BNF 68 2.6.2 Calcium-channel blockers HAL.

133

AMLODIPINE
Indications hypertension, prophylaxis of angina Cautions

interactions: Appendix 1 (calcium-channel blockers)

Contra-indications cardiogenic shock, unstable angina, significant aortic stenosis

Hepatic impairment may need dose reduction—halflife prolonged

Pregnancy no information available—manufacturer advises avoid, but risk to fetus should be

balanced against risk of uncontrolled maternal hypertension

Breast-feeding manufacturer advises avoid—no information available

Side-effects abdominal pain, nausea; palpitation, flushing, oedema; headache, dizziness, sleep
disturbances, fatigue; less commonly gastro-intestinal disturbances, dry mouth, taste disturbances,
hypotension, syncope, chest pain, dyspnoea, rhinitis, mood changes, asthenia, tremor, paraesthesia,
urinary disturbances, impotence, gynaecomastia, weight changes, myalgia, muscle cramps, back
pain, arthralgia, visual disturbances, tinnitus, pruritus, rashes (including isolated reports of erythema
multiforme), sweating, alopecia, purpura, and skin discolouration; very rarely gastritis, pancreatitis,
hepatitis, jaundice, cholestasis, gingival hyperplasia, myocardial infarction, arrhythmias, tachycardia,
vasculitis, coughing, peripheral neuropathy, hyperglycaemia, thrombocytopenia, angioedema, and
urticaria; overdosage, see Emergency Treatment of Poisoning, p. 39

Dose . Hypertension or angina, initially 5 mg once daily; max. 10 mg once daily

Note Tablets from various suppliers may contain different salts (e.g. amlodipine besilate, amlodipine
maleate, and amlodipine mesilate) but the strength is expressed in terms of amlodipine (base);
tablets containing different salts are considered interchangeable

Amlodipine (Non-proprietary) A Tablets, amlodipine (as maleate or as mesilate) 5 mg, net price 28-
tab pack = 89p; 10 mg, 28-tab pack = 94p Brands include Amlostin ®

Istin® (Pfizer) A Tablets, amlodipine (as besilate) 5 mg, net price 28- tab pack = £11.08; 10 mg, 28-
tab pack = £16.55

With valsartan Note For hypertension in patients stabilised on the individual components in the
same proportions. For prescribing information on valsartan, see section 2.5.5.2

Exforge® (Novartis) A Tablets 5/80, f/c, dark yellow, amlodipine 5 mg, valsartan 80 mg, net price 28-
tab pack = £16.76 Tablets 5/160, f/c, dark yellow, amlodipine 5 mg, valsartan 160 mg, net price 28-
tab pack = £22.09 Tablets 10/160, f/c, light yellow, amlodipine 10 mg, valsartan 160 mg, net price
28-tab pack = £22.09

HAL. 464 6.1.2 Antidiabetic drugs BNF 68

GLIMEPIRIDE
Indications type 2 diabetes mellitus
Cautions see notes above; manufacturer recommends regular hepatic and haematological
monitoring but limited evidence of clinical value; interactions: Appendix 1 (antidiabetics)

Contra-indications see notes above

Hepatic impairment see notes above

Renal impairment see notes above

Pregnancy see notes above

Breast-feeding see notes above

Side-effects see notes above

Dose . Initially 1 mg daily, adjusted according to response in 1-mg steps at 1–2 week intervals; usual
max. 4 mg daily (exceptionally, up to 6 mg daily may be used); taken shortly before or with first main
meal

Glimepiride (Non-proprietary) A Tablets, glimepiride 1 mg, net price 30-tab pack = £1.20; 2 mg, 30-
tab pack = £1.12; 3 mg, 30-tab pack = £7.25; 4 mg, 30-tab pack = £1.33

Amaryl® (Sanofi-Aventis) A Tablets, all scored, glimepiride 1 mg (pink), net price 30-tab pack = £4.33;
2 mg (green), 30-tab pack = £7.13; 3 mg (yellow), 30-tab pack = £10.75; 4 mg (blue), 30-tab pack =
£14.2

METFORMIN HYDROCHLORIDE Indications diabetes mellitus (see notes above); polycystic ovary
syndrome [unlicensed indication] Cautions see notes above; determine renal function before
treatment and at least annually (at least twice a BNF 68 6.1.2 Antidiabetic drugs 465 6 Endocrine
system year in patients with additional risk factors for renal impairment, or if deterioration
suspected); interactions: Appendix 1 (antidiabetics) Lactic acidosis Use with caution in renal
impairment— increased risk of lactic acidosis; avoid in significant renal impairment. NICE1
recommends that the dose should be reviewed if eGFR less than 45 mL/minute/1.73 m2 and to
avoid if eGFR less than 30 mL/minute/1.73 m2 . Withdraw or interrupt treatment in those at risk of
tissue hypoxia or sudden deterioration in renal function, such as those with dehydration, severe
infection, shock, sepsis, acute heart failure, respiratory failure or hepatic impairment, or those who
have recently had a myocardial infarction Contra-indications ketoacidosis, see also Lactic Acidosis
above; use of general anaesthesia (suspend metformin on the morning of surgery and restart when
renal function returns to baseline) Iodine-containing X-ray contrast media Intravascular
administration of iodinated contrast agents can cause renal failure, which can increase the risk of
lactic acidosis with metformin—see Lactic Acidosis above. Suspend metformin prior to the test;
restart no earlier than 48 hours after the test if renal function has returned to baseline Hepatic
impairment withdraw if tissue hypoxia likely Renal impairment see under Cautions Pregnancy used
in pregnancy for both pre-existing and gestational diabetes—see also p. 463 Breast-feeding may be
used during breast-feeding— see p. 463 Side-effects anorexia, nausea, vomiting, diarrhoea (usually
transient), abdominal pain, taste disturbance, rarely lactic acidosis (withdraw treatment), decreased
vitamin-B12 absorption, erythema, pruritus and urticaria; hepatitis also reported Dose . Diabetes
mellitus, ADULT and CHILD over 10 years initially 500 mg with breakfast for at least 1 week then 500
mg with breakfast and evening meal for at least 1 week then 500 mg with breakfast, lunch and
evening meal; usual max. 2 g daily in divided doses . Polycystic ovary syndrome [unlicensed], initially
500 mg with breakfast for 1 week, then 500 mg with breakfast and evening meal for 1 week, then
1.5–1.7 g daily in 2–3 divided doses Note Metformin doses in the BNF may differ from those in the
product literature Metformin (Non-proprietary) A Tablets, coated, metformin hydrochloride 500 mg,
net price 28-tab pack = 87p, 84-tab pack = £1.00; 850 mg, 56-tab pack = £1.36. Label: 21 Oral
solution, sugar-free, metformin hydrochloride 500 mg/5 mL, net price 100 mL = £40.50. Label: 21
Glucophage® (Merck Serono) A Tablets, f /c, metformin hydrochloride 500 mg, net price 84-tab pack
= £2.88; 850 mg, 56-tab pack = £3.20. Label: 21 Oral powder, sugar-free, metformin hydrochloride
500 mg/sachet, net price 30-sachet pack = £3.29, 60-sachet pack = £6.58; 1 g/sachet, 30-sachet pack
= £6.58, 60-sachet pack = £13.16. Label: 13, 21, counselling, administration Excipients include
aspartame (section 9.4.1) Counselling The contents of each sachet should be mixed with 150 mL of
water and taken immediately The Scottish Medicines Consortium (p. 4) has advised (March 2010)
that Glucophage ® oral powder is accepted for restricted use within NHS Scotland for the treatment
of type 2 diabetes mellitus in patients who are unable to swallow the solid dosage form. Modified
release Metformin (Non-proprietary) A Tablets, m/r, metformin hydrochloride 500 mg, net price 28
tab-pack = £2.66, 56 tab-pack = £5.32. Label: 21, 25 Brands include Bolamyn ® SR, Glucient ® SR,
Metabet ® SR Dose initially 500 mg once daily, increased every 10–15 days, max. 2 g once daily with
evening meal; if control not achieved, use 1 g twice daily with meals, and if control still not achieved
change to standard-release tablets Note Patients taking up to 2 g daily of the standard-release
metformin may start with the same daily dose of metformin modified release; not suitable if dose of
standard-release tablets more than 2 g daily Glucophage® SR (Merck Serono) A Tablets, m/r,
metformin hydrochloride 500 mg, net price 28-tab pack = £2.66, 56-tab pack = £5.32; 750 mg, 28-tab
pack = £3.20, 56-tab pack = £6.40; 1 g, 28-tab pack = £4.26, 56-tab pack = £8.52. Label: 21, 25 Dose
initially 500 mg once daily, increased every 10–15 days, max. 2 g once daily with evening meal; if
control not achieved, use 1 g twice daily with meals, and if control still not achieved change to
standard-release tablets Note Patients taking up to 2 g daily of the standard-release metformin may
start with the same daily dose of Glucophage ® SR; not suitable if dose of standard-release tablets
more than 2 g daily The Scottish Medicines Consortium (p. 4) has advised (September 2009) that
Glucophage ® SR is accepted for restricted use within NHS Scotland for the treatment of type 2
diabetes mellitus in adult patients who are intolerant of standard-release metformin, and in whom
the prolongedrelease tablet allows the use of a dose of metformin not previously tolerated, or in
patients for whom a once daily preparation offers a clinically significant benefit.

FUROSEMIDE

(Frusemide)

Indications oedema (see notes above); resistant hypertension (see notes above)

Cautions see notes above; also hypoproteinaemia may reduce diuretic effect and increase risk of
sideeffects; hepatorenal syndrome; intravenous administration rate should not usually exceed 4
mg/minute, however single doses of up to 80 mg may be administered more rapidly

Contra-indications see notes above

Hepatic impairment see notes above

Renal impairment see notes above; also lower rate of infusion may be necessary
Pregnancy see notes above

Breast-feeding amount too small to be harmful; may inhibit lactation Side-effects see notes above;
also intrahepatic cholestasis and gout Dose . By mouth, oedema, initially 40 mg in the morning;
maintenance 20–40 mg daily; CHILD under 18 years see BNF for Children Resistant oedema, 80–120
mg daily Resistant hypertension, 40–80 mg daily . By intramuscular injection or slow intravenous
injection (rate of administration, see Cautions above), initially 20–50 mg, increased if necessary in
steps of 20 mg not less than every 2 hours; doses greater than 50 mg by intravenous infusion only;
max. 1.5 g daily; CHILD under 18 years see BNF for Children Furosemide (Non-proprietary) A Tablets,
furosemide 20 mg, net price 28 = 82p; 40 mg, 28 = 78p; 500 mg, 28 = £18.04 Brands include Rusyde ®
Oral solution, sugar-free, furosemide, net price 20 mg/5 mL, 150 mL = £14.36; 40 mg/5 mL, 150 mL =
£18.54; 50 mg/5 mL, 150 mL = £20.03 Brands include Frusol ® (contains alcohol 10%) Injection,
furosemide 10 mg/mL, net price 2-mL amp = 35p, 5-mL amp = 32p, 25-mL amp = £2.50 Lasix®
(Sanofi-Aventis) A Injection, furosemide 10 mg/mL, net price 2-mL amp = 75p Note Large-volume
furosemide injections also available; brands include Minijet