BNF for Children 2011-2012

104 2.6 Nitrates and calcium-channel blockers BNFC 2011–20122 Cardiovascular systemhoea, nausea, vomiting, angina, palpitation, oedema,dyspnoea, cough, headache, sleep disorders, drowsiness,urticaria, pruritus, rash; rarely hepatitis, atrialfibrillation, cerebrovascular accident, and paraesthesia;also reported pancreatitis, depression, erectiledysfunction, thrombocytopenia, hyponatraemia,arthralgia, myalgia, rhabdomyolysis, tinnitus, photosensitivity,and vasculitis (including Henoch-Schönleinpurpura)Indication and doseHypertension (under specialist supervision). By mouthChild 6–18 yearsBody-weight 20–50 kg initially 700 micrograms/kg (max. 25 mg) once daily (lower dose in intravascularvolume depletion), adjusted according toresponse; max. 50 mg once dailyBody-weight 50 kg and over initially 50 mg oncedaily (initially 25 mg once daily in intravascularvolume depletion), adjusted according toresponse; max. 1.4 mg/kg (max. 100 mg) oncedailyLosartan Potassium (Non-proprietary)Tablets, losartan potassium 12.5 mg, net price 28-tabpack = £7.70; 25 mg, 28-tab pack = £2.64; 50 mg, 28-tab pack = £2.38; 100 mg, 28-tab pack = £2.84Cozaar c (MSD) TATablets, f/c, losartan potassium 12.5 mg (blue), netprice 28-tab pack = £8.09; 25 mg (white), 28-tab pack= £16.18; 50 mg (white, scored), 28-tab pack = £12.80;100 mg (white), 28-tab pack = £16.18Oral suspension, losartan potassium 12.5 mg/5 mLwhen reconstituted with solvent provided, net price200 mL (berry-citrus flavour) = £53.68VALSARTANCautions see notes aboveContra-indications biliary cirrhosis, cholestasisHepatic impairment max. 80 mg daily in mild tomoderate impairment; avoid in severe impairmentRenal impairment see notes above; also avoid ifestimated glomerular filtration rate less than 30 mL/minute/1.73m 2 —no information availablePregnancy see notes aboveBreast-feeding see notes aboveSide-effects see notes above; also less commonlyabdominal pain, nausea, diarrhoea, cough, malaise,headache; also reported anaemia, renal failure, neutropenia,thrombocytopenia, myalgia, vasculitis,serum sickness, rash, pruritusLicensed use capsules not licensed for use in childrenIndication and doseHypertension (under specialist supervision). By mouthChild 6–18 yearsBody-weight 18–35 kg initially 40 mg once daily,adjusted according to response; max. 80 mg dailyBody-weight 35–80 kg initially 80 mg once daily,adjusted according to response; max. 160 mg dailyBody-weight 80 kg and over initially 80 mg oncedaily, adjusted according to response; max. 320 mgdailyDiovan c (Novartis) TACapsules, valsartan 40 mg (grey), net price 28-cappack = £13.97; 80 mg (grey/pink), 28-cap pack =£13.97; 160 mg (grey/pink), 28-cap pack = £18.41Tablets, f/c, scored, valsartan 40 mg (yellow), netprice 7-tab pack = £3.49; 320 mg (dark grey-violet),28-tab pack = £20.232.6 Nitrates, calcium-channelblockers, and otherantianginal drugs2.6.1 Nitrates2.6.2 Calcium-channel blockers2.6.3 Other antianginal drugs2.6.4 Peripheral vasodilators and relateddrugsNitrates and calcium-channel blockers have a vasodilatingand, consequently, blood-pressure lowering effect.Vasodilators can act in heart failure by arteriolar dilatation,which reduces both peripheral vascular resistanceand left ventricular pressure during systole resulting inimproved cardiac output. They can also cause venousdilatation, which results in dilatation of capacitancevessels, increase of venous pooling, and diminution ofvenous return to the heart (decreasing left ventricularend-diastolic pressure).2.6.1 NitratesNitrates are potent coronary vasodilators, but theirprincipal benefit follows from a reduction in venousreturn which reduces left ventricular work. Unwantedeffects such as flushing, headache, and postural hypotensionmay limit therapy, especially if the child isunusually sensitive to the effects of nitrates or is hypovolaemic.For the use of glyceryl trinitrate in extravasation, seesection 10.3.Children receiving nitrates continuously throughout theday can develop tolerance (with reduced therapeuticeffects). Reduction of blood-nitrate concentrations tolow levels for 4 to 8 hours each day usually maintainseffectiveness in such patients.GLYCERYL TRINITRATECautions hypothyroidism; malnutrition; hypothermia;recent history of myocardial infarction; heart failuredue to obstruction; hypoxaemia or other ventilationand perfusion abnormalities; susceptibility to angleclosureglaucoma; metal-containing transdermal systemsshould be removed before magnetic resonanceimaging procedures, cardioversion, or diathermy;avoid abrupt withdrawal; monitor blood pressure andheart rate during infusion; tolerance (see notesabove); interactions: Appendix 1 (nitrates)