BNF for Children 2011-2012

BNFC 2011–2012 3.1.1 Adrenoceptor agonists 137CroupMild croup is largely self-limiting, but treatment with asingle dose of a corticosteroid (e.g. dexamethasone150 micrograms/kg) by mouth is of benefit.Severe croup (or mild croup that might cause complications)calls for hospital admission—a single dose ofeither dexamethasone 150 micrograms/kg or prednisolone1–2 mg/kg, can be administered by mouth beforetransfer to hospital. In hospital, dexamethasone150 micrograms/kg (by mouth or by injection) or budesonide2 mg by nebulisation (section 3.2) will oftenreduce symptoms; the dose may be repeated after 12hours if necessary.For severe croup not effectively controlled with corticosteroidtreatment, nebulised adrenaline (section 3.4.3)solution 1 in 1000 (1 mg/mL) can be given with closeclinical monitoring in a dose of 400 micrograms/kg(max. 5 mg) repeated after 30 minutes if necessary (thedose may be diluted with sterile sodium chloride 0.9%solution). The effects of nebulised adrenaline last 2–3 hours; the child needs to be carefully monitored forrecurrence of the obstruction.3.1.1 Adrenoceptor agonists(Sympathomimetics)3.1.1.1 Selective beta 2 agonists3.1.1.2 Other adrenoceptor agonistsThe selective beta 2 agonists (selective beta 2 -adrenoceptoragonists, selective beta 2 stimulants) such as salbutamolor terbutaline are the safest and most effectiveshort-acting beta 2 agonists for the treatment of asthma.Adrenaline (epinephrine), which has both alpha- andbeta-adrenoceptor agonist properties, is used in theemergency management of acute allergic and anaphylacticreactions (section 3.4.3); it is also used as anebuliser solution to treat severe croup.3.1.1.1 Selective beta 2 agonistsSelective beta 2 agonists produce bronchodilation. Ashort-acting beta 2agonist is used for immediate reliefof asthma symptoms while a long-acting beta 2agonist isused in addition to an inhaled corticosteroid in childrenrequiring prophylactic treatment.Management of Chronic Asthma table, see p. 135Management of Acute Asthma table, see p. 136For guidance on the use of inhalers and spacerdevices, see section 3.1.5Short-acting beta 2agonists Mild to moderatesymptoms of asthma respond rapidly to the inhalationof a selective short-acting beta 2 agonist such as salbutamolor terbutaline. If beta 2 agonist inhalation isneeded more often than once daily, prophylactic treatmentshould be considered, using a stepped approach asoutlined in the Management of Chronic Asthma table,p. 135. Regular treatment with an inhaled short-actingbeta 2 agonist is less effective than ‘as required’ inhalationand is not appropriate prophylactic treatment.A short-acting beta 2 agonist inhaled immediately beforeexertion reduces exercise-induced asthma; however,frequent exercise-induced asthma probably reflectspoor overall control and calls for reassessment ofasthma treatment.Long-acting beta 2 agonists Formoterol and salmeterolare longer-acting beta 2 agonists which areadministered by inhalation. They should be used forasthma only in children who regularly use an inhaledcorticosteroid (see CHM advice below). They have arole in the long-term control of chronic asthma (seeManagement of Chronic Asthma table, p. 135) and theycan be useful in nocturnal asthma. Salmeterol shouldnot be used for the relief of an asthma attack; it has aslower onset of action than salbutamol or terbutaline.Formoterol is licensed for short-term symptom reliefand for the prevention of exercise-induced bronchospasm;its speed of onset of action is similar to that ofsalbutamol.Combination inhalers that contain a long-acting beta 2agonist and a corticosteroid (section 3.2) ensure thatlong-acting beta 2 agonists are not used without concomitantcorticosteroids, but reduce the flexibility toadjust the dose of each component.CHM adviceTo ensure safe use, the CHM has advised that for themanagement of chronic asthma, long-acting beta 2agonists (formoterol and salmeterol) should:. be added only if regular use of standard-doseinhaled corticosteroids has failed to controlasthma adequately;. not be initiated in patients with rapidly deterioratingasthma;. be introduced at a low dose and the effectmonitored before considering dose increase;. be discontinued in the absence of benefit;. not be used for the relief of exercise-inducedasthma symptoms unless regular inhaled corticosteroidsare also used;. be reviewed as clinically appropriate: steppingdown therapy should be considered when goodlong-term asthma control has been achieved.A daily dose of 24 micrograms of formoterol shouldbe sufficient for the majority of children, particularlyfor younger age-groups; higher doses should be usedrarely, and only when control is not maintained onthe lower dose.Children and their carers should be advised to reportany deterioration in symptoms following initiation oftreatment with a long-acting beta 2 agonist, see Managementof Chronic Asthma table, p. 135.Inhalation A pressurised metered-dose inhaler is aneffective method of drug administration in mild tomoderate chronic asthma; to deliver the drug effectivelyparticularly in children under 12 years, a spacer deviceshould be used (see also NICE guidance, section 3.1.5).When a pressurised metered-dose inhaler with a spaceris unsuitable or inconvenient, a dry-powder inhaler orbreath-actuated inhaler may be used instead if the childis able to use the device effectively. At recommendedinhaled doses the duration of action of salbutamol andterbutaline is about 3 to 5 hours and for salmeterol andformoterol is about 12 hours. The dose, the frequency,and the maximum number of inhalations in 24 hours ofthe beta 2 agonist should be stated explicitly to the childand the child’s carer. High doses of beta 2 agonists can bedangerous in some children (see Cautions, below).Excessive use is usually an indication of inadequately3 Respiratory system