BNF for Children 2011-2012

BNFC 2011–2012 1.3.1 H 2 -receptor antagonists 43Test for Helicobacter pylori13C-Urea breath test kits are available for confirming thepresence of gastro-duodenal infection with Helicobacterpylori. The test involves collection of breath samplesbefore and after ingestion of an oral solution of 13 C-urea;the samples are sent for analysis by an appropriatelaboratory. The test should not be performed within 4weeks of treatment with an antibacterial or within 2weeks of treatment with an antisecretory drug. A specific13 C-Urea breath test kit for children is available(Helicobacter Test INFAI for children of the age 3–11 c ). However the appropriateness of testing for H.pylori infection in children has not been established.Breath, saliva, faecal, and urine tests for H. pylori arefrequently unreliable in children; the most accuratemethod of diagnosis is endoscopy with biopsy.Helicobacter Test INFAI for children of the age 3–11 c (Infai) AOral powder, 13 C-urea 45 mg, net price 1 kit (including4 breath sample containers, straws) = £19.20 (spectrometricanalysis included)Helicobacter Test INFAI c (Infai) AOral powder, 13 C-urea 75 mg, net price 1 kit (including4 breath-sample containers, straws) = £19.20 (spectrometricanalysis included); 1 kit (including 2 breathbags) = £14.20 (spectroscopic analysis not included);50-test set = £855.00 (spectrometric analysisincluded)NSAID-associated ulcersGastro-intestinal bleeding and ulceration can occur withNSAID use (section 10.1.1). In adults, the risk of seriousupper gastro-intestinal side-effects varies between individualNSAIDs (see Gastro-intestinal side-effects,p. 501). Whenever possible, NSAIDs should be withdrawnif an ulcer occurs.Children at high risk of developing gastro-intestinalcomplications with a NSAID include those with a historyof peptic ulcer disease or serious upper gastrointestinalcomplication, those taking other medicinesthat increase the risk of upper gastro-intestinal sideeffects,or those with serious co-morbidity. In children atrisk of ulceration, a proton pump inhibitor (section 1.3.5)or an H 2 -receptor antagonist, such as ranitidine, may beconsidered for protection against gastric and duodenalulcers associated with non-selective NSAIDs.NSAID use and H. pylori infection are independent riskfactors for gastro-intestinal bleeding and ulceration. Inchildren already taking a NSAID, eradication of H.pylori is unlikely to reduce the risk of NSAID-inducedbleeding or ulceration. However, in children about tostart long-term NSAID treatment who are H. pyloripositive and have dyspepsia or a history of gastric orduodenal ulcer, eradication of H. pylori may reduce theoverall risk of ulceration.If the NSAID can be discontinued in a child who hasdeveloped an ulcer, a proton pump inhibitor usuallyproduces the most rapid healing; alternatively theulcer can be treated with an H 2 -receptor antagonist.If NSAID treatment needs to continue, the ulcer istreated with a proton pump inhibitor (section 1.3.5).1.3.1 H 2 -receptor antagonistsHistamine H 2 -receptor antagonists heal gastric andduodenal ulcers by reducing gastric acid output as aresult of histamine H 2 -receptor blockade; they are alsoused to relieve symptoms of dyspepsia and gastrooesophagealreflux disease (section 1.1). H 2 -receptorantagonists should not normally be used for Zollinger–Ellison syndrome because proton pump inhibitors (section1.3.5) are more effective.Maintenance treatment with low doses has largely beenreplaced in Helicobacter pylori positive children byeradication regimens (section 1.3).H 2 -receptor antagonist therapy can promote healing ofNSAID-associated ulcers (section 1.3).Treatment with a H 2 -receptor antagonist has not beenshown to be beneficial in haematemesis and melaena,but prophylactic use reduces the frequency of bleedingfrom gastroduodenal erosions in hepatic coma, andpossibly in other conditions requiring intensive care.Treatment also reduces the risk of acid aspiration inobstetric patients at delivery (Mendelson’s syndrome).H 2-receptor antagonists are also used to reduce thedegradation of pancreatic enzyme supplements (section1.9.4) in children with cystic fibrosis.Side-effects Side-effects of H 2 -receptor antagonistsinclude diarrhoea, headache, and dizziness. Rash(including erythema multiforme and toxic epidermalnecrolysis) occurs less frequently. Other side-effectsreported rarely or very rarely include hepatitis, cholestaticjaundice, bradycardia, psychiatric reactions(including confusion, depression, and hallucinations)particularly in the very ill, blood disorders (includingleucopenia, thrombocytopenia, and pancytopenia),arthralgia, and myalgia. There are isolated reports ofgynaecomastia and impotence.RANITIDINECautions acute porphyria; interactions: Appendix 1(histamine H 2 -antagonists)Renal impairment use half normal dose if estimatedglomerular filtration rate less than 50 mL/minute/1.73 m 2Pregnancy manufacturer advises avoid unless essential,but not known to be harmfulBreast-feeding significant amount present in milk,but not known to be harmfulSide-effects see notes above; also less commonlyblurred vision; also reported pancreatitis, involuntarymovement disorders, interstitial nephritis, alopeciaLicensed use oral preparations not licensed for usein children under 3 years; injection not licensed foruse in children under 6 monthsIndication and doseReflux oesophagitis, benign gastric and duodenalulceration, prophylaxis of stress ulceration,other conditions where gastric acidreduction is beneficial (see notes above and section1.9.4). By mouthNeonate 2 mg/kg 3 times daily but absorptionunreliable; max. 3 mg/kg 3 times daily1 Gastro-intestinal system