):. Codeine phosphate p. 492 solution for injection. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32. xvii Copyright © 2023. Pharmaceutical Press. All rights reserved. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 11:34:32.

BNF 85 (British National Formulary) March-September 2023 PDF

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