What's new in BNF 58?
Welcome to BNF 58. We have highlighted below some of the key changes you will find in this new edition.
Updated prescribing information
Management of arrhythmias
Guidance on the management of atrial flutter, paroxysmal supraventricular tachycardia, and ventricular tachycardia has been revised in section 2.3.1. Treatment options are discussed, including selection of drug treatment and indications for direct current cardioversion, pacing, and catheter ablation.
Management of acute and chronic asthma
The Management of Chronic Asthma table and the Management of Acute Asthma table have been reviewed in the light of the latest update of the British Guideline on the Management of Asthma (June 2009).
Clostridium difficile infection
Guidance on the antibacterial treatment of Clostridium difficile infection has been updated in Table 1, section 5.1 to take into account recent recommendations from the UK health departments (including Clostridium difficile infection: how to deal with the problem, December 2008 ). While oral metronidazole remains a first-line treatment, oral vancomycin is reserved for third or subsequent episodes of infection, for severe infection, for infection not responding to metronidazole, or for patients who are intolerant of metronidazole. A combination of oral vancomycin and intravenous metronidazole can be used for infection not responding to oral vancomycin alone or for life-threatening infection.
Guidance on the treatment of hospital-acquired pneumonia has been updated in Table 1, section 5.1 to take into account the recommendations of a Working Party of the British Society for Antimicrobial Chemotherapy (J Antimicrob Chemother 2008; 62:5–34). Patients with early-onset infection can be treated with either co-amoxiclav or cefuroxime. More broad-spectrum antibacterials are recommended for patients with late-onset infection that occurs more than 5 days after admission to hospital, for those with a history of recent antibacterial treatment, for life-threatening infection, or if resistant organisms are suspected.
Although safety data are limited, BNF 58 (section 5.3.4) recommends that either oseltamivir or zanamivir can be used in women who are pregnant or breast-feeding when the potential benefit outweighs the risk (e.g. during a pandemic). Zanamivir is the preferred drug during pregnancy; however, oseltamivir is recommended during severe infection or when zanamivir cannot be used. Oseltamivir is the preferred drug in women who are breast-feeding.
BNF 58 also includes a summary of the latest NICE guidance on the prevention and treatment of influenza.
Adjustment of drug dosages in renal impairment
Following a wide-ranging consultation, including discussions with the Department of Health, the regulatory authorities, and experts in the field, advice on the adjustment of drug doses in renal impairment in BNF 58 has been reviewed and updated.
A table in the introduction to Appendix 3 shows the classification of renal impairment from Chronic Kidney Disease in Adults: UK Guidelines for Identification, Management and Referral (March 2006), in which estimated glomerular filtration rate (eGFR) is derived from the Modification of Diet in Renal Disease (MDRD) formula.
The introduction to Appendix 3 explains that in the majority of cases BNF will now express advice on dosage adjustment in renal impairment in terms of eGFR rather than creatinine clearance. This is further qualified with information on the limitations of eGFR, such as:
eGFR should not be used to adjust dosages of nephrotoxic drugs or drugs with a narrow therapeutic index; in such cases, use plasma-drug levels to adjust dose or creatinine clearance calculated using the Cockcroft and Gault formula;
eGFR should not be used to adjust drug dosages in patients at both extremes of weight; in such cases, use the absolute glomerular filtration rate or creatinine clearance calculated using the Cockcroft and Gault formula;
the MDRD formula is not validated for use in children under 18 years; see BNF for Children for advice on drug dosage adjustment in renal impairment in children.
References to creatinine clearance have been replaced with eGFR throughout Appendix 3 and the rest of the publication where applicable.
Wound management products and elasticated garments
In the light of the NHS Purchasing and Supplies Agency (PASA) publication, Buyers’ Guide: Advanced Wound Dressings; Oct 2008, Appendix 8 of the BNF, Wound Management Products and Elasticated Garments, has been updated and revised. A new table of wound contact materials is intended to aid selection of the appropriate type of dressing based on the appearance and condition of the wound. Advanced wound contact dressings (A8.2) have been classified in order of increasing absorbency, and dressings with antimicrobial properties have been moved to a separate section (A8.3).
Reorganised sections in BNF 58
Chapter 14: Immunological products and vaccines
For BNF 58, section 14.5 (Immunoglobulins) has been updated and reformatted to follow the same style as the rest of the BNF, including notes for prescribers followed by a monograph and preparation entries.
The appendix on borderline substances (Appendix 7) has been revised. Tables based on energy and protein content of ACBS-approved enteral feeds and nutritional supplements have been created. There are separate tables for specialised formulas for specific clinical conditions. Additional nutritional information is included for standard dilutions of powder formulations throughout the appendix.
Guidance notes at the beginning of Appendix 7 have been updated to provide more information on the composition of enteral feeds and nutritional supplements.