RxPG - What is New in BNF 49 (March 2005)?

The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society of Great Britain. It is published biannually under the authority of a Joint Formulary Committee which comprises representatives of the two professional bodies and of the UK Health Departments. The current edition must always be used for making clinical decisions. The more important changes for this edition are listed under Significant changes. For doctors wishing to practise in UK (PLAB Exam Takers) or already working in UK, the knowledge of the updates of BNF is absolutely essential.

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Treatment and prophylaxis of bacterial infections
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Table 1 in section 5.1 is regularly updated in the light of changing patterns of resistance and emergence of new evidence. Of particular note for this edition are the adjustments to the advice on oral infections, septicaemia and meningitis.
Advice on the treatment of bacterial endocarditis (Table 1, section 5.1) in the BNF has been updated to reflect the guidelines of a working group of the British Society for Antimicrobial Chemotherapy (J Antimicrob Chemother 2004; 54: 971–81).
The BNF now includes advice on the choice of antibacterials for initial ‘blind’ therapy of endocarditis as well as on endocarditis caused by ‘HACEK’ organisms (haemophilus, actinobacillus, cardiobacterium, eikenella and kingella spp.).
Changes to Table 2 (section 5.1) include new information on antibacterial prophylaxis in surgical patients, e.g. those undergoing vascular operations.
Promulgation of disparate advice on endocarditis prophylaxis has created considerable difficulty for practitioners (particularly dental surgeons) when caring for patients at increased risk of endocarditis. The BNF continues to reflect the advice of the British Society for Antimicrobial Chemotherapy since it is well understood and there is no evidence to suggest that it is inappropriate.
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Childhood vaccination
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Changes to the childhood immunisation schedule were announced by the Department of Health in August 2004 (Letter from the Chief Medical Officer, the Chief Nursing Officer and the Chief Pharmaceutical Officer, PL/CMO/2004/3). Inactivated poliomyelitis vaccine has replaced the live (oral) poliomyelitis vaccine and acellular pertussis vaccine has replaced the whole-cell pertussis vaccine.
The immunisation schedule (BNF section 14.1) shows the new advice and the text on diphtheria, haemophilus influenzae type B, pertussis, poliomyelitis and tetanus vaccines has been revised to reflect the advice of the Joint Committee on Vaccination and Immunisation. The newly introduced combination vaccines are listed under Diphtheria Vaccines in section 14.4.
BNF 49 also provides details of changes to the pneumococcal immunisation programme publicised in the letter from the Chief Medical Officer, the Chief Nursing Officer and the Chief Pharmaceutical Officer (PL/CMO/2004/4 of 9 August 2004).
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Cardiovascular risk assessment
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Last year the British Hypertension Society, updated the recommendations for managing hypertension and included charts for assessing cardiovascular risks (J Hum Hypertens 2004; 18: 139–85). With increasing use of these charts (which take into account the risk for stroke), BNF 49 now includes the cardiovascular risk prediction charts in favour of the coronary risk prediction charts included previously. They appear at the end of the printed version of the BNF.
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Co-proxamol
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The BNF considers most combinations of opioids with non-opioid analgesics less suitable for prescribing. The rationale for this view is outlined in section 4.7.1. For many years the BNF has included warnings about co-proxamol (paracetamol with dextropropoxyphene); there is little formal evidence that the combination is more effective than full doses of paracetamol alone and, more importantly, co-proxamol can be especially dangerous in overdosage.
The CSM has announced plans for the withdrawal of co-proxamol (31 January 2005, reference CEM/CMO/2005/2). The practical implications of this action are that patients should no longer be prescribed co-proxamol and that the analgesic requirements of those already taking it should be reviewed with the aim of switching to another analgesic (BNF 49).
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Herpes simplex and varicella–zoster
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Notes on the drug management of herpes simplex and varicella–zoster infections (section 5.3.2.1) have been rewritten.
BNF 49 includes doses of aciclovir for attenuating chickenpox (where varicella–zoster immunoglobulin is not indicated) and for parenteral treatment of chickenpox in infants aged under 3 months; these indications are not licensed but their inclusion is justifiable on clinical grounds.
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Cyclo-oxygenase-2 selective inhibitors
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Emerging concerns about the cardiovascular safety of anti-inflammatory drugs that selectively inhibit cyclo-oxygenase-2 have resulted in new advice from the CSM. In December 2004 the CSM advised that patients on cyclo-oxygenase-2 inhibitors who had ischaemic heart disease or cerebrovascular disease should be switched to alternative treatment. In February 2005, the CSM issued further advice that moderate heart failure is now a contra-indication to the use of celecoxib, etoricoxib, and valdecoxib. The advice also states that etoricoxib should not be used in patients with uncontrolled hypertension and those receiving it should have their blood pressure monitored. BNF 49 reflects these concerns.

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The Dental Formulary Subcommittee oversees the preparation of advice on the drug management of dental and oral conditions; the Subcommittee includes representatives of the British Dental Association.

The BNF aims to provide prescribers, pharmacists and other healthcare professionals with sound up-to-date information about the use of medicines.

The BNF provides ready access to key information on the selection, prescribing, dispensing and administration of medicines. Medicines that are 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 about drugs is drawn from the manufacturers' product literature, medical and pharmaceutical literature, regulatory and professional authorities, and data used for pricing prescriptions. Advice is constructed from clinical literature and reflects, as far as possible, an evaluation of the evidence from diverse sources. The advice also takes account of authoritative national guidelines and emerging safety concerns. In addition, the Joint Formulary Committee receives expert clinical advice on all therapeutic areas in tune with current best evidence; this ensures that the BNF's recommendations are relevant to practice. Many individuals and organisations contribute towards the preparation of each edition of the BNF.

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. The BNF should be interpreted in 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.