British National Formulary
How should I reference the BNF?
The Uniform Requirements for Manuscripts Submitted to Biomedical Journals (http://www.icmje.org), formerly referred to as the Vancouver convention, is preferred by many medical journals. The style for referencing the BNF using the Uniform Requirements for Manuscripts is as follows:
Joint Formulary Committee. British National Formulary. [edition number] ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; [year of publication]
Why do digital versions of the BNF expire but I can go on using a printed copy of the same edition as long as I want?
The information in the printed version of the BNF does actually expire. Under 'Significant changes' the BNF says,
'The BNF is revised twice yearly and numerous changes are made between issues. All copies of BNF No. … should therefore be withdrawn and replaced by BNF No. ….'
The BNF believes that there is now too much new information available for practitioners to keep abreast of it all. This was highlighted to us by a GP who was not aware of the change to recommendations regarding the dose of amoxicillin in pneumonia—he had not read the 'Changes for this edition' section at the front of his latest BNF.
The BNF is a point-of-care tool and as such it is important that it provides practitioners with the most up-to-date information on prescribing and dispensing medicines effectively and safely.
How often is BNF data updated?
Whilst the central BNF data is updated twice a year, the other pages on the website are updated on a more regular basis. The BNF text is compiled with the help of over fifty expert clinical advisers under the authority of the Joint Formulary Committee (comprising representatives of the two publishers and the Department of Health). This allows the publication to provide impartial, authoritative and practical advice and ensures that the BNF remains reliable. BNF's clinical advisers, the Joint Formulary Committee and the editorial team work together to:
The rigour and consultative nature of this process limit the frequency with which the BNF text can be updated and certainly preclude a monthly production cycle. However, the BNF has a good record of anticipating future recommendations even though it is a biannual rather than monthly publication. And, as indicated above, the BNF website is able to provide any vital information that comes to light between editions.
How is the BNF funded?
The BNF is entirely funded from sales made by the joint publishers, the British Medical Association and the Royal Pharmaceutical Society of Great Britain. The great bulk of sales are of the printed version and made to the Department of Health for distribution within the NHS. The publishers also sell the publication in both printed and electronic formats in the UK and the rest of the world.
Why does the BNF not include a disclaimer covering liability for its clinical content?
The BNF has often thought about adding a disclaimer. But we've come to the view that it really doesn't make any practical difference.
We take great care to ensure that our editorial processes are as robust as we can make them. So, we check that we have interpreted new data correctly and that the presentation of information is accurate and unambiguous. To this end we use expert clinical advisers to verify our data and, within the editorial team, subject the text to several layers of checking. Changes to clinical advice are also reviewed by the Joint Formulary Committee. Therefore, should the BNF be challenged, an important argument in our defence would be the rigour of our editorial processes; this strength comes not just from the mechanical processes but also from the experience, training and expertise of the personnel who contribute to the construction of the text.
The following summary points from an article by Brian Hurwitz (BMJ 1999; 318: 661-4) might also be relevant:
The publishers of the BNF and staff are insured against damage that might possibly result from the BNF's advice.
How do I go get permission to reproduce information from the BNF?
Permission to reproduce material from the BNF is granted in certain circumstances and should be sought from
BNF,Please note that the publishers do not permit the reproduction of any part of the BNF for promotional purposes.
Many websites provide information on medicines. What's special about BNF.org?
BNF.org includes the entire content of the British National Formulary, which is widely regarded by doctors, pharmacists and other healthcare professionals as an up to date and highly authoritative information resource on medicines prescribed in the UK. BNF.org also includes supplementary information of relevance to those with an interest in the effective use of medicines.
The BNF is published jointly by the British Medical Association and the Royal Pharmaceutical Society of Great Britain. The NHS purchases a large number of copies of each edition and provides them to NHS doctors and pharmacists, to hospital wards and clinics and to medical and pharmacy students. A Joint Formulary Committee (comprising representatives of the two publishers and the Department of Health) is responsible for the content of the BNF - this allows the publication to provide impartial, authoritative and practical advice.
Find out about how the BNF is constructed.
Can the BNF office offer advice about the treatment of my specific condition?
We regret that we are unable to comment on individual cases and we cannot enter into correspondence with patients (or their relatives). These matters are best dealt with by properly qualified professionals who are familiar with all the circumstances surrounding the case.
Whereas the BNF tries to give the best possible advice on treatment, there are sometimes special circumstances when the doctor may want to deviate from this advice.
Corresponding with the BNF
The BNF receives a great many comments and it is not always possible to acknowledge each one or to specify what action the BNF will take in response. However, we are very grateful for the comments and we will consider each comment carefully. The comments which the BNF is most likely to respond to are those received from the intended audience of the BNF (healthcare professionals dealing with medicines), especially when there is definite concern about the correct use of medicines. Before making an enquiry to the editorial department, the BNF also expects healthcare professionals to have checked other sources of information, including a medicines information centre. More advice about this is available on our Contacts page.
Readers of the BNF should note that the BNF is an aide memoire (for use by practitioners with a high level of background knowledge about medicines) and the BNF cannot be exhaustive in its coverage. Supplementary information is available from the summaries of product characteristics of individual products and from works such as Martindale: the complete drug reference as well as from medicines information centres.
Why does the BNF no longer list preparations on sale to the public?
Owing to the large number of frequently changing products that are available for purchase, it has become difficult to maintain the lists accurately and the Joint Formulary Committee considers that incomplete or out of date information is potentially dangerous. To identify the active ingredients in preparations on sale to the public, it is safer to consult the product literature or the manufacturer.
Why are herbal and homeopathic remedies not included in the BNF?
We appreciate that such an expansion of the BNF would enable practitioners to access various options from a single volume. However, to expand the BNF in this way is unlikely to be practicable currently.
The infrastructure of the BNF (the Joint Formulary Committee, the clinical advisers and the editorial staff) has been set up to possess special expertise and knowledge on the use of conventional medicines. Such a structure enables the BNF to provide authoritative information. In order to provide reliable and authoritative information on homeopathic or herbal medicines, it would be necessary to set up a parallel structure with specific expertise in complementary medicine. It would be very difficult to achieve this and to include all the information in one volume which provides advice on the selection of both types of medicines would add a further level of complexity. In short, we feel that it is best for the BNF to focus on what it does best! To expand its scope could risk devaluing the product.
Nevertheless, we are sympathetic to healthcare professionals' needs and we are looking into ways of providing information on complementary medicines without compromising the core content of the BNF.
Why has the BNF changed the names of some drugs? Why does the BNF use adrenaline and not epinephrine?
European law requires the use of the Recommended International Non-proprietary Name (rINN) for medicinal substances. In most cases the familiar British Approved Name (BAN) and the rINN are identical. Where they were different the BANs have been amended to conform to the rINNs. The only exception to this is adrenaline and noradrenaline.
Adrenaline and noradrenaline are the terms used in the titles of monographs in the European Pharmacopoeia and are thus the official names in the member states. For these substances the British Pharmacopoeia shows the European Pharmacopoeia names and the rINNs (epinephrine and norepinephrine respectively) at the head of the monographs; the BNF uses a similar style.
The list of commonly used substances whose names have been affected by the name change is available here.
How are the prices in the BNF calculated?
Prices are included in the BNF to allow comparison between products. They are not suitable for quoting to patients since they do not include elements such as container allowance and professional fees.
Prices in the BNF are generally calculated from the net cost used in pricing NHS prescriptions. This information comes from the Prescription Pricing Division and is updated each edition. Suitable original packs or patient packs are usually priced as the basis for comparison, but the unit of 20 is still sometimes used for tablets and capsules particularly if a suitable patient pack is not available.
Where does the BNF get its information?
Find out how the BNF is constructed.
Why is there sometimes a discrepancy between a product SPC and the BNF monograph?
The most important source of information on drug entries is the manufacturer's product literature (including Summaries of Product Characteristics and Patient Information Leaflets). However, the BNF entries may not be entirely consistent with the manufacturers' literature because the entries are constructed according to internal editorial guidelines; the following examples illustrate how the BNF 'rules' are applied:
Information from other sources (such as
journal articles, CSM statements and expert advice) may also be
incorporated into the BNF drug entries.
For some drugs there is good reason to include indications or
doses that are inconsistent with those in the Summaries of Product
Characteristics. In such cases the BNF verifies its information
with clinical literature and with expert advisers.
Why does the BNF include information on some 'unlicensed' medicines?
Occasionally where a particular clinical need has been identified, the BNF gives information on the use of unlicensed medicines or for the use of licensed medicines in an unlicensed way ('off-label' use). Such information is included on the basis of robust evidence of safety and efficacy, and advice from clinical experts.
How does BNF.org choose links to other websites?
The inclusion of links to other websites is at the discretion of the BNF. Criteria for linking to other websites include:
Why doesn't the BNF recommend brand-name prescribing for all modified-release preparations?
The MHRA recommends that all modified-release preparations should be prescribed by their brand name.
The BNF warns against changing brands only where there is the possibility of significant clinical impact (e.g. loss of clinical control or increased risk of adverse effects). In many instances, variation that results from non-bioequivalence is likely to have a smaller effect than other factors that determine absorption and distribution of the drug (e.g. not taking the medicine exactly on time and varying the time of taking the medicine with respect to food). For these reasons the BNF does not highlight the need to keep to the same brand for every modified-release drug.
Is it safe to prescribe products containing arachis (peanut) oil where peanut allergy is known or suspected?
Oils obtained from nuts can be said to be "crude" or "refined". A report in 1998 from the Department of Health's Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment has advised that refined arachis oil does not contain allergenic peanut proteins. As Arachis Oil BP contains refined arachis oil it is unlikely to cause a reaction in those with peanut allergy.
A further distinction needs to be made between those substances (in topical products) that are associated with skin sensitisation and those which cause systemic reactions (e.g. anaphylaxis), such as peanut proteins. The list of sensitising excipients in section 13.1.3 of the BNF includes only those substances that are associated with skin sensitisation; arachis oil is not thought to sensitise the skin.
However, the manufacturer should be contacted if it is essential to check details and the BNF or the product literature does not provide the necessary information.
The report of the Department of Health's Committee can be found on the Department of Health website.
How do I report a suspected adverse drug reaction?
Doctors, dentists, coroners, pharmacists, and nurses are strongly encouraged to report suspected adverse drug reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) via the Yellow Card Scheme; patients, parents, and carers are also encouraged to report suspected adverse reactions directly to the MHRA. Yellow Cards can be found at the back of printed copies of the BNF and sent to the MHRA via FREEPOST, or can be completed on-line.
Should I report all suspected adverse drug reactions?
For established drugs and vaccines all serious suspected reactions should be reported. These are reactions which are fatal, life-threatening, incapacitating, disabling, or which result in prolonged hospitalisation; they should be reported even if the reaction is well recognised.
Newer drugs and vaccines are subject to intense monitoring and they are denoted in the BNF by the symbol 
. Doctors and pharmacists are asked to report all suspected reactions, however minor, which could conceivably be attributed to these drug, even if causality is uncertain or other drugs are being given concurrently.
See the BNF for more details about reporting adverse drug reactions.
Why has the IV digoxin rate changed from 10-20 minutes to an infusion over 2 hours?
On the whole, the BNF reflects licensed doses. However, sometimes, because of safety, efficacy or for practical considerations, the BNF does provide alternative advice. On these occasions the advice is carefully verified by expert clinicians and it is vetted by the Joint Formulary Committee. The dose of intravenous digoxin is an example of this.
Advice to infuse digoxin 0.75-1 mg over at least 2 hours has been in the BNF for many years. However, in editions prior to BNF 42, this advice was in the preamble to section 2.1.1. The digoxin entry reflected the licensed dose and it included a cross-reference to the notes for an alternative regimen. This was confusing. Therefore, for BNF 42, the licensed dose was dropped after, once again, confirming the appropriateness of the alternative dose with expert advisers and with the Joint Formulary Committee. BNF 43 was amended further to warn that even after intravenous administration, response may take a number of hours and persistence of tachycardia is not an indication for exceeding the dose recommended.
Our expert clinical advisers commend the 'alternative regimen' for digoxin infusion in the BNF, because it is simple, safe and more practical. They point out that the licensed regimen is more complicated and it is no safer; indeed, problems have been reported with the administration of 500 micrograms over 10-20 minutes, particularly in elderly patients. We have not been able to establish a clear rationale for the licensed regimen of digoxin in current therapeutics.
You may wish to consult Diseases of the heart, second edition (edited by DG Julian, AJ Camm, KM Fox, RJC Hall and PA Poole-Wilson) which also shows a digoxin dose of 0.75-1 mg over 2 hours.
Why does the BNF advise that streptokinase should not be used again beyond 4 days of first using it?
The BNF advises that streptokinase (section 2.10.2) should not be used if a second dose of this drug is needed more than 4 days after first using it. Streptokinase should also be avoided if anistreplase (no longer on the UK market) has been used in the past.
Antibodies to streptokinase develop soon after using it. These antibodies bind to streptokinase and reduce the effectiveness of subsequent treatment with this thrombolytic drug. Although some manufacturers' literature suggests that streptokinase needs to be avoided only for a finite period, the BNF has received expert advice that streptokinase should not be used again beyond 4 days of first using it.
An editorial in the BMJ1 also came to a similar conclusion; it includes useful references.
Why does the BNF consider it unnecessary to increase the dose of atenolol above 50 mg daily in hypertension?
In view of expert advice, the Joint Formulary Committee of the BNF agreed in 2005 that the BNF should indicate that a dose of atenolol 25–50mg is usually adequate for the treatment of hypertension. The advice is consistent with published papers1, 2. There is also an article in Drugs3 that provides useful background.
The BNF is under continuous review and the dose advice for atenolol will be reviewed in the light of any new studies.
Why does the BNF not recommend brand-name prescribing of modified-release opioids?
The BNF has not seen any evidence to indicate that switching between brands of modified-release opioids that have the same release profile (e.g. between different brands of 12-hourly oral morphine, or between different brands of fentanyl patch) alters the therapeutic effect. Furthermore, when used in accordance with the product licence, there are no grounds for a clinical difference between brands of fentanyl patch.
A suggestion has been made that brand-name prescribing of opioids should be adopted on grounds of safety. However, the BNF is not clear why modified-release opioids should be treated differently to other drugs commonly associated with medication errors (e.g. carbamazepine), or, indeed, other drugs in general. We have not seen any evidence to show that brand-name prescribing of modified-release opioids would have a significant impact on the incidence of medication errors associated with these preparations—if users of the BNF know of such evidence, we would be pleased to consider it.
Why doesn't the BNF include the new warning label for aspirin: "Do not give to children aged under 16 years, unless on the advice of a doctor"?
The notes at the beginning of appendix 9 in the BNF provide details about the scope of cautionary advisory labels. The Joint Formulary Committee recently agreed to include the following clarification to BNF 47 (March 2004):
"The label wordings recommended by the BNF apply to medicines dispensed against a prescription. Patients should be aware that a dispensed medicine should never be taken by, or shared with, anyone other than for whom the prescriber intended it. Therefore, the BNF does not include warnings against the use of a dispensed medicine by persons other than for whom it was specifically prescribed."
Why does the BNF say that nicotine replacement therapy 'is regarded as the pharmacological treatment of choice in the management of smoking cessation'? NICE guidance [March 2002] does not make such a distinction between nicotine replacement therapy and bupropion.
Nicotine replacement therapy products as well as bupropion are licensed for the management of smoking cessation in nicotine-dependent individuals. Working simply from the marketing authorisation (i.e. licensed indications), either product could be used to help individuals stop smoking. However, the BNF aims to help health professionals choose a medicine and therefore it has to make an assessment that goes beyond the marketing authorisation.
BNF's advice is based on evidence and on an expert view of clinical practice. The Joint Formulary Committee reviews this advice. Where two treatment options offer similar outcome, choice is guided by an assessment of risks. The use of nicotine replacement products by an individual who is already accustomed to nicotine introduces few new risks. Furthermore, nicotine replacement therapy is available in a wide variety of formulations, giving greater scope for choosing one that is most likely to work for a given individual. Many nicotine replacement therapy products can be supplied without a prescription.
The BNF's stance on smoking-cessation products is consistent with other opinions (e.g. Martindale: The Complete Drug Reference 33rd edition and Prescrire International 2001; 10: 163-7). In formulating its advice, the BNF received advice from expert advisers in addictive behaviour.
The BNF's advice does not preclude use of alternatives to nicotine replacement therapy. It would be perfectly justifiable for a healthcare professional and the individual wanting to stop smoking to choose another product for good reasons.
Why doesn't the BNF include more detail about drugs used for the management of malignant disease?
Chapter 8 of the BNF includes information about the indications of cytotoxic drugs as well as some of the principal side-effects associated with them. Because oncology is an area that is likely to be managed by specialists, the BNF does not include detail of chemotherapy regimens. Such information is best obtained from up-to-date specialist literature. In addition, many cancer treatments take place within the context of clinical trials and it is not possible to include the necessary information in the BNF.
Information is included about doses of drugs that are given by mouth but information about drugs used by the parenteral route in chemotherapy regimens is omitted.
Why is the BNF's dose of colchicine for acute gout different from that in the product literature?
The BNF reflects the advice in the British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout (2007) and further expert advice that for the treatment of acute gout, colchicine should be given no more frequently than 2–4 times daily. This dose is preferred to the licensed dose of every 2–3 hours because, while remaining effective, it is less likely to cause side-effects.
What is the source for the BNF advice on the expiry of eye drops?
Advice on expiry of eye drops was originally based on the advice of a Working Party convened by the Department of Health and Social Security in 1972. The BNF recognised that these recommendations pre-dated the use of plastic dropper bottles and improvements to preservative systems. However, it is our understanding that since the Department of Health has not rescinded these recommendations, they still remain in force.
Some changes (based on expert advice) have been made to reflect current practice. For example, the BNF has been amended as follows:
Definitive advice is not easy to give because the way eye drops are used in different institutions varies as do the conditions being treated. View the BNF's advice on the use of eye drops.
What is the risk of aplastic anaemia with chloramphenicol eye drops?
An association between the use of chloramphenicol eye drops and aplastic anaemia has been suggested. Case-control studies involving a population of 40 million people found no evidence of an increased risk.1 Another study,2 using a UK general practice database, identified 442 543 patients who received 674 148 prescriptions for chloramphenicol eye drops, 3 individuals experienced serious haematological toxicity.
Recommendations to avoid use of chloramphenicol eye drops therefore appear to be not well founded and the BNF considers it the drug of choice for superficial eye infections.
What has led to the change in the dose of nystatin oral suspension for treating oral and perioral candidal infections?
Until recently the BNF advised nystatin in a dose of 100 000 units 4 times daily for the treatment of candidal infections in patients of all ages. However, prompted by an enquiry to the BNF, clarification was sought from the marketing authorisation holder of Nystan Oral Suspension, Bristol-Myers Squibb. The company has confirmed that nystatin should be used for treating candidal infections only in individuals aged over 1 month (personal communication 6 December 2001).
In the light of the Summary of Product Characteristics for Nystan Oral Suspension and information from the marketing authorisation holder, the BNF and NPF were amended to show that nystatin oral suspension is not licensed for treating candidiasis in neonates under 1 month
Why are the proprietary preparations for ear wax removal denoted less suitable for prescribing?
In most cases simple remedies such as olive oil, almond oil or sodium bicarbonate ear drops are just as effective for the removal of ear wax as proprietary preparations and the simple remedies are less likely to cause irritation. Some proprietary preparations contain organic solvents, which can irritate the meatal skin. The BNF therefore considers proprietary preparations less suitable for prescribing. The use of proprietary preparations may however be justified in some circumstances.
Why are some ear drops that contain a combination of antimicrobial drugs considered to be less suitable for prescribing?
The BNF has been unable to find justification for the presence of more than one antimicrobial in some proprietary products. Obviously, the unnecessary administration of antibiotics should be avoided. Although the BNF considers such products to be less suitable for prescribing, their use may be justifiable in certain circumstances.
How does the BNF decide which drug interactions to include and what criteria are used for determining their clinical significance?
Interactions in the BNF are based on the Summary of Product Characteristics (SPCs), the medical literature and expert advice. The SPCs sometimes include 'theoretical interactions', not actually studied but predicted from knowledge of the cytochrome P450 isoenzymes involved in the drug's metabolism, the BNF does not usually add such theoretical interactions (unless the manufacturer contra-indicates a particular combination).
As for the significance of drug interactions, those that are potentially hazardous are shown in bold type on a red background, (a 'black spot' is used in the printed version of the BNF to denote a potentially hazardous interaction). It is not possible to define a type of interaction that will always be designated 'potentially hazardous'. For example, increased plasma concentration of one drug by another may be significant for a drug with a narrow therapeutic index, such as ciclosporin, but much less important for some other drugs. Interactions involving anticoagulants are often (but not always) designated 'potentially hazardous'.
The 'potentially hazardous' designation is not an indication of the likelihood of an interaction, but of how serious the potential effect could be if it occurred. Thus, combinations that might result in ventricular arrhythmia are designated 'potentially hazardous' even though it may occur very rarely.
Why does the BNF recommend an interval of 3 months between the end of treatment with methotrexate and conception?
The BNF advises avoidance of conception for 3 months following treatment with methotrexate. The advice takes account of the summaries of product characteristics (SPCs) for Maxtrex® tablets 10 mg (date of last revision March 2003), Wyeth's Methotrexate injection 25mg/mL (date of last revision May 2000), and Wyeth's Methotrexate tablets 10 mg (date of last revision May 2000).
The SPCs for the two strengths of Maxtrex® tablets differ in their recommendations; Maxtrex® 2.5mg SPC1 recommends avoidance of pregnancy for 6 months whereas Maxtrex® 10 mg SPC2 recommends avoidance of pregnancy for 3 months after discontinuation of methotrexate. The manufacturers as well as the Medicines and Healthcare products Regulatory Agency are aware of this discrepancy. The BNF understands that it is intended to standardise the advice to show that pregnancy should be avoided for 3 months after treatment with methotrexate.
Why does the BNF recommend a 24-hour expiry for drug additions to intravenous infusions not made in aseptic units?
The BNF advice on additions to intravenous infusions that are not made in an aseptic unit is based on popular opinion. The period of 24 hours is arbitrary; it represents a compromise between what is practical and what is safe. The BNF takes the view that the microbial hazard increases if the infusion fluid to which the additive has been made on the ward is stored much longer than 24 hours. As far as we know there is no evidence to indicate what might be a safe cut-off period; in the absence of such evidence, the BNF has provided an expert opinion. Obviously, rates of contamination when additions are made on the ward will depend on factors such as technique, equipment, and training.
Who decides on what foods and toiletries can be prescribed?
The Advisory Committee on Borderline Substances (ACBS) has identified certain foods and toiletry products which may be prescribed on the NHS for the management of specified conditions. Doctors should satisfy themselves that the products can safely be prescribed, that patients are adequately monitored and that, where necessary, expert hospital supervision is available.
What foods are listed in the BNF?
The BNF lists those food preparations which the Advisory Committee on Borderline Substances (ACBS) considers can be prescribed for certain specified conditions.
Who decides on what cautionary advisory labels should be used?
The wording of the advisory and cautionary labels was originally recommended by a working party of the Royal Pharmaceutical Society of Great Britain. The BNF's Joint Formulary Committee has subsequently made some minor adjustments to the wording of the existing labels.
The label or labels for each preparation are recommended after careful consideration of the information available. However, it is recognised that in some cases the information on the recommended label may be either incomplete or open to a different interpretation.
The BNF will be grateful to receive any constructive comments on the labelling suggested for any preparation.
Should the suggested cautionary advisory labels always be used?
It is recognised that there may be occasions when pharmacists will use their knowledge and professional discretion and decide to omit one or more of the recommended labels for a particular patient. In this case counselling takes on even greater importance.
There may also be occasions when a prescriber does not wish additional cautionary labels to be used, in which case the prescription should be endorsed 'NCL' (no cautionary labels). The exact wording that is required instead should then be specified on the prescription.
