BNF for Children 2011-2012

BNFC 2011–2012 9.1.3 Drugs used in hypoplastic, haemolytic, renal anaemias 449cutaneously or intravenously once weekly or subcutaneouslyonce every 2 weeks or subcutaneouslyonce every monthNote Subcutaneous route preferred in patients not onhaemodialysis. Reduce dose by approximately 25% if rise inhaemoglobin concentration exceeds 2 g/100 mL over 4weeks or if haemoglobin concentration exceeds 12 g/100 mL; if haemoglobin concentration continues to rise,despite dose reduction, suspend treatment until haemoglobinconcentration decreases and then restart at a doseapproximately 25% lower than the previous dose. Whenchanging route give same dose then adjust according toweekly or fortnightly haemoglobin measurements. Adjustdoses not more frequently than every 2 weeks duringmaintenance treatment.Aranesp c (Amgen) AInjection, prefilled syringe, darbepoetin alfa,25 micrograms/mL, net price 0.4 mL (10 micrograms)= £14.68; 40 micrograms/mL, 0.375 mL (15 micrograms)= £22.03, 0.5 mL (20 micrograms) = £29.37;100 micrograms/mL, 0.3 mL (30 micrograms) =£44.05, 0.4 mL (40 micrograms) = £58.73, 0.5 mL(50 micrograms) = £73.41; 200 micrograms/mL,0.3 mL (60 micrograms) = £88.09, 0.4 mL (80 micrograms)= £117.45, 0.5 mL (100 micrograms) =£146.81, 0.65 mL (130 micrograms) = £190.86;500 micrograms/mL, 0.3 mL (150 micrograms) =£220.22, 0.6 mL (300 micrograms) = £440.43, 1 mL(500 micrograms) = £734.05Injection (Aranesp c SureClick), prefilled disposableinjection device, darbepoetin alfa, 40 micrograms/mL, net price 0.5 mL (20 micrograms) = £29.36;100 micrograms/mL, net price 0.4 mL (40 micrograms)= £58.72; 200 micrograms/mL, net price0.3 mL (60 micrograms) = £88.09, 0.4 mL (80 micrograms)= £117.45, 0.5 mL (100 micrograms) =£146.81; 500 micrograms/mL, net price 0.3 mL(150 micrograms) = £220.22, 0.6 mL (300 micrograms)= £440.43, 1 mL (500 micrograms) = £734.05EPOETIN ALFA, BETA, and ZETA(Recombinant human erythropoietins)Note The prescriber must specify which epoetin is required,see also Biosimilar medicines, p. 2Cautions see notes above; also inadequately treated orpoorly controlled blood pressure (monitor closelyblood pressure, reticulocyte counts, haemoglobin, andelectrolytes), interrupt treatment if blood pressureuncontrolled; sudden stabbing migraine-like pain iswarning of hypertensive crisis; sickle-cell disease(lower target haemoglobin concentration may beappropriate); ischaemic vascular disease; thrombocytosis(monitor platelet count for first 8 weeks); epilepsy;malignant disease; increase in unfractionated orlow molecular weight heparin dose may be neededduring dialysisContra-indications pure red cell aplasia followingerythropoietin therapy (see also notes above);uncontrolled hypertension; avoid injections containingbenzyl alcohol in neonates (see under preparations,below)Hepatic impairment manufacturers advise caution inchronic hepatic failurePregnancy no evidence of harm; benefits probablyoutweigh risks of anaemia and blood transfusionBreast-feeding unlikely to be present in milk; effecton infant minimalSide-effects diarrhoea, nausea, vomiting; dosedependentincrease in blood pressure or aggravationof hypertension; in isolated patients with normal orlow blood pressure, hypertensive crisis withencephalopathy-like symptoms and generalised tonicclonicseizures requiring immediate medical attention;dose-dependent increase in platelet count (butthrombocytosis rare) regressing during treatment;influenza-like symptoms (may be reduced if intravenousinjection given over 5 minutes); cardiovascularevents; shunt thrombosis especially if tendency tohypotension or arteriovenous shunt complications;very rarely sudden loss of efficacy because of pure redcell aplasia, particularly following subcutaneousadministration in patients with chronic renal failure(discontinue erythropoietin therapy)—see also notesabove, hyperkalaemia, hypersensitivity reactions(including anaphylaxis and angioedema), skin reactions,injection-site reactions, and peripheral oedemaalso reportedLicensed use Eprex c 20 000–unit, 30 000–unit, and40 000–unit prefilled syringes not licensed for use inchildrenIndication and doseSee under preparations, belowEpoetin alfaBinocrit c (Sandoz) TAInjection, prefilled syringe, epoetin alfa, net price1000 units = £5.09; 2000 units = £10.18; 3000 units =£15.27; 4000 units = £20.36; 5000 units = £25.46;6000 units = £30.55; 8000 units = £40.73; 10 000 units= £50.91Note Biosimilar Medicine, p. 2DoseSymptomatic anaemia associated with chronic renalfailure in children on haemodialysis (see also notesabove). By intravenous injection over 1–5 minutesChild 1 month–18 years initially 50 units/kg 3 timesweekly adjusted according to response in steps of25 units/kg 3 times weekly at intervals of at least 4weeks; maintenance dose, body-weight under 10 kgusually 75–150 units/kg 3 times weekly, body-weight 10–30 kg usually 60–150 units/kg 3 times weekly, bodyweightover 30 kg usually 30–100 units/kg 3 timesweeklyNote Reduce dose by approximately 25 % if rise in haemoglobinconcentration exceeds 2 g/100 mL over 4 weeksor if haemoglobin concentration exceeds 12 g/100 mL; ifhaemoglobin concentration continues to rise, despite dosereduction, suspend treatment until haemoglobin concentrationdecreases and then restart at a dose approximately 25 %lower than the previous doseEprex c (Janssen) AInjection, prefilled syringe, epoetin alfa, net price1000 units = £5.53; 2000 units = £11.07; 3000 units =£16.60; 4000 units = £22.13; 5000 units = £27.66;6000 units = £33.19; 8000 units = £44.25; 10 000 units= £55.31; 20 000 units = £110.62; 30 000 units =£199.11; 40 000 units = £265.48. An auto-injectordevice is available for use with prefilled syringesDoseSymptomatic anaemia associated with chronic renalfailure in children on haemodialysis (see also notesabove). By intravenous injection over 1–5 minutesChild 1 month–18 years initially 50 units/kg 3 timesweekly adjusted according to response in steps of25 units/kg 3 times weekly at intervals of at least 49 Nutrition and blood