BNF for Children 2011-2012

BNFC 2011–2012 11.6 Treatment of glaucoma 527Acetazolamide is given by mouth or, rarely in children,by intravenous injection (intramuscular injections arepainful because of the alkaline pH of the solution). It isused as an adjunct to other treatment for reducing intraocularpressure. Acetazolamide is a sulfonamide derivative;blood disorders, rashes, and other sulfonamiderelatedside-effects occur occasionally; children andtheir carers should be told to report any unusual skinrash. It is not generally recommended for long-term use;electrolyte disturbances and metabolic acidosis thatoccur can be corrected by administering potassiumbicarbonate (as effervescent potassium tablets, section9.2.1.3).Dorzolamide and brinzolamide are topical carbonicanhydrase inhibitors. They are unlicensed in childrenbut are used in those resistant to beta-blockers or thosein whom beta-blockers are contra-indicated. They areused alone or as an adjunct to a topical beta-blocker.Systemic absorption can rarely cause sulfonamide-likeside-effects and may require discontinuation if severe.The osmotic diuretics, intravenous hypertonic mannitol(section 2.2.5) or glycerol by mouth, are usefulshort-term ocular hypotensive drugs.ACETAZOLAMIDECautions not generally recommended for prolongeduse but if given monitor blood count and plasmaelectrolyte concentration; pulmonary obstruction andimpaired alveolar ventilation (risk of acidosis); diabetesmellitus; renal calculi; avoid extravasation atinjection site (risk of necrosis); interactions: Appendix1 (diuretics)Contra-indications hypokalaemia, hyponatraemia,hyperchloraemic acidosis; adrenocortical insufficiency;long-term administration in chronic angleclosureglaucoma; sulfonamide hypersensitivityHepatic impairment manufacturer advises avoidRenal impairment avoid; metabolic acidosisPregnancy manufacturer advises avoid, especially infirst trimester (toxicity in animal studies)Breast-feeding amount too small to be harmfulSide-effects see notes above; also nausea, vomiting,diarrhoea, taste disturbance, loss of appetite, paraesthesia,flushing, headache, dizziness, fatigue, irritability,excitement, ataxia, depression, thirst, polyuria; lesscommonly melaena, drowsiness, confusion, hearingdisturbances, fever, glycosuria, metabolic acidosis andelectrolyte disturbances on long-term therapy, haematuria,crystalluria, renal and ureteral colic, renallesions or calculi, renal failure, blood disorders, bonemarrow suppression, rash (including Stevens-Johnsonsyndrome and toxic epidermal necrosis); rarely fulminanthepatic necrosis, hepatitis, cholestatic jaundice,flaccid paralysis, convulsions, photosensitivity;also reported transient myopiaLicensed use not licensed for use in children fortreatment of glaucomaIndication and doseReduction of intra-ocular pressure in openangleglaucoma, secondary glaucoma, perioperativelyin angle-closure glaucoma. By mouth or by intravenous injectionChild 1 month–12 years 5 mg/kg 2–4 times daily,adjusted according to response, max. 750 mg dailyChild 12–18 years 250 mg 2–4 times dailyEpilepsy. By mouth or slow intravenous injectionNeonate initially 2.5 mg/kg 2–3 times daily, followedby 5–7 mg/kg 2–3 times daily (maintenancedose)Child 1 month–12 years initially 2.5 mg/kg 2–3times daily, followed by 5–7 mg/kg 2–3 times daily,max. 750 mg daily (maintenance dose)Child 12–18 years 250 mg 2–4 times dailyRaised intracranial pressure. By mouth or slow intravenous injectionChild 1 month–12 years initially 8 mg/kg 3 timesdaily, increased as necessary to max. 100 mg/kgdailyDiamox c (Goldshield) ATablets, acetazolamide 250 mg. Net price 112-tabpack = £12.68. Label: 3Sodium Parenteral (= injection), powder for reconstitution,acetazolamide (as sodium salt). Net price500-mg vial = £14.76Modified releaseDiamox c SR (Goldshield) ACapsules, m/r, orange, enclosing orange f/c pellets,acetazolamide 250 mg. Net price 30-cap pack =£13.88. Label: 3, 25DoseChild 12–18 years glaucoma, 1–2 capsules dailyExtemporaneous formulations available seeExtemporaneous Preparations, p. 6BRINZOLAMIDECautions systemic absorption follows topical application;neonates and infants with immature renaltubules—risk of metabolic acidosis; interactions:Appendix 1 (brinzolamide)Contra-indications hyperchloraemic acidosisHepatic impairment manufacturer advises avoidRenal impairment see Cautions above; also avoid ifestimated glomerular filtration rate less than 30 mL/minute/1.73 m 2Pregnancy manufacturer advises avoid unless essential—toxicityin animal studiesBreast-feeding manufacturer advises avoidSide-effects local irritation, taste disturbance; lesscommonly nausea, dyspepsia, dry mouth, chest pain,epistaxis, haemoptysis, dyspnoea, rhinitis, pharyngitis,bronchitis, paraesthesia, depression, dizziness,headache, dermatitis, alopecia, corneal erosionLicensed use not licensed for use in childrenIndication and doseAdjunct to beta-blockers or used alone in raisedintra-ocular pressure in ocular hypertensionand in open-angle glaucoma if beta-blockeralone inadequate or inappropriateApply twice daily increased to 3 times daily ifnecessaryAzopt c (Alcon) AEye drops, brinzolamide 10 mg/mL, net price 5 mL =£6.56Excipients include benzalkonium chloride, disodium edetate11 Eye