What’s new in BNF 64?A CPPE learning programme

CENTRE FOR PHARMACYPOSTGRADUATE EDUCATION

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Thank you for downloading this CPPE interactive learning programme. We hope that you will find it a fun way to bring you up to date with the latest changes in the British National Formulary (BNF).

Welcome toWhat’s new inBNF 64?

The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities for the pharmacy workforce. We are based in the University of Manchester’s School of Pharmacy and Pharmaceutical Sciences and are funded by the Department of Health to provide continuing education for practising pharmacists and pharmacy technicians providing NHS services in England. http://www.cppe.ac.uk

Learning with CPPE

This document uses interactive features that may not be supported if you are using it on a mobile device. For best results, please use on your PC or laptop, using anup-to-date version of Adobe Reader.

CONTENTS

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This programme contains the following sections:

Click on a title to go directly to that section.

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How to use this learning programme1

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How to use this learning programmeThis programme uses an interactive PDF format. You

can navigate your way through by using the arrows in

the bottom right corner of each page. Where directed,

you can also navigate to sections by clicking on text

or images. The programme uses case studies and web

links to help you explore the changes in BNF 64. You

will need to be connected to the internet to access the

web links. Text which links to other sections or to the

internet will be in blue.

You will be able to type, save and reveal answers

to the case studies. We would recommend that you

keep notes as you go along as these could be ideal

to generate CPD records. If you are using a printed

version of this programme, you will not be able to view

our suggested answers. To see these, either open this

document on your computer using Adobe Reader or

download the separate answers document from the

CPPE website.

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About What’s new in BNF 63?2

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This programme will keep you up to date with significant changes in the BNF

that are relevant to your clinical practice. You will need about 60 minutes to

complete the questions.

Before you start, make sure you have read the section of the BNF listing the key

changes for this edition. If you are using a print version of BNF 64, full details of

changes to this edition are on pages xvii to xviii. The margins of these pages are

marked in blue.

You can access the BNF online by clicking on the image. If you are not already

registered, you will have to do so. Click here to register.

About What’s new in BNF 64?

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3 Learning objectives

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Learning objectives

locate information on changes in the latest

BNF

identify situations in the healthcare setting

where the management of a patient is

affected by these changes

recommend appropriate courses of action

based on what you know about a patient

and the latest information in the BNF.

By the end of this learning programme, you should be able to:

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4 Case studies – introduction

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Case studies – introductionThis programme contains ten case studies, each with two

parts, to explore significant changes to the BNF.

In these, there will be space for you to type answers to

the questions. You can save your answers by saving this

document to your computer and view our suggested

answers _ these are hidden behind the Reveal answer text.

Some of the scenarios are based in primary care and some

in secondary. However, the decisions we ask you to make

in each question will apply to your practice, regardless of

your area of work.

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5 Case studies

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Case studiesThe case studies look at the following areas (click on a title to go straight to that case).You will be able to return to this menu by clicking the link at the bottom of the page at the end of each question.

lung cancer Haemophilus influenzae type b

type 2 diabetes

gout

paracetamol overdose

anaphylaxismedication review

influenza

multiple sclerosis

anticoagulation

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1: Hypertension and CVD

Medication review

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You are reviewing Dorothy McKenzie’s medication. She is

70 years old and tells you that each day she takes a

125 microgram digoxin tablet for “her heart” and an aspirin

for “her blood”. She takes two paracetamol tablets four

times a day and ibuprofen 400 mg three times a day for her

joints. She also takes lansoprazole 30 mg daily to protect

her stomach from the painkillers. She has been taking these

tablets for several years. She looks well, her heart rate is

78 beats per minute and regular, and her blood pressure is

124/78 mmHg. She is not in pain. Her urea and electrolytes

and renal function are all within the normal range.

Her menopause occurred uneventfully at the age of 52

years. She has a body mass index of 26 kg/m2, smokes 15

cigarettes a day, drinks 18 units of alcohol a week and tries

to lead an active life.

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1: Hypertension and CVD

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1. Which other blood test should be checked?

1. Hypomagnesaemia can occur after long-term use of a proton pump inhibitor (usually after one year of treatment, but sometimes after three months of treatment). Measurement of serum-magnesium concentrations should be considered before and during prolonged treatment with a proton pump inhibitor, especially when used with other drugs that can cause hypomagnesaemia or with digoxin.

Dorothy has been taking lansoprazole and digoxin for several years, so it would be appropriate to measure her serum-magnesium concentration if it has not been checked recently.

Don’t forget to save your answers Click to return to case study menu

BNF Section: 1.3.5 – Pages: 55-56For further information, click on: proton pump inhibitors. You may also find CPPE’s guide to targeting your MURs more effectively, our materials on the new medicine service and our MURs: Improving patient outcomes workshop useful.

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1: Hypertension and CVD

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2. What action will you take to reduce Dorothy’s risk of osteoporosis?

2. Proton pump inhibitors can increase the risk of fractures, particularly when used at high doses for over a year in the elderly. Patients at risk of osteoporosis should maintain an adequate intake of calcium and vitamin D and, if necessary, receive other preventative therapy. Dorothy is at risk of osteoporosis because she is postmenopausal, smokes, drinks excess alcohol and has been taking lansoprazole for several years. She should be advised to maintain an adequate intake of calcium and vitamin D, and any deficiency should be corrected by increasing dietary intake or taking supplements. She should be given advice on smoking cessation and on reducing her intake of alcohol.

A proton pump inhibitor should be prescribed for appropriate indications at the lowest effective dose for the shortest period; the need for long-term treatment should be reviewed periodically. As Dorothy has been receiving analgesics for several years and is no longer in pain, the need to continue them should be reviewed. Lansoprazole can be discontinued if the ibuprofen is stopped.

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 1.3.5 – Pages: 55-56For further information, click on: proton pump inhibitors. You may also find CPPE’s guide to targeting your MURs more effectively, our materials on the new medicine service and our MURs: Improving patient outcomes workshop useful.

Anticoagulation

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Bhaira Poduval is an 81-year-old woman with a history of

hypertension, diabetes, heart failure, and non-valvular atrial

fibrillation. She lives alone, but is supported twice a day by

carers who assist her in dressing and preparing meals. She has

a walking distance of 25 yards, limited by shortness of breath

secondary to her heart failure.

Her INR today is 7.6. The anticoagulation clinic report shows that

her INR has been increasingly labile over the last year despite

good compliance and following of appropriate lifestyle advice on

diet and alcohol consumption. Her renal and liver functions are

normal.

Her current drug history is: warfarin as per international normalised ratio (INR)

digoxin 125 micrograms daily

simvastatin 40 mg each night

ramipril 5 mg twice daily

bisoprolol 10 mg once daily

furosemide 80 mg each morning

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1: Hypertension and CVD

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1. Would Bhaira benefit from switching the warfarin to dabigatran?

1. The National Institute for Health and Clinical Excellence (NICE) recommends dabigatran etexilate as an option for the prevention of stroke and systemic embolism in atrial fibrillation according to its licensed indications. Dabigatran etexilate is licensed for this indication in patients with non-valvular atrial fibrillation and at least one of the following risk factors: previous stroke, transient ischaemic attack, or systemic embolism, left-ventricular ejection fraction below 40 percent, symptomatic heart failure, age 75 years or over, or 65 years or over in patients with diabetes, coronary artery disease, or hypertension.

Bhaira is at high risk of stroke because she is over 65 years of age and has atrial fibrillation, diabetes, hypertension and heart failure. Her risk of haemorrhage with warfarin is increased because she has a labile INR. In Bhaira’s case, dabigatran would be a suitable alternative because it has the advantage of a set dosage regimen and does not require monitoring of INR.

Don’t forget to save your answers Click to return to case study menu

BNF Section: 2.8.2 – Pages: 150-151For further information, click on: dabigatran etexilate. You may also find CPPE’s Advances in anticoagulation: new oral treatments learning@lunch flex and NICPLD’s Anticoagulant therapy: an introduction useful.

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1: Hypertension and CVD

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2. What dose of dabigatran etexilate will you recommend and what

monitoring is necessary? How will you counsel Bhaira about dabigatran?

2. For the prevention of stroke and systemic embolism in non-valvular atrial fibrillation, a dose of dabigatran etexilate110 mg twice daily is recommended for patients over 80 years of age. When warfarin is stopped, dabigatran can be started as soon as the INR is less than 2.0.

Bhaira’s renal function should be checked before commencing treatment and, because she is elderly, at least annually thereafter. She should also be monitored for signs of bleeding and anaemia, which are among the common side-effects of this drug. Bhaira should be advised to report any bleeding or bruising. She should be advised that dabigatran does not require monitoring of INR. She needs to ensure that she takes it regularly as, if she stops taking it, there is a high risk that she will have a stroke.

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 2.8.2 – Pages: 150-151For further information, click on: dabigatran etexilate. You may also find CPPE’s Advances in anticoagulation: new oral treatments learning@lunch flex and NICPLD’s Anticoagulant therapy: an introduction useful.

1: Hypertension and CVD

Anaphylaxis

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Huang Lanfen is a 40-year-old woman who recently had an

anaphylactic reaction following a wasp sting.

She presents today with the following prescription: Adrenaline auto-injector device 1 mg/mL x 2.

She confirms that she has been trained to use the device in

clinic. She is not taking any other medication and has no history

of any other clinical condition.

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1. Which adrenaline auto-injector device will you supply?

1. Injection technique is device specific. In order to ensure patients receive the auto-injector device that they have been trained to use, prescribers should specify the brand to be dispensed. You should find out which brand Lanfen has been trained to use and dispense that type.

2. You find out that Lanfen has been trained to use Jext® 300 micrograms.

What advice should you provide?

Don’t forget to save your answers Click to return to case study menu

BNF Section: 3.4.3 – Pages: 203-204For further information, click on: self-administration of adrenaline and Jext®.

2. You should ensure that Lanfen can recognise the early symptoms of anaphylaxis so that she can summon help quickly and prepare to use the auto-injector. The dose of Jext® 300 micrograms can be repeated every 5 to 15 minutes as necessary. She should be advised to carry her adrenaline auto-injector with her at all times. You should check that she feels confident in using the device and go over specific issues as necessary. She should practise using a suitable training device regularly. It is also advised that her close family and friends also know how to use the adrenaline auto-injector.

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Ben Goodwin, aged seven years, has a severe sore throat and

is refusing food and fluids. His temperature is 38oC and he

has neck tenderness. On admission, he was having difficulty

breathing, but this has eased with the administration of oxygen.

Epiglottitis caused by Haemophilus influenzae type b (Hib) is

suspected and he is started on intravenous cefotaxime. An X-ray

of the neck is arranged.

Ben is up to date with his childhood vaccinations. His five-

year-old brother has had a heart transplant and takes

immunosuppressant therapy.

Haemophilus influenzae type b

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1: Hypertension and CVD

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1. What antibacterial prophylaxis (if any) should Ben and his household

contacts receive?

1. Ben should be given antibacterial prophylaxis against Hib because he is suspected to have invasive Hib disease, is under ten years of age and is in contact with a vulnerable individual (his brother). Vulnerable individuals include the immunocompromised, those with asplenia and children under ten years of age.

Antibacterial prophylaxis should be given to all household contacts of an index case with confirmed or suspected invasive Hib disease if there is a vulnerable individual in the household. Ben’s household contacts should be given antibacterial prophylaxis because he and his brother are under ten years of age and his brother is immunocompromised.

The antibacterial prophylaxis of choice is rifampicin, which should be given for four days.

Don’t forget to save your answers Click to return to case study menu

BNF Section: 5.1, 14.4 – Pages: 341, 781-782For further information, click on: prevention of Hib disease. You may also find CPPE’s focal point, Children and their medicines, useful.

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1: Hypertension and CVD

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2. Should Ben and his household contacts receive the Hib vaccine?

2. As Ben is up to date with his childhood vaccinations and he is under ten years of age, he should be given an additional dose of Hib vaccine (combined with meningococcal group C conjugate vaccine) if Hib antibody concentrations are low or if it is not possible to measure antibody concentrations.

You should check that all household contacts under ten years of age are up to date with their age specific course of immunisation.

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 5.1, 14.4 – Pages: 341, 781-782For further information, click on: prevention of Hib disease and Hib vaccine. You may also find CPPE’s focal point, Children and their medicines, useful.

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James Simpson, aged nine, has asthma which is controlled with

Flixotide Evohaler® 50 micrograms twice daily. He only uses

a salbutamol inhaler occasionally and has not had the need to

use it for several weeks. He completed a course of oseltamivir

one week ago following exposure to a family member who was

diagnosed with influenza. It is winter and national surveillance

schemes have announced that influenza is circulating in the

community.

James has not had a seasonal influenza vaccine before, and

has no history of egg allergy.

Influenza19

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1. Would it be appropriate for James to receive Fluenz® (intranasal influenza vaccine)?

1. James is in the high risk group for influenza because he has a chronic respiratory disease that is treated with repeated use of inhaled corticosteroids. Therefore, he should receive annual immunisation against influenza.

Fluenz® is contraindicated in severe asthma, but James can use it because he has mild asthma (at step 2 of the chronic asthma table). Fluenz® should be avoided for at least 48 hours after stopping antiviral therapy for influenza. James finished taking oseltamivir a week ago so it is appropriate for him to be vaccinated.

As James has not had a seasonal influenza vaccine before, the dose of 0.1 mL in each nostril should be repeated after four weeks.

Don’t forget to save your answers Click to return to case study menu

BNF Section: 14.4 – Pages: 786-787For further information, click on: influenza vaccines and Fluenz®. You may also find module 1 and module 2 of CPPE’s Influenza open learning programme useful.

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2. Fluenz® contains live attenuated influenza virus. Therefore close contact between James and his brother should be avoided for one to two weeks after vaccination.

To allow contact between the brothers, an inactivated influenza vaccine given by intramuscular injection would be more appropriate for James.

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2. James’ brother has had a heart transplant and takes immunosuppressant therapy. What additional precautions are necessaryif James receives Fluenz®?

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 14.4 – Pages: 786-787For further information, click on: influenza vaccines and Fluenz®. You may also find module 1 and module 2 of CPPE’s Influenza open learning programme useful.

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Margaret Connor is a 57-year-old patient who is being treated

with gefitinib for metastatic non-small-cell lung cancer.

During her review today, she mentions that her eyes have

been troubling her for the past few days and that she may

have an infection. You notice that both eyes appear red

and inflamed, and that there is some watery discharge. On

further questioning, it becomes clear that Margaret is in some

discomfort and that her vision is blurred. She tells you that it

feels worse today than it did yesterday and she is now finding

it quite painful to be outside in bright sunlight.

Lung cancer

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1. What do you suspect Margaret’s symptoms might indicate?

1. Keratitis and ulcerative keratitis have been reported following treatment with epidermal growth factor receptor inhibitors such as gefitinib for cancer. In rare cases this has resulted in corneal perforation and blindness.

2. What action should you take?

Don’t forget to save your answers Click to return to case study menu

BNF Section: 8.1.5 – Page: 554For further information, click on: epidermal growth factor receptor inhibitors. You may also find CPPE’s Palliative care open learning programme and Adverse drug reactions e-learning series useful.

2. Patients undergoing treatment with epidermal growth factor receptor inhibitors who present with acute or worsening signs and symptoms suggestive of keratitis should be referred promptly to an ophthalmology specialist due to the risk of corneal perforation and blindness. The gefitinib treatment should be interrupted or discontinued if ulcerative keratitis is diagnosed.

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Jorge Gonzalez was started on allopurinol for the long-term

control of his gout after he had three episodes of acute gout

within eight months. He stopped the allopurinol recently because

he developed erythema multiforme.

His medical history includes upper gastrointestinal bleeding

associated with a peptic ulcer secondary to the use of

sulfinpyrazone.

Gout

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1. Febuxostat is recommended as an option for the management of chronic hyperuricaemia in gout only for patients who are intolerant to allopurinol or for whom allopurinol is contraindicated. Febuxostat can be used for Jorge as he is unable to tolerate allopurinol. Prophylactic colchicine should be given for at least six months after starting febuxostat to avoid precipitating an acute attack of gout.

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1. What options are available to prevent Jorge’s gout?

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BNF Section: 10.1.4 – Pages: 680-681For further information, click on: long-term control of gout. You may also find CPPE’s Adverse drug reactions e-learning series useful.

2. There have been rare but serious reports of hypersensitivity reactions, including Stevens-Johnson syndrome and acute anaphylactic shock, with febuxostat. Jorge should be advised to look out for signs and symptoms of severe hypersensitivity (including facial oedema, fever, rash which may be accompanied by blistering, oral lesions, and eye irritation). Febuxostat should be stopped immediately if signs or symptoms of serious hypersensitivity reactions occur; early withdrawal is associated with a better prognosis. Most cases occur during the first month of treatment and patients with a history of hypersensitivity to allopurinol may be more susceptible to hypersensitivity with febuxostat.

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2. What particular adverse drug reaction is Jorge at risk of with febuxostat and how will you counsel him?

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 10.1.4 – Pages: 680-681For further information, click on: long-term control of gout and febuxostat. You may also find CPPE’s Adverse drug reactions e-learning series useful.

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David Smith is a 57-year-old Caucasian man with type 2 diabetes

who is taking gliclazide 160 mg twice daily. He previously took

metformin but this was stopped because of persistent nausea

and vomiting.

David has a history of heart failure and also takes ramipril 5 mg

twice daily, furosemide 80 mg each morning and bisoprolol

10 mg daily.

He works as a shift worker for a courier service and is reluctant

to inject himself with insulin on a daily basis because it will

interfere with his work.

His body mass index is 34 kg/m2, his HbA1c is 64 mmol/mol and

his urea and electrolytes and renal function are normal.

Type 2 diabetes

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1. Pioglitazone is contraindicated because David has heart failure.

A dipeptidylpeptidase-4 inhibitor, such as sitagliptin or vildagliptin, can be added to a sulfonylurea when metformin is not tolerated. NICE has recommended that treatment with sitagliptin or vildagliptin is only continued if the HbA1c concentration is reduced by at least 0.5 percent points within six months of starting treatment.

David may find the standard-release glucagon-like peptide-1 receptor activators, such as exenatide, unacceptable because they have to be given by subcutaneous injection on a daily basis.

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1. What treatment options are available for David’s diabetes?

Don’t forget to save your answers Click to return to case study menu

BNF Section: 6.1.2 – Pages: 443-446For further information, click on: antidiabetic drugs. You may also find CPPE’s Type 2 diabetes focal point programme, Diabetes – evidence-based management open learning programme and Adverse drug reactions e-learning series useful.

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2. NICE recommends modified-release exenatide in dual-therapy regimens (in combination with metformin or a sulfonyurea) only if treatment with metformin or a sulphonylurea is contraindicated or not tolerated, and if treatment with thiazolidinediones and dipeptidylpeptidase-4 inhibitors are also contraindicated or not tolerated. Modified-release exenatide in dual-therapy regimens should only be continued if the HbA1c concentration is reduced by at least one percentage point within six months of starting treatment.

Exenatide can help prevent further weight gain and may possibly promote weight loss, which can be beneficial in an overweight patient such as David.

Modified-release exenatide is given by subcutaneous injection once weekly so this frequency of administration may be more acceptable to David. However, exenatide has been associated with pancreatitis and David should be advised to seek prompt medical attention if symptoms of pancreatitis (eg, abdominal pain, nausea or vomiting) occur.

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2. David is started on sitagliptin, but it is soon discontinued because he develops acute pancreatitis. Is it appropriate to use modified-release exenatide?

Don’t forget to save your answers Click to return to case study menu

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BNF Section: 6.1.2 – Pages: 443-446For further information, click on: antidiabetic drugs. You may also find CPPE’s Type 2 diabetes focal point programme, Diabetes – evidence-based management open learning programme and Adverse drug reactions e-learning series useful.

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Olga Slovic presents in accident and emergency seven hours

after intentionally taking a paracetamol overdose. She took

13 g of paracetamol over 15 minutes. Weighing 68 kg, Olga is

normally fit and well. She has no past medical history and takes

no regular medication. She drinks two glasses of wine a week

and eats a normal diet. A plasma-paracetamol concentration is

taken immediately on presentation and is reported as 80 mg/

litre (0.55 mmol/litre).

Paracetamol overdose

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1. Olga has taken more than 150 mg/kg of paracetamol in 15 minutes and is therefore at risk of hepatotoxicity. She should be given acetylcysteine by intravenous infusion because her plasma-paracetamol concentration is above the treatment line on the paracetamol treatment graph.

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1. Should Olga be given intravenous acetylcysteine as an antidote?

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BNF Section: Emergency treatment of poisoning – Pages: 35-37For further information, click on: paracetamol overdosage.

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2. For paracetamol overdosage, acetylcysteine is given in a total dose that is divided into three consecutive intravenous infusions over a total of 21 hours. The tables in the BNF include the dose of acetylcysteine in terms of the volume of acetylcysteine concentrate for intravenous infusion required for each of the three infusions. The requisite dose of acetylcysteine is added to glucose intravenous infusion five percent.

Olga weighs 68 kg (falling within the 60-69 kg body-weight category). Therefore, using the dose tables in the BNF:

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2. What dose of intravenous acetylcysteine should Olga receive and how should it be administered?

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Infusion 1 should be prepared by adding 49 mL of acetylcysteine concentrate for intravenous infusion to200 mL of glucose intravenous infusion five percent. Infusion 1 should be administered over one hour.Infusion 2 should be prepared by adding 17 mL of acetylcysteine concentrate for intravenous infusion to500 mL of glucose intravenous infusion five percent. Infusion 2 should be administered over four hours.Infusion 3 should be prepared by adding 33 mL of acetylcysteine concentrate for intravenous infusion to1 litre of glucose intravenous infusion five percent.Infusion 3 should be administered over 16 hours.

BNF Section: Emergency treatment of poisoning – Pages: 35-37For further information, click on: paracetamol overdosage.

Multiple sclerosis

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Artur Marburg, a 51-year-old gentleman with multiple sclerosis, complains of extreme tiredness, paresthesia, muscle weakness and difficulty moving for the last week. His multiple sclerosis was in remission after starting interferon beta two years ago; however, he has had multiple severe relapses in the last six months requiring hospital admission.

His urea and electrolytes are normal, as are his renal, hepatic and cardiac functions. His blood pressure is 130/80 mmHg and his C-reactive protein is 46 (0-8 mg/litre).

His current medications include: Betaferon® 250 micrograms on alternate days by subcutaneous

injection

co-codamol 30/500 mg two tablets four times a day

senna two tablets at night.

Artur is diagnosed with a severe relapse of highly active relapsing-remitting multiple sclerosis and treatment options are discussed with his specialist neurologist.

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1. NICE recommends fingolimod as a treatment option for highly active relapsing-remitting multiple sclerosis where the patient is experiencing unchanged or increased relapse rates or ongoing severe relapses compared with the previous year despite treatment with interferon beta. Fingolimod can be considered for Artur if the manufacturer provides the drug with the discount agreed as part of the patient access scheme.

Artur has no contraindications for fingolimod. In particular, he is not at high risk of cardiovascular events and he is not taking any antiarrhythmic drugs or heart rate lowering drugs which would be of concern.

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1. Would it be appropriate for Artur to receive treatment with fingolimod?

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BNF Section: 8.2 – Page: 585To find out more about multiple sclerosis click on Neurological disorders: evidence-based management or neurological disorders: advancing your practice

2. All patients receiving fingolimod should receive comprehensive monitoring at initiation and following interruption of treatment for more than two weeks. A 12-lead electrocardiogram (ECG) and blood pressure measurement are required before starting treatment.

Continuous ECG monitoring is recommended for the first six hours of treatment. Blood pressure and heart rate should be monitored every hour for the first six hours of treatment. After six hours of treatment, a further 12-lead ECG and blood pressure measurement should be taken. If the heart rate after six hours of treatment is at its lowest rate since commencing treatment, monitoring should be extended by at least two hours until the heart rate increases. If clinically important cardiac effects are noted during the first six hours of treatment, monitoring should be extended until resolution and this should include an overnight assessment.

Due to risks of macular oedema with fingolimod, an eye examination is recommended three to four months after initiation. Hepatic transaminases should be monitored before treatment, then every three months for a year, then periodically thereafter.

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2. What monitoring will you recommend with fingolimod?

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BNF Section: 8.2 – Page: 585To find out more about multiple sclerosis click on Neurological disorders: evidence-based management or neurological disorders: advancing your practice

6 Next steps

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Next stepsNow that you have completed the case studies, what’s next?

You might like to:

revisit the learning objectives. Are you

confident that you have achieved these?

tackle the reflective essay that you can

download from your CPPE record

complete a CPD record

email CPPE with any feedback you may

have on your learning experience.

take the BNF 64-themed CPPE e-challenge (issue 23)

We hope that you have enjoyed your learning. Come back for more

learning when we publish What’s new in BNF 65? next year.

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7 Programme credits

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CreditsCPPE programme manager Ceinwen Mannall, regional manager, East Midlands

AuthorsAlison Astles, tutor, CPPE

Tania Cork, chief officer, North Staffordshire Local Pharmaceutical

Committee

Beth Carney, prescribing advisor, NHS Nottinghamshire County

Jo Clarke, tutor, CPPE

Emma Graham-Clark, consultant pharmacist, critical care,

Sandwell and West Birmingham Hospitals NHS Trust

Matthew Lea, foundation doctor, Derby Hospitals Foundation Trust

Jaime Miks, palliative care pharmacist, University Hospitals Coventry

and Warwickshire NHS Trust

Neil Powell, antibiotics and HIV pharmacist, Royal Cornwall

Hospitals Trust

Kevin Ratcliffe, consultant pharmacist, Birmingham & Solihull

Mental Health NHS Foundation Trust

Jennie Stephens, specialist registrar in acute and intensive care

medicine, Royal Devon and Exeter Hospital NHS Foundation Trust

EditorsCeinwen Mannall, regional manager, East Midlands, CPPE

Neil Condron, editor, CPPE

Shama Wagle, lead editor, British National Formulary

DisclaimerWe have developed this learning programme to support your

practice in this topic area. We recommend that you use it in

combination with other established reference sources. If you are

using it significantly after the date of initial publication, then you

should refer to current published evidence. CPPE does not accept

responsibility for any errors or omissions.

Acknowledgements CPPE acknowledges the support of the British National Formulary

for allowing us to use links and text from their publication.

ProductionAmbassador, 25 Hockeys Lane, Fishponds, Bristol, BS16 3HH

T: 0117 965 5252. http://www.ambassador.co.uk

Published in October 2012 by the Centre for Pharmacy Postgraduate Education, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester M13 9PT.http://www.cppe.ac.uk

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