BNF for Children 2011-2012

BNFC 2011–2012 2.2.1 Thiazides and related diuretics 77Bendroflumethiazide is licensed for use in children;chlorothiazide is also used.Chlortalidone, a thiazide-related compound, has alonger duration of action than the thiazides and maybe given on alternate days in younger children.Metolazone is particularly effective when combinedwith a loop diuretic (even in renal failure) and is mosteffective when given 30–60 minutes before furosemide;profound diuresis can occur and the child should thereforebe monitored carefully.Cautions See also section 2.2. Thiazides and relateddiuretics can exacerbate diabetes, gout, and systemiclupus erythematosus. Electrolytes should be monitoredparticularly with high doses, long-term use, or in renalimpairment. Thiazides and related diuretics should alsobe used with caution in nephrotic syndrome, hyperaldosteronism,and malnourishment; interactions: Appendix1 (diuretics).Contra-indications Thiazides and related diureticsshould be avoided in refractory hypokalaemia, hyponatraemia,and hypercalcaemia, symptomatic hyperuricaemia,and Addison’s disease.Hepatic impairment Thiazides and related diureticsshould be used with caution in mild to moderate impairmentand avoided in severe impairment. Hypokalaemiamay precipitate coma, although hypokalaemia can beprevented by using a potassium-sparing diuretic.Renal impairment Thiazides and related diureticsshould be used with caution because they can furtherreduce renal function. They are ineffective if estimatedglomerular filtration rate is less than 30 mL/minute/1.73 m 2 and should be avoided; metolazone remainseffective but with a risk of excessive diuresis.Pregnancy Thiazides and related diuretics should notbe used to treat gestational hypertension. They maycause neonatal thrombocytopenia, bone marrow suppression,jaundice, electrolyte disturbances, and hypoglycaemia;placental perfusion may also be reduced.Stimulation of labour, uterine inertia, and meconiumstaining have also been reported.Breast-feeding The amount of bendroflumethiazide,chlorothiazide, chlortalidone, and metolazone present inmilk is too small to be harmful; large doses may suppresslactation.Side-effects Side-effects of thiazides and related diureticsinclude mild gastro-intestinal disturbances, posturalhypotension, altered plasma-lipid concentrations,metabolic and electrolyte disturbances including hypokalaemia(see also notes above), hyponatraemia, hypomagnesaemia,hypercalcaemia, hyperglycaemia, hypochloraemicalkalosis, and hyperuricaemia, and gout.Less common side-effects include blood disordersincluding agranulocytosis, leucopenia and thrombocytopenia,and impotence. Pancreatitis, intrahepatic cholestasis,cardiac arrhythmias, headache, dizziness, paraesthesia,visual disturbances, and hypersensitivityreactions (including pneumonitis, pulmonary oedema,photosensitivity, and severe skin reactions) have alsobeen reported.BENDROFLUMETHIAZIDE(Bendrofluazide)Cautions see notes aboveContra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding see notes aboveSide-effects see notes aboveIndication and doseOedema in heart failure, renal disease, andhepatic disease; pulmonary oedema; hypertension. By mouthChild 1 month–2 years 50–100 micrograms/kgdaily adjusted according to responseChild 2–12 years initially 50–400 micrograms/kg(max. 10 mg) daily then 50–100 micrograms/kgdaily adjusted according to response (max. 10 mgdaily)Child 12–18 years initially 5–10 mg daily or onalternate days (2.5 mg daily in hypertension) as asingle morning dose, adjusted according toresponse (max. 10 mg daily)Bendroflumethiazide (Non-proprietary) ATablets, bendroflumethiazide 2.5 mg, net price 28-tabpack = 79p; 5 mg, 28-tab pack = 86pBrands include Aprinox c , Neo-NaClex cExtemporaneous formulations available seeExtemporaneous Preparations, p. 6CHLOROTHIAZIDECautions see notes above; also neonate (theoreticalrisk of kernicterus if very jaundiced)Contra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding see notes aboveSide-effects see notes aboveLicensed use not licensedIndication and doseHeart failure, hypertension, ascites. By mouthNeonate 10–20 mg/kg twice dailyChild 1–6 months 10–20 mg/kg twice dailyChild 6 months–12 years 10 mg/kg twice daily(max. 1 g daily)Child 12–18 years 0.25–1 g once daily or 125–500 mg twice dailyChronic hypoglycaemia section 6.1.4Diabetes insipidus section 6.5.2PreparationsChlorothiazide oral suspension 250 mg/5 mL is availablefrom ‘special-order’ manufacturers or specialistimporting companies, see p. 8092 Cardiovascular system