BNF for Children 2011-2012

BNFC 2011–2012 10.1.4 Gout and cytotoxic-induced hyperuricaemia 511hepatitis C infection; children should be brought up todate with current immunisation schedule (section14.1) before initiating therapy; heart failure (risk ofexacerbation); history or increased risk of demyelinatingdisorders; history or development of malignancy;monitor for skin cancer before and duringtreatment particularly in those at risk (including childrenwith psoriasis or a history of PUVA treatment);history of blood disorders; diabetes mellitus; interactions:Appendix 1 (etanercept)Tuberculosis Children should be evaluated for tuberculosisbefore treatment. Active tuberculosis should be treated withstandard treatment (section 5.1.9) for at least 2 monthsbefore starting etanercept. Children who have previouslyreceived adequate treatment for tuberculosis can start etanerceptbut should be monitored every 3 months for possiblerecurrence. In those without active tuberculosis but whowere previously not treated adequately, chemoprophylaxisshould ideally be completed before starting etanercept. Inchildren at high risk of tuberculosis who cannot be assessedby tuberculin skin test, chemoprophylaxis can be givenconcurrently with etanercept. Children and their carersshould be advised to seek medical attention if symptomssuggestive of tuberculosis (e.g. persistent cough, weight loss,and fever) developBlood disorders Children and their carers should be advisedto seek medical attention if symptoms suggestive of blooddisorders (such as fever, sore throat, bruising, or bleeding)developContra-indications active infection; avoid injectionscontaining benzyl alcohol in neonates (see preparationsbelow)Hepatic impairment use with caution in moderate tosevere alcoholic hepatitisPregnancy manufacturer advises avoid—no informationavailableBreast-feeding manufacturer advises avoid—presentin milk in animal studiesSide-effects see under Cytokine Modulators, p. 509;also less commonly interstitial lung disease, skincancer, uveitis, rash, new onset or worsening psoriasis;rarely demyelinating disorders, seizures,lymphoma, Stevens-Johnson syndrome, vasculitis;very rarely toxic epidermal necrolysis; also reportedappendicitis, gastritis, oesophagitis, inflammatorybowel disease, vomiting, diabetes mellitus, malignancy(including solid tumours and leukaemia),macrophage activation syndrome, and cutaneousulcerIndication and doseActive polyarticular juvenile idiopathic arthritisin children who have had an inadequateresponse to methotrexate or who cannot tolerateit. By subcutaneous injectionChild 4–17 years 400 micrograms/kg (max.25 mg) twice weekly, with an interval of 3–4 daysbetween dosesSevere plaque psoriasis section 13.5.3Enbrel c (Wyeth) TAInjection, powder for reconstitution, etanercept, netprice 25-mg vial (with solvent) = £89.38. Label: 10,alert card, counselling, tuberculosis and blood disordersPaediatric injection, powder for reconstitution, etanercept,net price 25-mg vial (with solvent) = £89.38.Label: 10, alert card, counselling, tuberculosis andblood disordersExcipients include benzyl alcohol (avoid in neonates, see Excipients,p. 2)Injection, etanercept, net price 25-mg prefilledsyringe = £89.38; 50-mg prefilled pen or prefilledsyringe = £178.75. Label: 10, alert card, counselling,tuberculosis and blood disordersSulfasalazineSulfasalazine has a beneficial effect in suppressing theinflammatory activity associated with some forms ofjuvenile idiopathic arthritis; it is generally not used insystemic-onset disease. Sulfasalazine may cause haematologicalabnormalities including leucopenia, neutropenia,and thrombocytopenia and close monitoring offull blood counts (including differential white cell countand platelet count) is necessary initially, and at monthlyintervals during the first 3 months (liver-function testsalso being performed at monthly intervals for the first 3months). Although the manufacturer recommends renalfunction tests, evidence of practical value is unsatisfactory.For use of sulfasalazine also see section 1.5.1,aminosalicylates.SULFASALAZINE(Sulphasalazine)Cautions see section 1.5.1 and notes aboveContra-indications see section 1.5.1Hepatic impairment section 1.5.1Renal impairment section 1.5.1Pregnancy section 1.5.1Breast-feeding section 1.5.1Side-effects see section 1.5.1 and notes aboveLicensed use not licensed for use in children forjuvenile idiopathic arthritisIndication and doseJuvenile idiopathic arthritis (see also notesabove). By mouthChild 2–18 years initially 5 mg/kg twice daily for1 week, then 10 mg/kg twice daily for 1 week, then20 mg/kg twice daily for 1 week, maintenancedose 20–25 mg/kg twice daily; Child 2–12 yearsmax. 2 g daily, Child 12–18 years max. 3 g dailyPreparationsSection 1.5.110.1.4 Gout and cytotoxicinducedhyperuricaemiaThis section is not included in BNF for Children. For therole of allopurinol and rasburicase in the prophylaxis ofhyperuricaemia associated with cancer chemotherapyand in enzyme disorders causing increased serum urate,see section 8.1. The management of gout in adolescentsrequires specialist supervision.10 Musculoskeletal and joint diseases