Long-acting beta2 agonists
The safety of long-acting beta2 agonists has come under close scrutiny, particularly following the recent publication of a meta-analysis (Salpeter SR, Buckley NS, Ormiston TM, Salpeter EE. Meta-analysis: effect of long-acting β-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med 2006; 144: 904–912). BNF 52 includes advice developed with the Commission on Human Medicines on the safe use of formoterol and salmeterol (section 188.8.131.52). It is important that use of a long-acting beta2 agonist accords with the guidance on stepwise management of chronic asthma (section 3.1) and that the drug is withdrawn in the absence of benefit.
Bisphosphonates and dental care
Bisphosphonates, first introduced for Paget’s disease of the bone, are now also used for the prevention and treatment of osteoporosis and in cancer for hypercalcaemia or bone metastases. Osteonecrosis of the jaw has emerged as a side-effect of bisphosphonates used intravenously in cancer and it has now also been reported with oral use (Woo S-B, Hellstein JW, Kalmar JR. Systematic review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med 2006; 144: 754–63). The condition often comes to light in the dental surgery. Remedial dental work is recommended before starting bisphosphonate treatment and due care should be given to oral hygiene during and after treatment (section 6.6.2).
Changes to Controlled Drug regulations
Changes to the regulations on Controlled Drugs are reflected in BNF 52 (see Controlled drugs and drug dependence). The BNF also includes guidance issued in June 2006 by the Department of Health on the safer management of Controlled Drugs.
Drugs and renal function
Changes in the reporting of renal function could lead to errors in dose adjustment for those with renal impairment. Biochemistry laboratories now report estimated glomerular filtration rate (eGFR) which is calculated from a formula derived from the Modification of Diet in Renal Disease (MDRD) study. The eGFR is reported in mL/minute/1.73m2. However, advice on dosage adjustment is based on creatinine clearance values (in mL/minute); in order to use dose adjustment guidelines in resources such as the BNF, it is important to convert the eGFR to creatinine clearance using the patient’s own body surface area. Appendix 3 gives more information on the two measures of creatinine clearance.
BNF 52 (section 2.8.2) reflects the new anticoagulation targets recommended by the British Society for Haematology (Guidelines on Oral Anticoagulation (warfarin): third edition—2005 update. Br J Haematol 2005; 132: 277–85).
The Commission on Human Medicines is aware of reports of raised INR associated with the concurrent use of glucosamine and warfarin (Current Problems in Pharmacovigilance 2006; 31: 8). The interaction has been included in Appendix 1 of BNF 52 (warfarin)
The Department of Health’s Chief Officers have announced plans to introduce routine immunisation against pneumococcal disease; the timing of haemophilus influenzae type b and meningococcal group C immunisation has also changed (Chief Medical Officer’s letter 12 July 2006; Gateway reference 6227). The changes are being introduced in September 2006. The Immunisation Schedule in BNF 52 has been updated to reflect the changes.
Guidelines on preventing and treating meticillin-resistant Staphylococcus aureus (MRSA) infections have been issued by the Joint Working Party of the British Society for Antimicrobial Chemotherapy, Hospital Infection Society and Infection Control Nurses Association (J Antimicrob Chemother 2006; 57: 589–608). BNF 52 reflects the Working Party’s advice on the selection of antibacterials for the management of MRSA infections at various sites (section 184.108.40.206).
Re-evaluation of the benefits of beta-blockers (e.g. Carlberg B, Samuelsson O, Lindholm LH. Atenolol in hypertension: is it a wise choice? Lancet 2004; 364: 1684–9) led to changes in the advice on atenolol in BNF 51. Further evidence has emerged from studies such as the ASCOT-BPLA trial (Lancet 2005; 366: 895–906). BNF 52 has continued to clarify the role of beta-blockers for hypertension and advises that other antihypertensive drugs are usually more effective for reducing the incidence of stroke, myocardial infarction and cardiovascular mortality (section 2.4). This is consistent with NICE guidance issued in June 2006 (Hypertension: management of hypertension in adults in primary care), which states that beta-blockers are no longer preferred as a routine initial therapy for hypertension. Furthermore, beta-blockers (especially if combined with a thiazide diuretic) are best avoided if there is concern about diabetes.
However, BNF 52 points out that beta-blockers have a role in angina and in the management of a patient who has suffered a myocardial infarction; they are also of benefit in heart failure.