British National Formulary
Welcome to BNF 55. We thought that it would be useful to inform you about some of the major changes in this edition. We also want to let you know about some of the changes to the online version and about the launch of our new e-newsletter.
In the glossy reference pages at the back of the book, there is now guidance on the community management of emergencies such as anaphylaxis and myocardial infarction. This new section provides doses of drugs used in such emergencies.
Information in the BNF is drawn from many sources: manufacturers’ product literature, medical and pharmaceutical literature, regulatory authorities and professional bodies. A description of how the national prescribing resource is constructed is provided.
BNF 55 (section 3.4.3) continues to take advice from the Resuscitation Council (UK) on the emergency treatment of anaphylactic reactions. We have once again worked closely with the working group to reflect the updated guideline (http://www.resus.org.uk) in BNF 55. Changes have been made to the doses of adrenaline by intramuscular and by intravenous injection; the guideline emphasises that adrenaline should usually be given by intramuscular injection; it should be given by slow intravenous injection only by specialists who are experienced in its use in their normal clinical practice.
The BNF editors and clinical advisers have reviewed the NICE guidelines on Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures (March 2008). BNF 55 (section 5.1) reflects these radical guidelines and advises that antimicrobial prophylaxis is no longer recommended for the prevention of endocarditis in patients undergoing dental and non-dental procedures. Prophylaxis may expose patients to the adverse effects of antimicrobials when the evidence of benefit has not been proven.
The guidance on the use of folic acid to reduce the risk of neural tube defects has been revised. BNF 55 (section 9.1.2) now includes more detailed advice on assessing whether a woman is at high risk of having a child with a neural tube defect and whether she should take folic acid 5 mg daily. Couples are considered to be at a high risk of conceiving a child with a neural tube defect if either partner has a neural tube defect (or either partner has a family history of neural tube defects), if they have had a previous pregnancy affected by a neural tube defect, or if the woman has coeliac disease (or other malabsorption state), diabetes mellitus, sickle-cell anaemia, or is taking antiepileptic medicines.
In view of the recent safety concerns raised by the MHRA and CHM (Drug Safety Update 2007; 1(5): 2-5), additional prescribing guidance has been included for erythropoietins. Evidence suggests that overcorrection of haemoglobin concentration in patients with chronic kidney disease may increase the risk of death and serious cardiovascular events, and in patients with cancer may increase the risk of thrombosis and related complications. BNF 55 (section 9.1.3) advises that patients may be treated with erythropoietins for the licensed indications in chronic kidney disease or cancer in patients receiving chemotherapy only if symptoms of anaemia are present, and that haemoglobin concentrations higher than 12 g/100 mL should be avoided.
Guidance on heart failure has been updated in BNF 55 (section 2.5.5) to take into account the recommendations of the SIGN clinical guideline: Management of Chronic Heart Failure (February 2007). This guideline emphasises that an ACE inhibitor and a beta-blocker are of value in any grade of heart failure due to left ventricular systolic dysfunction.
Guidance on angina and myocardial infarction has been updated in BNF 55 (section 2.6 and section 2.10.1) to take into account the recommendations of the SIGN clinical guidelines: Management of stable angina (February 2007) and Acute Coronary Syndromes (February 2007). The text on myocardial infarction also reflects the guidance issued by NICE in May 2007 on secondary prevention of myocardial infarction.
Guidance on the management of anticoagulated patients who require dental surgery has been updated (see Prescribing in Dental Practice) to take account of the recommendations of the British Committee for Standards in Haematology (Br Dental J 2007; 203: 389–93). The INR should be measured 72 hours before the dental procedure to allow time for dose modification, if necessary. The INR should be assessed within 24 hours of the dental procedure in those with an unstable INR. Patients with an INR of less than 4.0 who require minor dental procedures (including extractions) may continue warfarin without dose adjustment. There is no need to check the INR for a patient requiring a non-invasive dental procedure.
As part of our commitment to make the knowledge within the BNF more accessible, we have made a change to the way preparation records are displayed online. These preparation records are now displayed along with the relevant monograph above so that monograph-level information (warnings, side-effects, doses and so on) are displayed without additional navigation.
A new dimension has been added to the means of accessing BNF information with the development of an interface to the NHS Dictionary of Medicines and Devices. The NHS dm+d provides a standard way of representing medicines to clinicans within prescribing and dispensing systems. The new interface on bnf.org allows system suppliers to provide their healthcare professional users with a robust and secure means of accessing BNF knowledge directly from their clinical software applications.
Historically, the BNF has included only a very small number of monographs representing medicinal products with two active ingredients. Digital versions of BNF 55 include the first of a large number of additional multi-ingredient monographs. The new monographs are Ramipril with felodipine, Triamterene with furosemide, Co-amilofruse, and Co-tenidone. This development provides a more accurate representation of the characteristics of these preparations than has hitherto been possible in print, and crucially presents this information in a single location within the publication.
The BNF and BNFC are launching a combined free e-newsletter service. Newsletters will be issued several times a year and will be designed to keep you up to date with the latest changes that are influencing clinical practice.
Communications will include: details of significant updates; tips for using the BNF and BNFC effectively; latest developments on BNF and BNFC publications; and links to case studies and examples of prescribing excellence. If you would like to be kept informed please sign up at the following URL: http://bnf.org/newsletter
Finally, a note for those of you who receive copies from the Department of Health in England, full details on the supply of copies of the BNF to NHS organisations is available at the DH website
Information relevant to Scotland, Wales and Northern Ireland will be provided shortly.
We welcome feedback from you, if you have any comments or suggestions please contact us
Numerous changes are made for each edition of the BNF. The most significant changes that have been made for BNF 55 can be reviewed by following the links below:
