BNF for Children 2011-2012

138 3.1.1 Adrenoceptor agonists BNFC 2011–20123 Respiratory systemcontrolled asthma and should be managed with aprophylactic drug such as an inhaled corticosteroid.The child and the child’s carer should be advised toseek medical advice when the prescribed dose of beta 2agonist fails to provide the usual degree of symptomaticrelief because this usually indicates a worsening of theasthma and the child may require alternative medication(see Management of Chronic Asthma table, p. 135).Children and their carers should be advised to followmanufacturers’ instructions on the care and cleansing ofinhaler devices.Nebuliser (or respirator) solutions of salbutamol andterbutaline are used for the treatment of severe acuteasthma both in hospital and in general practice. Childrenwith a severe attack of asthma should have oxygen ifpossible during nebulisation since beta 2 agonists canincrease arterial hypoxaemia, see also section 3.1.5.Oral Oral preparations of beta 2 agonists may be usedfor children if an inhaler device cannot be used butinhaled beta 2agonists are more effective and have fewerside-effects. A modified-release formulation of salbutamolmay be of value in nocturnal asthma as an alternativeto modified-release theophylline preparations(section 3.1.3), but an inhaled long-acting beta 2 agonistis preferable.Parenteral Beta 2 agonists can be given intravenouslyin children with severe or life-threatening acute asthma.Chronic asthma unresponsive to stepwise treatment(see Management of Chronic Asthma, p. 135) may benefitfrom continuous subcutaneous infusion of a beta 2agonist, but this should be used only under the supervisionof a respiratory specialist; the evidence of benefitis uncertain and it may be difficult to withdraw suchtreatment once started.Cautions Beta 2 agonists should be used with caution indiabetes—monitor blood glucose (risk of ketoacidosis,especially when a beta 2 agonist is given intravenously).Beta 2 agonists should also be used with caution inhyperthyroidism, cardiovascular disease, arrhythmias,susceptibility to QT-interval prolongation, and hypertension.Interactions: Appendix 1 (sympathomimetics,beta 2 ).Hypokalaemia Potentially serious hypokalaemia mayresult from beta 2 agonist therapy. Particular caution isrequired in severe asthma, because this effect may bepotentiated by concomitant treatment with theophyllineand its derivatives, corticosteroids, and diuretics, and byhypoxia. Plasma-potassium concentration should thereforebe monitored in severe asthma.Side-effects Side-effects of the beta 2 agonists includefine tremor (particularly in the hands), nervous tension,headache, peripheral dilatation and palpitation. Otherside-effects include tachycardia, arrhythmias, peripheralvasodilation, myocardial ischaemia, and disturbances ofsleep and behaviour. Muscle cramps and hypersensitivityreactions including paradoxical bronchospasm(occasionally severe), urticaria, angioedema, hypotension,and collapse have also been reported. Highdoses of beta 2 agonists are associated with hypokalaemia(see Hypokalaemia, above).FORMOTEROL FUMARATE(Eformoterol fumarate)Note For use in asthma only in children who regularly use aninhaled corticosteroid, see notes aboveCautions see notes abovePregnancy see p. 133Breast-feeding see p. 133Side-effects see notes above; nausea, dizziness, rash,taste disturbances, and pruritus also reportedIndication and doseReversible airways obstruction (includingnocturnal asthma and prevention of exerciseinducedbronchospasm) in patients requiringlong-term regular bronchodilator therapy seealso Management of Chronic Asthma table, p. 135;for dose see preparations belowCounselling Advise children and carers not to exceed prescribeddose, and to follow manufacturer’s directions; if apreviously effective dose of inhaled formoterol fails toprovide adequate relief, a doctor’s advice should be obtainedas soon as possibleFormoterol (Non-proprietary) ADry powder for inhalation, formoterol fumarate12 micrograms/metered inhalation, net price 120-dose unit = £23.75. Counselling, administrationBrands include Easyhaler c FormoterolDoseChronic asthma. By inhalation of powderChild 6–18 years 12 micrograms twice daily, increasedto 24 micrograms twice daily in more severe airwaysobstruction (see also CHM advice above)Atimos Modulite c (Chiesi) AAerosol inhalation, formoterol fumarate 12 micrograms/meteredinhalation, net price 100-dose unit =£30.06. Counselling, administrationDoseChronic Asthma. By aerosol inhalationChild 12–18 years 12 micrograms twice daily, increasedto max. 24 micrograms twice daily in more severe airwaysobstructionForadil c (Novartis) ADry powder for inhalation, formoterol fumarate12 micrograms/capsule, net price 60-cap pack (withinhaler device) = £23.38. Counselling, administrationDoseChronic asthma. By inhalation of powderChild 5–12 years 12 micrograms twice dailyChild 12–18 years 12 micrograms twice daily, increasedto 24 micrograms twice daily in more severe airwaysobstructionOxis c (AstraZeneca) ATurbohaler c (= dry powder inhaler), formoterolfumarate 6 micrograms/inhalation, net price 60-doseunit = £24.80; 12 micrograms/inhalation, 60-dose unit= £24.80. Counselling, administrationDoseChronic asthma. By inhalation of powderChild 6–18 years 6–12 micrograms 1–2 times daily;occasionally up to 48 micrograms daily may be needed(max. single dose 12 micrograms); reassess treatment ifadditional doses required on more than 2 days a week(see also CHM advice above)