BNF for Children 2011-2012

BNFC 2011–2012 4.5 Drugs used in the treatment of obesity 191hypertrophy, of cor pulmonale, or of clinically significantstimulant-induced mitral-valve prolapse(including ischaemic ECG changes, chest pain andarrhythmias)Hepatic impairment halve dose in severe impairmentRenal impairment use with caution—no informationavailablePregnancy avoidBreast-feeding avoid—present in milk in animalstudiesSide-effects dry mouth, appetite changes, gastrointestinaldisturbances (including nausea, diarrhoea,constipation, and dyspepsia), abdominal pain; tachycardia,vasodilation, chest pain, palpitation; headache(uncommonly migraine), anxiety, sleep disturbances,dizziness, depression, confusion, paraesthesia, asthenia;visual disturbances; less commonly mouth ulcers,glossitis, pharyngitis, dysphagia, taste disturbance,increased thirst, hypertension, hypotension, bradycardia,arrhythmia, peripheral oedema, hypercholesterolaemia,rhinitis, dyspnoea, agitation, dyskinesia,amnesia, emotional lability, abnormal dreams,suicidal ideation, tremor, decreased libido, weightchanges, hyperglycaemia, urinary frequency, menstrualdisturbances, eosinophilia, leucopenia, myasthenia,muscle cramps, dry eye, sinusitis, epistaxis,myalgia, arthralgia, acne, sweating, rash, and pruritus;rarely hallucinations, mania, psychosis; very rarely,multi-organ hypersensitivity reaction, Stevens-Johnsonsyndrome, and toxic epidermal necrolysisLicensed use not licensed for use in childrenIndication and doseNarcolepsy. By mouthChild 5–12 years initially 100 mg daily in themorning, dose adjusted according to response to100–400 mg daily either in 2 divided doses morningand at noon or as a single dose in the morningChild 12–18 years 200 mg daily, either in 2divided doses morning and at noon or as a singledose in the morning, dose adjusted according toresponse to 200–400 mg daily in 2 divided doses oras a single doseProvigil c (Cephalon) TATablets, modafinil 100 mg, net price 30-tab pack =£52.60; 200 mg, 30-tab pack = £105.204.5 Drugs used in thetreatment of obesityObesity is associated with many health problems includingcardiovascular disease, diabetes mellitus, gallstones,and osteoarthritis. Factors that aggravate obesity mayinclude depression, other psychosocial problems, andsome drugs.The main treatment of the obese individual is a suitablediet, carefully explained to the individual or carer, withappropriate support and encouragement; increasedphysical activity should also be encouraged. If appropriate,smoking cessation (while maintaining bodyweight) may be worthwhile before attempting supervisedweight loss, since cigarette smoking may be moreharmful than obesity.Obesity should be managed in an appropriate setting bystaff who have been trained in the management ofobesity in children; the individual or carer shouldreceive advice on diet and lifestyle modification andshould be monitored for changes in weight as well as inblood pressure, blood lipids, and other associated conditions.NICE has recommended (December 2006) that drugtreatment should only be considered for obese childrenafter dietary, exercise, and behavioural approaches havebeen started, and who have associated conditions suchas orthopaedic problems or sleep apnoea; treatment isintended both to facilitate weight loss and to maintainreduced weight. Initial treatment should involve a 6–12month trial of orlistat, with regular reviews of effectiveness,tolerance, and adherence.Choice Orlistat, a lipase inhibitor, reduces the absorptionof dietary fat. Some weight loss in those takingorlistat probably results from a reduction in fat intake toavoid severe gastro-intestinal effects including steatorrhoea.Vitamin supplementation (especially of vitaminD) should be considered.Thyroid hormones have no place in the treatment ofobesity except in biochemically proven hypothyroidchildren. The use of diuretics, chorionic gonadotrophin,or amfetamines is not appropriate for weight reduction.ORLISTATCautions may impair absorption of fat-soluble vitamins;chronic kidney disease or volume depletion;interactions: Appendix 1 (orlistat)Multivitamins If a multivitamin supplement is required, itshould be taken at least 2 hours after orlistat doseContra-indications chronic malabsorption syndrome;cholestasisPregnancy use with cautionBreast-feeding avoid—no information availableSide-effects oily leakage from rectum, flatulence,faecal urgency, liquid or oily stools, faecal incontinence,abdominal distension and pain (gastro-intestinaleffects minimised by reduced fat intake), toothand gingival disorders, respiratory infections, malaise,anxiety, headache, menstrual disturbances, urinarytractinfection, hypoglycaemia; also reported rectalbleeding, diverticulitis, cholelithiasis, hepatitis, hypothyroidism,oxalate nephropathy, bullous eruptionsLicensed use not licensed for use in childrenIndication and doseAdjunct in obesity initiated by specialist. By mouthChild 12–18 years 120 mg taken immediatelybefore, during, or up to 1 hour after each mainmeal (max. 120 mg 3 times daily); continue treatmentbeyond 12 weeks only under specialistrecommendationNote If a meal is missed or contains no fat, the dose oforlistat should be omittedXenical c (Roche) ACapsules, turquoise, orlistat 120 mg, net price 84-cappack = £31.634 Central nervous system