Art & science medicines management

Using the British National Formulary: best practice for nurse prescribers
Wagle S (2011) Using the British National Formulary: best practice for nurse prescribers. Nursing Standard. 26, 3, 43-48. Date of acceptance: July 28 2011.

Abstract
This article explains how the British National Formulary (BNF) should be used to facilitate safe, effective and appropriate prescribing. It also outlines, by use of examples, how to find significant changes in a new edition of the BNF so that nurses can remain up to date with the latest prescribing information.

Author
Shama Wagle Assistant editor, BNF Publications, Royal Pharmaceutical Society, London. Correspondence to: swagle@bnf.org

Keywords
British National Formulary, drug interactions, medicines, prescribing, side effects These keywords are based on subject headings from the British Nursing Index.

Review
All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online
Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

other healthcare professionals. The BNF is updated every six months and new information added, yet it remains a portable size. The BNFs editorial team has identified that nurses want to learn more about how to use the BNF effectively. The section How to Use the BNF (page xi, BNF 62) was therefore revised and linked to the process of using medicines rationally. This involves finding a balance between maximising treatment effectiveness, minimising risk, respecting patient choice and minimising cost. This article discusses how to use the BNF in the context of changes to its clinical content. These include changes to the management of common diseases, changes to the prescribing information of specific drugs and preparations, classification changes, information on new and discontinued preparations, and changes to statutory information and prescribing policy. We recommend that the article be read in conjunction with BNF 62 (Joint Formulary Committee 2011) because the clinical concepts we discuss can be found in this latest edition. BNF 62 can be accessed online at http://bnf.org; registration and use of this website is free in the UK.

Identifying effective drug treatments

The prescribing notes in the BNF provide an overview of the drug management of common disorders and enable rapid appraisal of treatment options. These notes usually precede relevant drug monographs and preparations. For ease of use, information on the drug treatment of common disorders or routine treatments (for example, immunisation) may be tabulated or placed in algorithms (Table 1). Where appropriate, advice issued by the National Institute for Health and Clinical Excellence (NICE) is integrated with the BNF prescribing notes. Summaries of NICE technology appraisals and relevant short guidelines are included in blue panels to make them easy to identify. Advice issued by the Scottish Medicines Consortium is included when a medicine is restricted or not recommended in NHS Scotland. september 21 :: vol 26 no 3 :: 2011 43

THE AUTHORITATIVE guide to selecting, prescribing and using medicines in the UK is the British National Formulary (BNF) (Cox et al 2010, Medicines Information Survey 2010). However, professional knowledge is essential for interpreting the information contained in the BNF, and it should be supplemented by specialised publications and the product literature. Information on treatments is also available from medicines information services; contact details are provided on the inside front cover of the BNFs printed version. The robust procedures that underpin the production of the BNF ensure that it caters for the day-to-day information needs of nurses and

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To select safe, effective medicines for individual patients, information in the prescribing notes must be used with other prescribing details about the drugs and detailed knowledge of the patients medical and treatment history.

Drug management of medical emergencies

Guidance on the drug management of medical emergencies can be found in the prescribing notes of relevant BNF chapters (for example, treatment of anaphylaxis is included in section 3.4.3). To aid rapid retrieval of information in an emergency situation, a summary of drug doses used for medical emergencies in the community and an algorithm for adult advanced life support can be found in the glossy pages at the back of the print version of the BNF or online (http://bnf.org).

Learning activity 1
Question A 62-year-old woman has been recently diagnosed with chronic obstructive pulmonary disease (COPD). She is concerned that, despite stopping smoking four weeks ago, she is still feeling breathless, particularly when walking. She has a persistent cough that produces sputum, and she has been using her salbutamol inhaler six to eight times a day. She is worried about how the disease will progress, and how it will affect her ability to look after her grandchildren. Her forced expiratory volume in one second (FEV1) is 60% of predicted. What treatment options are available? Answer This patients treatment should be reviewed because she is using her salbutamol inhaler frequently but is still experiencing symptoms of COPD. According to the algorithm on the Use of Inhaled Therapies in Chronic Obstructive Pulmonary Disease (section 3.1, page 176), as her FEV1 is more than 50% of predicted, she should be started on either a long-acting antimuscarinic bronchodilator (for example, tiotropium) or a long-acting beta2 agonist (for example, formoterol or salmeterol). She may continue to use the salbutamol inhaler as required.

Unlicensed medicines
The BNF discusses the unlicensed use of medicines when the clinical need cannot be met by licensed medicines. However, such use should be supported by appropriate evidence and experience. When the BNF recommends an unlicensed medicine or the off-label use of a licensed medicine, this is denoted by [unlicensed].

Drugs that are less suitable for prescribing

The BNF uses the symbol to denote preparations considered by the Joint Formulary Committee to be less suitable for prescribing. Examples of these are drugs or preparations not considered first line treatment for a particular

TABLE 1
Location of useful tables in British National Formulary (BNF) 62
Treatment topic Equivalent single doses of opioid analgesics in palliative care Equivalent doses of morphine and diamorphine in palliative care Regimens for Helicobacter pylori eradication Management of chronic asthma Management of acute asthma Summary of antibacterial therapy for infections Summary of antibacterial prophylaxis Combined oral contraceptives Suitable quantities of dermatological preparations to be prescribed for specific areas of the body Suitable quantities of corticosteroid preparations to be prescribed for specific areas of the body Immunisation schedule Wound contact material for different types of wounds
(Joint Formulary Committee 2011)

Relevant section in BNF 62 Prescribing in Palliative Care (page 20) Prescribing in Palliative Care (page 24) 1.3 (page 50) 3.1 (page 174) 3.1 (page 175) 5.1 (page 328) 5.1 (page 337) 7.3.1 (page 507) 13.1.2 (page 715)

Learning activity 2
Question You are treating several patients with epilepsy at the clinic that you run in a GP practice. Which antiepileptic drug(s) should be kept at the practice in case status epilepticus occurs? Answer According to the prescribing notes on status epilepticus (section 4.8.2), when facilities for resuscitation are not immediately available, either diazepam can be administered as a rectal solution, or midazolam [unlicensed] can be given in to the buccal cavity.

Learning activity 3
Question You are asked to prescribe Lyclear Creme Rinse for a seven-year-old girl with head lice because it only needs to be left on the hair for ten minutes. Should you prescribe Lyclear Creme Rinse in this case? Answer Lyclear Creme Rinse is denoted with in the BNF because the formulation and the licensed method of application is unsuitable for the treatment of head lice because shampoos are diluted too much when used to be effective (section 13.10.4).

13.4 (page 722)

14.1 (page 763) Appendix 5 (page 965)

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indication because: they have lower benefit or increased risk compared with other treatments; the preparation contains fixed combinations of drugs that do not allow the necessary dose titration; or the inclusion of unnecessary active ingredients in a formulation might make it less suitable for prescribing. Although such preparations may not be considered as drugs of first choice, their use may be justifiable in certain circumstances.

Minimising harm in patients with comorbidities

The drug chosen to treat a condition should have minimal detrimental effects on other conditions the patient may have, and minimise the patients susceptibility to adverse effects. The cautions, contraindications and side effects of the relevant drug, usually found in the drug monograph, should be reviewed carefully. Where a class of drugs (for example, opioid analgesics) share the same cautions, contraindications and side effects, these are amalgamated in the prescribing notes; those unique to a particular drug in that class are included in the individual drug monograph. Occasionally, the cautions, contraindications and side effects may be included in a preparation record if they are specific to that preparation or if the preparation is not accompanied by a monograph.

The information under cautions can be used to assess the risks of prescribing a drug in a patient who has comorbidities that are also included in the cautions for that drug; if a safer alternative cannot be found, the drug may be prescribed while monitoring for adverse effects or deterioration in the comorbid disorder. Contraindications are far more restrictive than cautions: the drug should be avoided in a patient with a condition that is contraindicated. The effect that potential side effects may have on a patients quality of life should also be assessed. For instance, in a patient who has constipation it would be preferable to avoid a drug that frequently causes constipation.

Minimising harm during pregnancy and breastfeeding

Drug treatment should be selected carefully to minimise harm to the fetus, nursing infant and mother. Infants should be monitored for potential side effects of drugs used by the mother during pregnancy or breastfeeding. The section on How to Use the BNF (page xiii, BNF 62) directs you to the general principles for prescribing in these patients. Since BNF 59 (Joint Formulary Committee 2010), specific information about the use of drugs during pregnancy and breastfeeding has been integrated within the drug monographs or in the prescribing notes under pregnancy and breastfeeding. This allows the information to be assessed in the context of other prescribing information about the drug. The prescribing notes also provide guidance on the drug treatment of common conditions that can occur during pregnancy and breastfeeding, such as asthma and vulvovaginal candidiasis.

Learning activity 4
Question A 65-year-old man wants to stop smoking and asks you for advice on the best nicotine replacement therapy (NRT) available for him to try. He smokes 25 cigarettes a day and he has not tried NRT before. His records show he has regular prescriptions for Dovobet (betamethasone and calcipotriol ointment) and Symbicort Turbohaler (budesonide and formoterol fumarate). Which NRT preparation will you prescribe for him? Answer The choice of NRT mainly depends on patient preference. According to the Cautions on Nicotine Replacement Therapy (section 4.10.2), nicotine patches should not be placed on broken skin and should be used with caution in patients with skin disorders; they may, therefore, not be appropriate for this man, who has psoriasis. Nicotine inhalation cartridges should be used with caution in obstructive lung disease or bronchospastic disease, and the nasal spray can worsen bronchial asthma. Both preparations should, therefore, be avoided if possible in this man because he is being treated for asthma. Oral NRT, such as gum, lozenges, or sublingual tablets may be more appropriate. Because he smokes more than 20 cigarettes a day, he should use the higher strength gum or lozenges, or the higher dose of sublingual tablets.

Learning activity 5
Question A woman presents with oropharyngeal candidiasis that has not responded to a seven-day course of nystatin. She is breastfeeding an eight-month-old healthy baby girl. How should you treat this patients oral thrush? Answer According to the prescribing notes on candidiasis (section 5.2), fluconazole is effective for oropharyngeal candidiasis that has not responded to topical therapy. The monograph on fluconazole (section 5.2.1) states that although the drug can transfer to breast milk, the amount is probably too small to be harmful (Briggs et al 2011). Before prescribing fluconazole, you should also consider the health of the nursing infant.

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Identifying adverse drug reactions
Information on clinically relevant side effects is included in the relevant drug monographs in most cases. If a class of drugs (for example, opioid analgesics) share the same side effects, these are presented in the prescribing notes, whereas those unique to a particular drug in that class are included in the individual drug monograph. The prescribing notes in the BNF may also highlight important safety concerns and differences in side-effect profiles. Side effects are generally listed in order of frequency and arranged broadly by the body system involved. Occasionally a rare side effect might be listed first if it is considered to be particularly serious. The frequency of side effects is described as: 4Very common (more than1 in 10). 4Common (1 in 100 to 1 in 10). 4Less commonly (1 in 1,000 to 1 in 100). 4Rarely (1 in 10,000 to 1 in 1,000). 4Very rarely (fewer than 1 in 10,000). 4Also reported (frequency not known).

Learning activity 7
Question You are reviewing a 38-year-old woman with a history of breast cancer. You notice that she was recently started on paroxetine (20mg daily) by her GP. She also takes tamoxifen (20mg daily). What changes would you recommend to this patients antidepressant therapy? Answer Appendix 1 (interactions) states that the metabolism of tamoxifen to its active metabolite might be inhibited by paroxetine and that concomitant use should be avoided. This interaction is highlighted as potentially serious. There may also be a similar interaction between fluoxetine and tamoxifen. You should advise the GP to switch this patient to an alternative antidepressant that is unlikely to interact, such as citalopram or a tricyclic antidepressant (Baxter 2010).

Minimising drug interactions

Details of drug interactions can be found in Appendix 1 of the BNF. Drugs and their interactions are listed in alphabetical order according to the non-proprietary drug name, and cross-referenced to interactions for a class of drugs (for example, antifungals, triazole) where appropriate. In the print version of the BNF, the symbol is placed against interactions that are potentially serious and where combined administration of

the drugs should be avoided (or only done with caution and appropriate monitoring). Interactions that have no symbol do not usually have serious consequences. In the online version of the BNF you can review drug interactions between several drugs by using the search function. Alternatively, you can review all the drug interactions for a single drug from a hyperlink displayed in the drug monograph.In the online version, interactions in bold against a red background are potentially serious; those on a beige background are without serious consequences. Further information on how to manage potentially serious drug interactions can be found in Stockleys Drug Interactions (Baxter 2010).

Learning activity 6
Question You are discussing the possibility of starting a 42-year-old man on varenicline. He asks you what the most likely side effects are with this treatment. Answer According to the varenicline monograph (section 4.10.2) very common or common side effects include gastrointestinal disturbances, appetite changes, dry mouth, taste disturbances, headache, drowsiness, dizziness and sleep disorders. Other side effects, such as hypertension, panic attacks and tremor, are less common. According to advice from the Medicines and Healthcare products Regulatory Agency and the Commission on Human Medicines, you should advise the patient to discontinue treatment and seek prompt medical advice if he develops agitation, depressed mood or suicidal thoughts; the frequency of these side effects is not known. Patients with a history of psychiatric illness should be monitored closely while taking varenicline.

Selecting the right dose

Information on drug dose is usually found in the dose section of the drug monograph or preparation record. The dose of a drug may vary according to indication and route of administration. If no indication is given next to the dose, that dose can be used for all the conditions specified in the indications section of that drug monograph, but

Learning activity 8
Question A 22-year-old woman is prescribed a five day course of aciclovir (400mg three times daily). What condition is this patient likely to have? Answer According to the aciclovir monograph (section 5.3.2.1), this dose is specific for the treatment of genital herpes simplex.

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not for any conditions cross-referring to other sections of the BNF. The dose is given in the preparation record when the dose varies according to different formulations of that drug (for example, amphotericin) or when a preparation has a dose different to that in the drug monograph (for example, Sporanox liquid). Occasionally, drug doses may be included in the prescribing notes for practical reasons (for example, doses of drugs in Helicobacter pylori eradication regimens). The correct dose should be selected for the correct indication, route of administration and preparation. Doses are either provided with a definite frequency or in a total daily dose format. In the latter case the total daily dose should be divided into equal individual doses. The doses of some drugs may need to be adjusted if their effects are altered by concomitant use with other drugs or in patients with hepatic or renal impairment. Doses for specific patient groups may be included if they are different to the standard dose.

Learning activity 10
Question An endoscopy on a 60-year-old man confirms severe peptic ulcer bleeding and haemostatic treatment is given. He is prescribed esomeprazole as an initial intravenous infusion of 80mg over 30 minutes, then a continuous intravenous infusion of 8mg/hour for 72 hours. How will you administer the intravenous esomeprazole? Answer Appendix 4 (intravenous additives) advises that the first 80mg dose of esomeprazole should be reconstituted with up to 100mL of infusion fluid (sodium chloride 0.9%) and infused over 30 minutes. The next 80mg of esomeprazole should be given in up to 100mL sodium chloride 0.9% over ten hours; this should be repeated until the continuous infusion has been given for 72 hours. The infusion is stable for 12 hours.

Learning activity 9
Question A colleague asks you to clarify whether you intended your patient to receive ten capsules of omeprazole 20mg. Your prescription reads omeprazole 20.0mg daily. What has gone wrong here? Answer According to the section on prescription writing, the unnecessary use of decimal points should be avoided on prescriptions. In this case, the dose has been misread as 200mg. The dose is best written as 20mg daily.

Appendix 4 provides practical information on the preparation of intravenous drug infusions, including compatibility of drugs with standard intravenous infusion fluids, method of dilution or reconstitution and administration rates.

Monitoring drug treatment

Patients should be monitored to ensure they are getting the expected benefits from drug treatment without any unwanted side effects. The prescribing notes or the cautions in the drug monograph specify any special monitoring requirements. Further information on monitoring the plasma concentration of drugs with a narrow therapeutic index can be found as a note under the dose section of the drug monograph (for example, theophylline, section 3.1.3). The anticoagulation targets recommended by the British Society for Haematology are outlined in section 2.8.2.

Writing prescriptions
The section on prescription writing in BNF 62 (Joint Formulary Committee 2011) provides tips on writing prescriptions in a way that will help reduce medication errors. Preparations containing controlled drugs from Schedules 2, 3, 4 (Part I) and 4 (Part II) of the Misuse of Drugs Regulations 2001 (and subsequent amendments) are identified throughout BNF 62 using symbols to indicate the Schedule to which they belong. The section on controlled drugs and drug dependence specifies the prescription requirements for these drugs and provides a key to the new symbols.

Significant changes in new editions

When a new edition of the BNF is published in March and September each year, you should

Learning activity 11
Question Are additional contraceptive precautions necessary when a women starts the combined oral contraceptive pill Ovranette on day 4 of her menstrual cycle? Answer According to the insert in BNF 62, information on starting and switching combined oral contraceptives has changed. Combined oral contraceptive pills, such as Ovranette, can be initiated on day 1-5 of the menstrual cycle without the need for additional contraceptive precautions. The advice on Qlaira remains unchanged because of limited experience with this brand.

Administration routes
If a drug can be given parenterally or by more than one route, the dose section in the monograph or preparation record specifies the administration route. Further information on administration may be found in the monograph or preparation record, often as a note or counselling advice.

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identify the changes in its clinical content that are relevant to your practice. The publication includes a number of aids to help you do this: 4 The print version includes an insert that summarises the background to several key changes. A copy of the insert can also be found at http://bnf.org in the updates section under Whats New in the BNF? 4 Changes for this Edition (page xvii, BNF 62) provides a list of significant changes, dose changes, classification changes, new names and new preparations that have been incorporated into the new edition, as well as a list of preparations that have been discontinued since the previous edition. For ease of identification in the print version, the pages have blue margins. 4 The BNF and the BNF for Children e-newsletter service is available free of charge. Available several times a year, these emails alert healthcare professionals to significant changes in the clinical content of these publications and to the way this information is delivered. Registration for the emails is free on the BNF website. Many changes are made to each BNF edition and not all can be shown in the insert and changes section. We encourage you to review regularly the information on drugs that you frequently encounter. The NPF is published every two years and is designed for use with the BNF. The next edition of the NPF is due to be published in autumn 2011. Nurses who have received specific preparation and training (distinct from that provided to community practitioner nurse prescribers) and are qualified as nurse independent prescribers are able to prescribe any medicine for any condition, including some controlled drugs. BNF 62 (Joint Formulary Committee 2011) includes a list of controlled drugs and the indications for which they may be prescribed by nurse independent prescribers (page 992, BNF 62).

Conclusion
This article captures only some of the recent changes to the BNF. Getting to know the BNF and keeping up to date with the changes in its clinical content are essential to every nurses continuing professional development. It is recommended that you review other aspects of How to Use the BNF, such as selecting wound dressings and prescribing for patients with hepatic or renal impairment NS

Navigating around the BNF

The most efficient way of finding information in the print version of the BNF is to turn to the index, where entries are included in alphabetical order of non-proprietary drug names, proprietary drug names, clinical conditions and prescribing topics. How to use the BNF provides details of other aids that may help you find relevant information.

References Nurse Prescribers Formulary

The Nurse Prescribers Formulary (page 989, BNF 62) includes a list of preparations approved by the Secretary of State and which may be prescribed for NHS patients by community practitioner nurse prescribers in England. Preparations are listed in alphabetical order of their generic names; however, the proprietary name is used where it would be inappropriate to use the generic name or where there is no approved generic name. The Nurse Prescribers Formulary for Practitioners (NPF) is a separate publication that provides further details about these medicines together with an overview of some common conditions that they are used to treat. 48 september 21 :: vol 26 no 3 :: 2011
Baxter K (2010) Stockleys Drug Interactions. Ninth edition. Pharmaceutical Press, London. Briggs GG, Freeman RK, Yaffe SJ (2011) Drugs in Pregnancy and Lactation. Ninth edition. Lippincott Williams & Wilkins, Philadelphia. Cox AR, Butt TF, Ferner RE (2010) An analysis and comparison of commonly available United Kingdom prescribing resources. Journal of Clinical Pharmacy and Therapeutics. 35, 4, 453-464. Joint Formulary Committee (2010) British National Formulary No. 59. British Medical Association and the Royal Pharmaceutical Society, London. Joint Formulary Committee (2011) British National Formulary. No. 62. British Medical Association and the Royal Pharmaceutical Society, London. Medicines Information Survey (2010) Kantar Health, Epsom.

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