BNF for Children 2011-2012

BNFC 2011–2012 6.1.2 Antidiabetic drugs 359Breast-feeding see notes aboveSide-effects see notes aboveLicensed use not licensed for use in childrenIndication and doseType 2 diabetes mellitus, maturity-onset diabetesof the young (specialist managementonly, see notes above). By mouthChild 12–18 years initially 2.5 mg daily with orimmediately after breakfast, adjusted according toresponse, max. 15 mg dailyGlibenclamide (Non-proprietary) ATablets, glibenclamide 2.5 mg, net price 28-tab pack= 95p; 5 mg, 28-tab pack = £1.07GLICLAZIDECautions see notes above; interactions: Appendix 1(antidiabetics)Contra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding see notes aboveSide-effects see notes aboveLicensed use not licensed for use in childrenIndication and doseType 2 diabetes mellitus, maturity-onset diabetesof the young (specialist managementonly, see notes above). By mouthChild 12–18 years initially 20 mg once daily withbreakfast, adjusted according to response; up to160 mg as a single dose; max. 160 mg twice dailyGliclazide (Non-proprietary) ATablets, gliclazide 40 mg, net price 28-tab pack =£3.36; 80 mg, 28-tab pack = £1.10, 60-tab pack = £1.52Brands include DIAGLYK c , c ZicronDiamicron c (Servier) ATablets, scored, gliclazide 80 mg, net price 60-tabpack = £4.38Tolbutamide (Non-proprietary) ATablets, tolbutamide 500 mg. Net price 28-tab pack =£1.74Extemporaneous formulations available seeExtemporaneous Preparations, p. 66.1.2.2 BiguanidesMetformin, the only available biguanide, has a differentmode of action from the sulfonylureas, and is not interchangeablewith them. It exerts its effect mainly bydecreasing gluconeogenesis and by increasing peripheralutilisation of glucose; since it acts only in thepresence of endogenous insulin it is effective only ifthere are some residual functioning pancreatic isletcells.Metformin is the drug of first choice in children withtype 2 diabetes, in whom strict dieting has failed tocontrol diabetes. When the combination of strict dietand metformin treatment fails, other options to beconsidered under specialist management only, include:. combining with insulin (section 6.1.1) but weightgain and hypoglycaemia can be problems (weightgain minimised if insulin given at night);. combining with a sulfonylurea (section 6.1.2.1)(reports of increased hazard with this combinationremain unconfirmed).Insulin treatment is almost always required in medicaland surgical emergencies; insulin should also be substitutedbefore elective surgery (omit metformin on themorning of surgery and give insulin if required).Hypoglycaemia does not usually occur with metformin;other advantages are the lower incidence of weight gainand lower plasma-insulin concentration. It does notexert a hypoglycaemic action in non-diabetic subjectsunless given in overdose.Gastro-intestinal side-effects are initially common withmetformin, and may persist in some children, particularlywhen high doses are given. A slow increase in dosemay improve tolerability.Very rarely, metformin can provoke lactic acidosiswhich is most likely to occur in children with renalimpairment, see Lactic Acidosis below.6 Endocrine systemTOLBUTAMIDECautions see notes above; interactions: Appendix 1(antidiabetics)Contra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding see notes aboveSide-effects see notes above; also headache, tinnitusLicensed use not licensed for use in childrenIndication and doseType 2 diabetes mellitus (see notes above), specialistmanagement only. By mouthChild 12–18 years 0.5–1.5 g (max. 2 g) daily individed doses with or immediately after meals oras a single dose with or immediately after breakfastMETFORMIN HYDROCHLORIDECautions see notes above; determine renal functionbefore treatment and at least annually (at least twice ayear in patients with additional risk factors for renalimpairment, or if deterioration suspected); interactions:Appendix 1 (antidiabetics)Lactic acidosis Use with caution in renal impairment—increased risk of lactic acidosis; avoid in significant renalimpairment. Withdraw or interrupt treatment in those at riskof tissue hypoxia or sudden deterioration in renal function,such as those with dehydration, severe infection, shock,sepsis, acute heart failure, respiratory failure, or hepaticimpairmentContra-indications ketoacidosis; use of generalanaesthesia (suspend metformin on the morning ofsurgery and restart when renal function returns tobaseline)Iodine-containing X-ray contrast media Intravascularadministration of iodinated contrast agents can cause renalfailure, which can increase the risk of lactic acidosis with