BNF for Children 2011-2012

BNFC 2011–2012 3.1.2 Antimuscarinic bronchodilators 141Evohaler c aerosol inhalation T, salmeterol (asxinafoate) 25 micrograms/metered inhalation, netprice 120-dose unit = £29.26. Counselling, administrationDiskhaler c (dry powder for inhalation), disks containing4 blisters of salmeterol (as xinafoate)50 micrograms/blister, net price 15 disks with Diskhalerc device = £35.79, 15-disk refill = £35.15.Counselling, administrationCompound preparationsFor compound preparations containing salmeterol,see section 3.2TERBUTALINE SULPHATECautions see notes abovePregnancy see p. 133Breast-feeding see p. 133Side-effects see notes aboveLicensed use tablets not licensed for use in childrenunder 7 years; injection not licensed for use inchildren under 2 yearsIndication and doseAcute asthma. By inhalation of nebulised solutionSee Management of Acute Asthma, p. 134. By subcutaneous or slow intravenous injectionChild 2–15 years 10 micrograms/kg (max.300 micrograms) up to 4 times dailyChild 15–18 years 250–500 micrograms up to 4times daily. By continuous intravenous infusionChild 1 month–18 years initially 2–4 micrograms/kgas a loading dose, then 1–10 micrograms/kg/houraccording to response and heartrate (doses above 10 micrograms/kg/hour withclose monitoring)Exacerbations of reversible airways obstruction(including nocturnal asthma) and prevention ofexercise-induced bronchospasm see Managementof Chronic Asthma table, p. 135. By inhalation of powderChild 5–18 years 500 micrograms (1 inhalation)up to 4 times daily (for occasional use only). By mouth (but not recommended)Child 1 month–7 years 75 micrograms/kg (max.2.5 mg) 3 times dailyChild 7–15 years 2.5 mg 2–3 times dailyChild 15–18 years initially 2.5 mg 3 times daily,increased if necessary to 5 mg 3 times dailyAdministration For continuous intravenous infusion,dilute to a concentration of 5 micrograms/mL withGlucose 5% or Sodium Chloride 0.9%; if fluidrestricted,dilute to a concentration of 100 micrograms/mLFor nebulisation, dilute nebuliser solution with sterileSodium Chloride 0.9% solution according to nebulisertype and duration of administration; terbutaline andipratropium bromide solutions are compatible andmay be mixed for nebulisation.Oral and parenteralBricanyl c (AstraZeneca) ATablets, scored, terbutaline sulphate 5 mg, net price100-tab pack = £4.09Syrup, sugar-free, terbutaline sulphate 1.5 mg/5 mL,net price 100 mL = £2.00Injection, terbutaline sulphate 500 micrograms/mL,net price 1-mL amp = 30p; 5-mL amp = £1.40InhalationCounselling Advise children and carers not to exceed prescribeddose and to follow manufacturer’s directions; if apreviously effective dose of inhaled terbutaline fails toprovide at least 3 hours relief, a doctor’s advice should beobtained as soon as possibleBricanyl c (AstraZeneca) ATurbohaler c (= dry powder inhaler), terbutalinesulphate 500 micrograms/metered inhalation, netprice 100-dose unit = £6.92. Counselling, administrationRespules c (= single-dose units for nebulisation),terbutaline sulphate 2.5 mg/mL, net price 20 2-mLunits (5 mg) = £4.043.1.1.2 Other adrenoceptor agonistsAdrenaline (epinephrine) injection (1 in 1000) is usedin the emergency treatment of acute allergic and anaphylacticreactions (section 3.4.3), in angioedema (section3.4.3), and in cardiopulmonary resuscitation (section2.7.3). Adrenaline solution (1 in 1000) is used bynebulisation in the management of severe croup (section3.1).3.1.2 AntimuscarinicbronchodilatorsIpratropium by nebulisation can be added to otherstandard treatment in life-threatening acute asthma orif acute asthma fails to improve with standard therapy(see Management of Acute Asthma, p. 134). Ipratropiumcan be used to provide short-term relief inchronic asthma, but short-acting beta 2agonists actmore quickly and are preferred.The aerosol inhalation of ipratropium has a maximumeffect 30–60 minutes after use; its duration of action is 3to 6 hours.IPRATROPIUM BROMIDECautions risk of glaucoma (see below), bladder outflowobstruction; interactions: Appendix 1 (antimuscarinics)Glaucoma Acute angle-closure glaucoma reported withnebulised ipratropium, particularly when given with nebulisedsalbutamol (and possibly other beta 2 agonists); careneeded to protect the child’s eyes from nebulised drug orfrom drug powderPregnancy see p. 133Breast-feeding see p. 133Side-effects dry mouth, nausea, throat irritation,cough, headache, dizziness; less commonly diarrhoea,constipation, vomiting, palpitation, tachycardia,bronchospasm (including paradoxical bronchospasm),laryngospasm, pharyngeal oedema, urinaryretention, blurred vision, mydriasis, raised intra-ocularpressure, angle-closure glaucoma, eye pain, con-3 Respiratory system