Drug reference
Acts on both alpha and beta receptors and increases both heart rate and contractility (beta1 effects); it can cause peripheral vasodilation (a beta2 effect) or vasoconstriction (an alpha effect). Loop diuretics inhibit reabsorption from the ascending limb of the loop of Henlé in the renal tubule and are powerful diuretics.
PDF pages 258, 262
Cardiopulmonary resuscitation ▶BY INTRAVENOUS INJECTION ▶Adult: 1 mg every 3–5 minutes as required, a 1 in 10 000 (100 micrograms/mL) solution is recommended Acute hypotension ▶BY CONTINUOUS INTRAVENOUS INFUSION ▶Neonate: Initially 100 nanograms/kg/minute, adjusted according to response, higher doses up to 1.5 micrograms/kg/minute have been used in acute hypotension. ▶Child: Initially 100 nanograms/kg/minute, adjusted according to response, higher doses up to 1.5 micrograms/kg/minute have been used in acute hypotension Emergency treatment of acute anaphylaxis (under expert supervision) | Angioedema (if laryngeal oedema is present) (under expert supervision) ▶BY INTRAMUSCULAR INJECTION ▶Child 1 month–5 years: 150 micrograms, doses may be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse, and respiratory function, suitable syringe to be used for measuring small volume; injected preferably into the anterolateral aspect of the middle third of the thigh ▶Child 6–11 years: 300 micrograms, doses may be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse, and respiratory function, to be injected preferably into the anterolateral aspect of the middle third of the thigh ▶Child 12–17 years: 500 micrograms, to be injected preferably into the anterolateral aspect of the middle third of the thigh, doses may be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse, and respiratory function, 300 micrograms (0.3 mL) to be administered if child small or prepubertal ▶Adult: 500 micrograms, to be injected preferably into the anterolateral aspect of the middle third of the thigh, doses may be repeated several times if necessary at 5 minute intervals according to blood pressure, pulse, and respiratory function Acute anaphylaxis when there is doubt as to the adequacy of the circulation (specialist use only) | Angioedema (if laryngeal oedema is present) (specialist use only) ▶BY SLOW INTRAVENOUS INJECTION ▶Adult: 50 micrograms, using 0.5 mL of the dilute 1 in 10 000 adrenaline injection, dose to be repeated according to response, if multiple doses required, adrenaline should be given as a slow intravenous infusion stopping when a response has been obtained Control of bradycardia in patients with arrhythmias after myocardial infarction, if there is a risk of asystole, or if the patient is unstable and has failed to respond to atropine ▶BY INTRAVENOUS INFUSION ▶Adult: 2–10 micrograms/minute, adjusted according to response EMERADE ® 150 MICROGRAMS Acute anaphylaxis (for self-administration)—product recalled, see Important Safety Information ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight up to 15 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required ▶Child (body-weight 15–30 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required, on the basis of a dose of 10 micrograms/kg, 300 micrograms may be more appropriate for some children EMERADE ® 300 MICROGRAMS Acute anaphylaxis (for self-administration)—product recalled, see Important Safety Information ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight 30 kg and above): 300 micrograms, then 300 micrograms after 5–15 minutes as required ▶Adult (body-weight 30 kg and above): 300 micrograms, then 300 micrograms after 5–15 minutes as required EMERADE ® 500 MICROGRAMS Acute anaphylaxis (for self-administration)—product recalled, see Important Safety Information ▶BY INTRAMUSCULAR INJECTION ▶Child 12–17 years: 500 micrograms, then 500 micrograms after 5–15 minutes as required ▶Adult: 500 micrograms, then 500 micrograms after 5–15 minutes as required EPIPEN ® AUTO-INJECTOR 0.3MG Acute anaphylaxis (for self-administration) ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight 26 kg and above): 300 micrograms, then 300 micrograms after 5–15 minutes as required ▶Adult: 300 micrograms, then 300 micrograms after 5–15 minutes as required EPIPEN ® JR AUTO-INJECTOR 0.15MG Acute anaphylaxis (for self-administration) ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight up to 15 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required ▶Child (body-weight 15–25 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required, on the basis of a dose of 10 micrograms/kg, 300 micrograms may be more appropriate for some children JEXT ® 150 MICROGRAMS Acute anaphylaxis (for self-administration) ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight up to 15 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required ▶Child (body-weight 15–30 kg): 150 micrograms, then 150 micrograms after 5–15 minutes as required, on the basis of a dose of 10 micrograms/kg, 300 micrograms may be more appropriate for some children JEXT ® 300 MICROGRAMS Acute anaphylaxis (for self-administration) ▶BY INTRAMUSCULAR INJECTION ▶Child (body-weight 31 kg and above): 300 micrograms, then 300 micrograms after 5–15 minutes as required ▶Adult (body-weight 31 kg and above): 300 micrograms, then 300 micrograms after 5–15 minutes as required l UNLICENSED USE ▶With intramuscular use for acute anaphylaxis in children Auto- injectors delivering 150-microgram dose of adrenaline may not be licensed for use in children with body-weight under 15 kg. ▶With intravenous use for acute hypotension in children Adrenaline 1 in 1000 (1 mg/mL) solution is not licensed for intravenous administration. Cardiovascular system
PDF pages 258, 259
Arteriosclerosis (in adults). arrhythmias. cerebrovascular disease. cor pulmonale. diabetes mellitus . elderly. hypercalcaemia. hyperreflexia. hypertension. hyperthyroidism. hypokalaemia. ischaemic heart disease. obstructive cardiomyopathy. occlusive vascular disease. organic brain damage. phaeochromocytoma. prostate disorders. psychoneurosis. severe angina. susceptibility to angle-closure glaucoma CAUTIONS, FURTHER INFORMATION Cautions listed are only for non-life-threatening situations. Can exacerbate diabetes (but hyperglycaemia less likely than with thiazides). can excacerbate gout. hypotension should be corrected before initiation of treatment. hypovolaemia should be corrected before initiation of treatment. urinary retention can occur in prostatic hyperplasia CAUTIONS, FURTHER INFORMATION ▶Elderly Lower initial doses of diuretics should be used in the elderly because they are particularly susceptible to the side-effects. The dose should then be adjusted according to renal function. Diuretics should not be used continuously on a long-term basis to treat simple gravitational oedema (which will usually respond to increased movement, raising the legs, and support stockings). Prescription potentially inappropriate (STOPP criteria): . as a first-line treatment for hypertension (safer, more effective alternatives available) . for treatment of hypertension with concurrent urinary incontinence (may exacerbate incontinence) . for dependent ankle oedema without evidence of heart failure, liver failure, nephrotic syndrome or renal failure (leg elevation and/or compression hosiery usually more appropriate) See also Prescribing in the elderly p. 33. ▶Potassium loss Hypokalaemia can occur with both thiazide and loop diuretics. The risk of hypokalaemia depends on the duration of action as well as the potency and is thus greater with thiazides than with an equipotent dose of a loop diuretic. Hypokalaemia is dangerous in severe cardiovascular disease and in patients also being treated with cardiac glycosides. Often the use of potassium-sparing diuretics avoids the need to take potassium supplements. In hepatic failure, hypokalaemia caused by diuretics can precipitate encephalopathy, particularly in alcoholic cirrhosis. ▶Urinary retention If there is an enlarged prostate, urinary retention can occur, although this is less likely if small doses and less potent diuretics are used initially; an adequate urinary output should be established before initiating treatment.
PDF pages 259, 262
▶With intramuscular use It is important, in acute anaphylaxis where intramuscular injection might still succeed, time should not be wasted seeking intravenous access. Great vigilance is needed to ensure that the correct strength of adrenaline injection is used; anaphylactic shock kits need to make a very clear distinction between the 1 in 10 000 strength and the 1 in 1000 strength. Patients with severe allergy should be instructed in the self-administration of adrenaline by intramuscular injection. Packs for self- administration need to be clearly labelled with instructions on how to administer adrenaline (intramuscularly, preferably at the midpoint of the outer thigh, through light clothing if necessary) so that in the case of rapid collapse someone else is able to give it. It is important to ensure individuals at risk and their carers understand that: . two injection devices should be carried at all times to treat symptoms until medical assistance is available; if, after the first injection, the individual does not start to feel better, the second injection should be given 5 to 15 minutes after the first; . an ambulance should be called after every administration, even if symptoms improve; . the individual should lie down with their legs raised (unless they have breathing difficulties, in which case they should sit up) and should not be left alone. Adrenaline for administration by intramuscular injection is available in ‘auto-injectors’ (e.g. Emerade ®— product recalled, see Important Safety Information, EpiPen ®, or Jext ®), pre-assembled syringes fitted with a needle suitable for very rapid administration (if necessary by a bystander or a healthcare provider if it is the only preparation available); injection technique is device specific. To ensure patients receive the auto-injector device that they have been trained to use, prescribers should specify the brand to be dispensed. If switching between brands, patients should receive full training in use of the new auto-injector device. Licensed doses differ between brands of adrenaline auto-injectors. Adrenaline bioavailability has the potential to be influenced by a number of factors including formulation, propulsive force of the device and needle length—consult product literature for further information.
PDF page 260
▶With intramuscular use POM restriction does not apply to the intramuscular administration of up to 1 mg of adrenaline injection 1 in 1000 (1 mg/mL) for the emergency treatment of anaphylaxis.
PDF page 260
Anuria. comatose and precomatose states associated with liver cirrhosis. renal failure due to nephrotoxic or hepatotoxic drugs. severe hypokalaemia. severe hyponatraemia
PDF page 262
SAFE PRACTICE Intravenous route should be used with extreme care by specialists only. MHRA/CHM ADVICE: ADRENALINE AUTO-INJECTORS: UPDATED ADVICE AFTER EUROPEAN REVIEW (AUGUST 2017) Following a European review of all adrenaline auto- injectors approved in the EU, the MHRA recommend that 2 adrenaline auto-injectors are prescribed, which patients should carry at all times. This is particularly important for patients with allergic asthma, who are at increased risk of a severe anaphylactic reaction. Patients with allergies and their carers should be trained to use the particular auto-injector they have been prescribed and encouraged to practise using a trainer device. Patients are advised to check the expiry date of the adrenaline auto-injectors and obtain replacements before they expire. MHRA/CHM ADVICE: CLASS 2 MEDICINES RECALL: EMERADE ® 150 MICROGRAMS (MARCH 2020); EMERADE ® 300 MICROGRAMS (APRIL 2020); EMERADE ® 500 MICROGRAMS (MAY 2020) SOLUTION FOR INJECTION IN PRE-FILLED SYRINGES The MHRA has advised that all unexpired batches of Emerade ® 150 microgram, 300 microgram, and 500 microgram auto-injector pens are being recalled from patients due to an error in one component of the auto-injector believed to cause the failure of some pens to activate. Healthcare professionals are advised to identify these patients and review their adrenaline prescription. Patients and their carers should immediately be informed that a prescription for a suitable alternative brand of adrenaline auto-injector is required. They should be advised to return their current Emerade ® pen(s) to a pharmacy once they have two pens of an alternative brand in their possession. Returned pens should be quarantined in pharmacies and returned to the supplier using the supplier’s approved process. This advice also applies to Emerade ® auto-injector pens that are kept in emergency anaphylaxis kits (e.g. in dental surgeries or schools). For patients who have been prescribed Emerade ®500 microgram auto-injector pens, the MHRA advises that EpiPen ® or Jext ®300 microgram (maximum strength) pens will be a suitable replacement, based on results from a bioavailability study. The MHRA has produced a Patient Letter on the Emerade ® recall for each strength of auto-injector which should be provided to patients and their carers. Healthcare professionals are reminded to follow existing advice on the use of adrenaline auto-injectors—see Prescribing and dispensing information. For the latest safety alerts, see the MHRA website.
PDF page 259
→Appendix 1: sympathomimetics, vasoconstrictor
PDF page 259
GENERAL SIDE-EFFECTS ▶Rare or very rare Cardiomyopathy ▶Frequency not known Angina pectoris. angle closure glaucoma. anxiety. appetite decreased. arrhythmias. asthenia. CNS haemorrhage. confusion. dizziness. dry mouth. dyspnoea. headache. hepatic necrosis. hyperglycaemia. hyperhidrosis. hypersalivation. Cardiovascular system hypertension (increased risk of cerebral haemorrhage). hypokalaemia. injection site necrosis. insomnia. intestinal necrosis. metabolic acidosis. mydriasis. myocardial infarction. nausea. pallor. palpitations. peripheral coldness. psychosis. pulmonary oedema (on excessive dosage or extreme sensitivity). renal necrosis. soft tissue necrosis. tremor. urinary disorders. vomiting SPECIFIC SIDE-EFFECTS ▶With intramuscular use Muscle necrosis. necrotising fasciitis . peripheral ischaemia ▶With intravenous use Hemiplegia. muscle rigidity ▶Common or very common Dizziness. electrolyte imbalance . fatigue. headache. metabolic alkalosis. muscle spasms. nausea ▶Uncommon Diarrhoea ▶Rare or very rare Bone marrow depression. photosensitivity reaction ▶Frequency not known Deafness (more common in renal impairment). leucopenia. paraesthesia. rash. severe cutaneous adverse reactions (SCARs). thrombocytopenia. tinnitus (more common with rapid intravenous administration, and in renal impairment). vomiting
PDF pages 259, 260, 262
May reduce placental perfusion and cause tachycardia, cardiac irregularities, and extrasystoles in fetus. Can delay second stage of labour. Manufacturers advise use only if benefit outweighs risk.
PDF page 260
Present in milk but unlikely to be harmful as poor oral bioavailability.
PDF page 260
Manufacturers advise use with caution in severe impairment. High doses or rapid intravenous administration can cause tinnitus and deafness. Dose adjustments High doses of loop diuretics may occasionally be needed in renal impairment.
PDF pages 260, 262
Monitor blood pressure and ECG. Monitor electrolytes during treatment. eiiii F above
PDF pages 260, 262
Hypokalaemia induced by loop diuretics may precipitate hepatic encephalopathy and coma—potassium-sparing diuretics can be used to prevent this. Diuretics can increase the risk of hypomagnesaemia in alcoholic cirrhosis, leading to arrhythmias.
PDF page 262
Acute hypotension ▶With intravenous use in children For continuous intravenous infusion, dilute with Glucose 5% or Sodium Chloride 0.9% and give through a central venous catheter. Incompatible with bicarbonate and alkaline solutions. Neonatal intensive care, dilute 3 mg/kg body-weight to a final volume of 50 mL with infusion fluid; an intravenous infusion rate of 0.1 mL/hour provides a dose of 100 nanograms/kg/minute; infuse through a central venous catheter. Incompatible with bicarbonate and alkaline solutions. These infusions are usually made up with adrenaline 1 in 1000 (1 mg/mL) solution. Cardiopulmonary resuscitation ▶With intravenous use in adults Administration through a central line results in a faster response than peripheral administration, however placement of a central line must not interfere with chest compressions; drugs administered peripherally must be followed by a flush of at least 20 mL Sodium Chloride 0.9% injection to aid entry into the central circulation.
PDF page 260
There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: solution for injection Solution for injection EXCIPIENTS: May contain Sulfites ▶Adrenaline/epinephrine (Non-proprietary) Adrenaline 100 microgram per 1 ml Adrenaline (base) 100micrograms/1ml (1 in 10,000) dilute solution for injection ampoules | 10 ampoule P £88.18 Adrenaline (base) 1mg/10ml (1 in 10,000) dilute solution for injection pre-filled syringes | 1 pre-filled disposable injection P £6.87 | 1 pre-filled disposable injection P £18.00 (Hospital only) | 10 pre- filled disposable injection P £180.00 (Hospital only) Adrenaline (as Adrenaline acid tartrate) 100 microgram per 1 ml Adrenaline (base) 1mg/10ml (1 in 10,000) dilute solution for injection ampoules | 10 ampoule P £102.19 Adrenaline (base) 500micrograms/5ml (1 in 10,000) dilute solution for injection ampoules | 10 ampoule P £93.94 Adrenaline 1 mg per 1 ml Adrenaline (base) 10mg/10ml (1 in 1,000) solution for injection ampoules | 10 ampoule P £106.02 Adrenaline (base) for anaphylaxis 1mg/1ml (1 in 1,000) solution for injection pre-filled syringes | 1 pre-filled disposable injection P £11.88 DT = £11.88 Adrenaline (base) 1mg/1ml (1 in 1,000) solution for injection pre-filled syringes | 1 pre-filled disposable injection P £11.88 DT = £11.88 Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 ml Adrenaline (base) 5mg/5ml (1 in 1,000) solution for injection ampoules | 10 ampoule P £108.09 Adrenaline (base) 500micrograms/0.5ml (1 in 1,000) solution for injection ampoules | 10 ampoule P £88.63 DT = £88.63 Adrenaline (base) 1mg/1ml (1 in 1,000) solution for injection ampoules | 10 ampoule P £6.00–£11.01 DT = £9.98 ▶Emerade (Bausch & Lomb UK Ltd) Adrenaline 1 mg per 1 ml Emerade 300micrograms/0.3ml (1 in 1,000) solution for injection auto-injectors | 1 pre-filled disposable injection P £25.99 DT = £34.30 Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 ml Emerade 150micrograms/0.15ml (1 in 1,000) solution for injection auto- injectors | 1 pre-filled disposable injection P £25.99 DT = £23.99 Emerade 500micrograms/0.5ml (1 in 1,000) solution for injection auto- injectors | 1 pre-filled disposable injection P £26.99 DT = £26.99 ▶EpiPen (Mylan) Adrenaline 500 microgram per 1 ml EpiPen Jr. 150micrograms/0.3ml (1 in 2,000) solution for injection auto-injectors | 1 pre-filled disposable injection P £34.30 DT = £34.30 | 2 pre- filled disposable injection P £68.60 DT = £68.60 Adrenaline 1 mg per 1 ml EpiPen 300micrograms/0.3ml (1 in 1,000) solution for injection auto-injectors | 1 pre-filled disposable injection P £34.30 DT = £34.30 | 2 pre-filled disposable injection P £68.60 ▶Jext (ALK-Abello Ltd) Adrenaline 1 mg per 1 ml Jext 300micrograms/0.3ml (1 in 1,000) solution for injection auto-injectors | 1 pre-filled disposable injection P £23.99 DT = £34.30 Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 ml Jext 150micrograms/0.15ml (1 in 1,000) solution for injection auto- injectors | 1 pre-filled disposable injection P £23.99 DT = £23.99 Oedema Diuretics Overview Thiazides are used to relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure. Loop diuretics are used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure. Combination diuretic therapy may be effective in patients with oedema resistant to treatment with one diuretic. Vigorous diuresis, particularly with loop diuretics, may induce acute hypotension; rapid reduction of plasma volume should be avoided. Thiazides and related diuretics Thiazides and related compounds are moderately potent diuretics; they inhibit sodium reabsorption at the beginning of the distal convoluted tubule. They act within 1 to 2 hours of oral administration and most have a duration of action of 12 to 24 hours; they are usually administered early in the day so that the diuresis does not interfere with sleep. In the management of hypertension a low dose of a thiazide produces a maximal or near-maximal blood pressure lowering effect, with very little biochemical disturbance. Higher doses cause more marked changes in plasma potassium, sodium, uric acid, glucose, and lipids, with little advantage in blood pressure control. Chlortalidone p. 244 and indapamide p. 178 are the preferred diuretics in the management of hypertension. Thiazides also have a role in chronic heart failure. Bendroflumethiazide p. 177 can be used for mild or moderate heart failure; it is licensed for the treatment of hypertension but is no longer considered the first-line diuretic for this indication, although patients with stable and controlled blood pressure currently taking bendroflumethiazide can continue treatment. Chlortalidone, a thiazide-related compound, has a longer duration of action than the thiazides and may be given on Cardiovascular system alternate days to control oedema. It is also useful if acute retention is liable to be precipitated by a more rapid diuresis or if patients dislike the altered pattern of micturition caused by other diuretics. Chlortalidone can also be used under close supervision for the treatment of ascites due to cirrhosis in stable patients. Xipamide p. 245 and indapamide are chemically related to chlortalidone. Indapamide is claimed to lower blood pressure with less metabolic disturbance, particularly less aggravation of diabetes mellitus. Metolazone p. 245 is particularly effective when combined with a loop diuretic (even in renal failure); profound diuresis can occur and the patient should therefore be monitored carefully. The thiazide diuretics benzthiazide, clopamide, hydrochlorothiazide, and hydroflumethiazide do not offer any significant advantage over other thiazides and related diuretics. Loop diuretics Loop diuretics are used in pulmonary oedema due to left ventricular failure; intravenous administration produces relief of breathlessness and reduces pre-load sooner than would be expected from the time of onset of diuresis. Loop diuretics are also used in patients with chronic heart failure. Diuretic-resistant oedema (except lymphoedema and oedema due to peripheral venous stasis or calcium-channel blockers) can be treated with a loop diuretic combined with a thiazide or related diuretic (e.g. bendroflumethiazide or metolazone). If necessary, a loop diuretic can be added to antihypertensive treatment to achieve better control of blood pressure in those with resistant hypertension, or in patients with impaired renal function or heart failure. Loop diuretics can exacerbate diabetes (but hyperglycaemia is less likely than with thiazides) and gout. If there is an enlarged prostate, urinary retention can occur, although this is less likely if small doses and less potent diuretics are used initially. Furosemide p. 241 and bumetanide p. 240 are similar in activity; both act within 1 hour of oral administration and diuresis is complete within 6 hours so that, if necessary, they can be given twice in one day without interfering with sleep. Following intravenous administration furosemide has a peak effect within 30 minutes. The diuresis associated with these drugs is dose related. Torasemide p. 242 has properties similar to those of furosemide and bumetanide, and is indicated for oedema and for hypertension. Potassium-sparing diuretics and aldosterone antagonists Amiloride hydrochloride p. 243 and triamterene p. 244 on their own are weak diuretics. They cause retention of potassium and are therefore given with thiazide or loop diuretics as a more effective alternative to potassium supplements. See compound preparations with thiazides or loop diuretics. Potassium supplements must not be given with potassium- sparing diuretics. Administration of a potassium sparing diuretic to a patient receiving an ACE inhibitor or an angiotensin-II receptor antagonist can also cause severe hyperkalaemia. Aldosterone antagonists Spironolactone p. 206 potentiates thiazide or loop diuretics by antagonising aldosterone; it is a potassium-sparing diuretic. Spironolactone is of value in the treatment of oedema and ascites caused by cirrhosis of the liver; furosemide can be used as an adjunct. Low doses of spironolactone are beneficial in moderate to severe heart failure and when used in resistant hypertension [unlicensed indication]. Cardiovascular system Spironolactone is also used in primary hyperaldosteronism (Conn’s syndrome). It is given before surgery or if surgery is not appropriate, in the lowest effective dose for maintenance. Eplerenone p. 205 is licensed for use as an adjunct in left ventricular dysfunction with evidence of heart failure after a myocardial infarction; it is also licensed as an adjunct in chronic mild heart failure with left ventricular systolic dysfunction. Potassium supplements must not be given with aldosterone antagonists Potassium-sparing diuretics with other diuretics Although it is preferable to prescribe thiazides and potassium-sparing diuretics separately, the use of fixed combinations may be justified if compliance is a problem. Potassium-sparing diuretics are not usually necessary in the routine treatment of hypertension, unless hypokalaemia develops. Other diuretics Mannitol p. 243 is an osmotic diuretic that can be used to treat cerebral oedema and raised intra-ocular pressure. Mercurial diuretics are effective but are now almost never used because of their nephrotoxicity. The carbonic anhydrase inhibitor acetazolamide p. 1244 is a weak diuretic and is little used for its diuretic effect. It is used for prophylaxis against mountain sickness [unlicensed indication] but is not a substitute for acclimatisation. Eye drops of dorzolamide p. 1246 and brinzolamide p. 1245 inhibit the formation of aqueous humour and are used in glaucoma. Diuretics with potassium Many patients on diuretics do not need potassium supplements. For many of those who do, the amount of potassium in combined preparations may not be enough, and for this reason their use is to be discouraged. Diuretics with potassium and potassium-sparing diuretics should not usually be given together. Diuretics and potassium supplements should be prescribed separately for children. Advanced Pharmacy Services Patients taking diuretics may be eligible for the New Medicines Service / Medicines Use Review service provided by a community pharmacist. For further information, see Advanced Pharmacy Services in Medicines optimisation p. 18. Other drugs used for Oedema Diamorphine hydrochloride, p. 477 DIURETICS › LOOP DIURETICS Loop diuretics f
PDF pages 260, 261, 262
▶With intramuscular use Individuals at considerable risk of anaphylaxis need to carry (or have available) adrenaline at all times and the patient, or their carers, need to be instructed in advance when and how to inject it. ▶With intramuscular use The MHRA has produced an advice sheet on the use of adrenaline auto-injectors, which should be provided to patients and their carers. Medicines for Children leaflet: Adrenaline auto-injector for anaphylaxis www.medicinesforchildren.org.uk/adrenaline-auto- injector-anaphylaxis-0 JEXT ® 300 MICROGRAMS 1.1 mL of the solution remains in the auto-injector device after use. JEXT ® 150 MICROGRAMS 1.25 mL of the solution remains in the auto-injector device after use. EPIPEN ® JR AUTO-INJECTOR 0.15MG 1.7 mL of the solution remains in the auto-injector device after use. EMERADE ® 150 MICROGRAMS 0.35 mL of the solution remains in the auto-injector device after use. EPIPEN ® AUTO-INJECTOR 0.3MG 1.7 mL of the solution remains in the auto-injector device after use. EMERADE ® 500 MICROGRAMS No solution remains in the auto-injector device after use. EMERADE ® 300 MICROGRAMS 0.2 mL of the solution remains in the auto-injector device after use.
PDF page 260
1 mg every 3–5 minutes as required, a 1 in
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
Initially 100 nanograms/kg/minute, adjusted
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
Initially 100 nanograms/kg/minute, adjusted
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
150 micrograms, doses may be
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
300 micrograms, doses may be
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
500 micrograms, to be injected
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
500 micrograms, to be injected preferably into
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
50 micrograms, using 0.5 mL of the dilute 1 in
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
2–10 micrograms/minute, adjusted according to
First-line fragment. Read the complete Indications and Dose section above.
PDF page 258
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms,
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms,
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
500 micrograms, then 500 micrograms
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
500 micrograms, then 500 micrograms after
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms,
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms, then 300 micrograms after
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
150 micrograms, then
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms,
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
300 micrograms,
First-line fragment. Read the complete Indications and Dose section above.
PDF page 259
