BNF for Children 2011-2012

BNFC 2011–2012 6.3 Corticosteroids 369Child 5–12 years initially 50 mg 3 times daily untileuthyroid then adjusted as necessary (see notesabove); higher doses occasionally required, particularlyin thyrotoxic crisisChild 12–18 years initially 100 mg 3 times dailyadministered until euthyroid then adjusted asnecessary (see notes above); higher doses occasionallyrequired, particularly in thyrotoxic crisisPropylthiouracil (Non-proprietary) ATablets, propylthiouracil 50 mg, net price 56-tab pack= £47.11, 100-tab pack = £67.38Extemporaneous formulations available seeExtemporaneous Preparations, p. 6PROPRANOLOL HYDROCHLORIDECautions see section 2.4Contra-indications see section 2.4Hepatic impairment section 2.4Renal impairment section 2.4Pregnancy section 2.4Breast-feeding section 2.4Side-effects see section 2.4Indication and doseHyperthyroidism with autonomic symptoms,thyrotoxicosis, thyrotoxic crisis. By mouthNeonate initially 250–500 micrograms/kg every6–8 hours, adjusted according to responseChild 1 month–18 years initially 250–500 micrograms/kgevery 8 hours, then adjusted accordingto response; doses up to 1 mg/kg every 8 hoursoccasionally required, max. 40 mg every 8 hours. By intravenous injection over 10 minutesNeonate initially 20–50 micrograms/kg every 6–8hours, adjusted according to responseChild 1 month–18 years initially 25–50 micrograms/kg(max. 5 mg) every 6–8 hours, adjustedaccording to responsePreparationsSee section 2.46.3 Corticosteroids6.3.1 Replacement therapy6.3.2 Glucocorticoid therapy6.3.1 Replacement therapyThe adrenal cortex normally secretes hydrocortisone(cortisol) which has glucocorticoid activity and weakmineralocorticoid activity. It also secretes the mineralocorticoidaldosterone.In deficiency states, physiological replacement is bestachieved with a combination of hydrocortisone (section6.3.2) and the mineralocorticoid fludrocortisone;hydrocortisone alone does not usually provide sufficientmineralocorticoid activity for complete replacement.In Addison’s disease or following adrenalectomy,hydrocortisone by mouth is usually required. This isgiven in 2–3 divided doses, the larger in the morning andthe smaller in the evening, mimicking the normal diurnalrhythm of cortisol secretion. The optimum dailydose is determined on the basis of clinical response.Glucocorticoid therapy is supplemented by fludrocortisone.In acute adrenocortical insufficiency, hydrocortisoneis given intravenously (preferably as sodium succinate)every 6 to 8 hours in sodium chloride intravenousinfusion 0.9%.In hypopituitarism, glucocorticoids should be given asin adrenocortical insufficiency, but since production ofaldosterone is also regulated by the renin-angiotensinsystem a mineralocorticoid is not usually required.Additional replacement therapy with levothyroxine(section 6.2.1) and sex hormones (section 6.4) shouldbe given as indicated by the pattern of hormone deficiency.In congenital adrenal hyperplasia, the pituitary glandincreases production of corticotropin to compensate forreduced formation of cortisol; this results in excessiveadrenal androgen production. Treatment is aimed atsuppressing corticotropin using hydrocortisone (section6.3.2). Careful and continual dose titration is required toavoid growth retardation and toxicity; for this reasonpotent, synthetic glucocorticoids such as dexamethasoneare usually reserved for use in adolescents.The dose is adjusted according to clinical response andmeasurement of adrenal androgens and 17-hydroxyprogesterone.Salt-losing forms of congenital adrenalhyperplasia (where there is a lack of aldosterone production)also require mineralocorticoid replacementand salt supplementation (particularly in early life).The dose of mineralocorticoid is adjusted according toelectrolyte concentration and plasma-renin activity.FLUDROCORTISONE ACETATECautions section 6.3.2; interactions: Appendix 1(corticosteroids)Contra-indications section 6.3.2Hepatic impairment see section 6.3.2Renal impairment see section 6.3.2Pregnancy see section 6.3.2Breast-feeding see section 6.3.2Side-effects section 6.3.2Indication and doseMineralocorticoid replacement in adrenocorticalinsufficiency. By mouthNeonate initially 50 micrograms once daily,adjusted according to response; usual range 50–200 micrograms daily; higher doses may berequiredChild 1 month–18 years initially 50–100 microgramsonce daily; maintenance 50–300 microgramsonce daily, adjusted according to responseNote Dose adjustment may be required if salt supplementsare administered6 Endocrine system