Dose and Administration. The licensed dose is 50mg twice daily. Riluzole is not recommended for patients with any level of impaired renal function. (See below for hepatic impairment) Preparations available Riluzole 50 mg film-coated tablets Riluzole 5mg/1ml oral suspension Neither preparation is licensed for administration via enteral feeding tubes however the liquid has been used in practice. The film-coated tablets have been crushed and dispersed in water for enteral tube administration however there have been reports of crushed riluzole tablets blocking enteral feeding tubes, therefore if used the tube should be flushed well after use. Adverse Effects Very common (≥1/10): Nausea, abnormal liver function tests, asthenia. Other reported adverse effects are headache, abdominal pain, vomiting, dizziness, tachycardia, somnolence and circumoral paraesthesia. For a full list of adverse effects, refer to the Summary of Product Characteristics for riluzole. Serious suspected reactions (even if well recognised or causal link uncertain) should be reported to the Commission on Human Medicines (CHM) via xxxx://xxxxxxxxxx.xxxx.xxx.xx. Cautions Hepatic impairment Riluzole should be prescribed with care in patients with a history of abnormal liver function, or in patients with slightly elevated serum transaminases (ALT/SGPT; AST/SGOT up to 3 times the upper limit of the normal range (ULN)), bilirubin and/or gamma-glutamyl transferase (GGT) levels. Baseline elevations of several LFTs (especially elevated bilirubin) should preclude the use of riluzole. Because of the risk of hepatitis, serum transaminases, including ALT, should be measured before and during therapy with riluzole. ALT should be measured every month during the first 3 months of treatment, every 3 months during the remainder of the first year, and annually thereafter. ALT levels should be measured more frequently in patients who develop elevated ALT levels. Riluzole should be discontinued if the ALT levels increase to 5 times the ULN. There is no experience with dose reduction or rechallenge in patients who have developed an increase of ALT to 5 times ULN. Re-administration of riluzole to patients in this situation cannot be recommended.
Dose and Administration. For new patients commencing drug treatment, medication should be initiated by the CAMHS doctor, paediatrician or non-medical prescriber (NMP). First choice Unless contraindicated, either short or long acting methylphenidate should be the first line choice of drug treatment.
Dose and Administration. The licensed dose is 50mg twice daily. Riluzole is not recommended for patients with any level of impaired renal function. (See below for hepatic impairment) Preparations available Riluzole 50 mg film-coated tablets Riluzole 5mg/1ml oral suspension Neither preparation is licensed for administration via enteral feeding tubes however the liquid has been used in practice. The film-coated tablets have been crushed and dispersed in water for enteral tube administration however there have been reports of crushed riluzole tablets blocking enteral feeding tubes, therefore if used the tube should be flushed well after use.
Dose and Administration. Prescribe by BRAND name In patients of average weight (70kg) an initial dose of 400 – 1200 mg of lithium carbonate may be given as a single daily dose in the morning or on retiring. Alternatively, the dose may be divided and given morning and evening. Lithium has linear pharmacokinetics; assuming stable renal function, and increase in dose of 25% will increase serum lithium concentration by 25%. Elderly patients or those below 50kg in weight, often require lower lithium dosage to achieve therapeutic serum levels: starting doses of 200 mg to 400 mg are recommended. Sustained released tablets should not be crushed or chewed. When changing between lithium preparations serum lithium levels should first be checked, then therapy commenced at a daily dose as close as possible to the dose of the other form of lithium. As bioavailability varies from product to product (particularly with regard to retard or slow release preparations) a change of product should be regarded as initiation of new treatment. Abrupt discontinuation of lithium increases the risk of relapse; gradual reduction over a period of at least 4 weeks (preferably over a period of up to 3 months) is recommended. If lithium is to be stopped abruptly, consideration should be given to changing to an atypical antipsychotic or valproate, and monitoring closely for early signs of mania and depression.
Dose and Administration. Leflunomide therapy is initiated with an oral loading dose of 100 mg/day for 3 days. The maintenance dose is 10 to 20 mg/day for RA and 20 mg/day for PsA. A washout period should be followed when switching to another hepato- or haematotoxic drug (e.g. methotrexate), or in cases of acute leflunomide toxicity (see the [SPC] for more details). A therapeutic effect usually starts at 4 - 6 weeks and may further improve up to 4 - 6 months. Monitoring: Pre-treatment Assessment: Height, weight, blood pressure, FBC, U&Es, LFTs, albumin, eGFR, CRP, VZV checked and results must be back before treatment commences. After commencing treatment: Check FBC, creatinine/calculated GFR, ALT and/or AST and albumin every 2 weeks until on stable dose for 6 weeks; then once on stable dose, monthly FBC, creatinine/calculated GFR, ALT and/or AST and albumin for 3 months; thereafter, FBC, creatinine/calculated GFR, ALT and/or AST and albumin at least every 12 weeks. More frequent monitoring is appropriate in patients at higher risk of toxicity. Dose increases should be monitored by FBC, creatinine/calculated GFR, ALT and/or AST and albumin every 2 weeks until on stable dose for 6 weeks then revert to previous schedule. Monitor BP and weight every 12 weeks or at dose increase. Monitoring of combination DMARD therapy (e.g. methotrexate and leflunomide) is monthly for 12 months then patients who have been stable can be considered for reduced frequency monitoring on an individual patient basis. Interruption of Treatment: Contact rheumatology team urgently and withhold treatment if any of the following develop: white cell count <3.5 x 109/l; mean cell volume >105 Fl and if B12 or folate low start supplementation; neutrophils <1.6 X 109/l; creatinine increase >30% over 12 months and/or calculated GFR <60 ml/min; unexplained eosinophilia >0.5 X109/l; ALT and/or AST >100 U/l; If ALT elevations of more than 2-fold the upper limit persist, or more than 3-fold the upper limit of normal are present, leflunomide treatment must be discontinued and wash-out procedures initiated. The SPC recommends that monitoring of liver enzymes be continued after discontinuation of treatment until liver enzyme levels have normalised. platelet count <140 X109/l; unexplained reduction in albumin <30 g/l During a serious infection, Leflunomide should be temporarily discontinued until the patient has recovered from the infection. Dose reduction: If WBC <3.5 x 109/l, Neutrophils <2.0 x 109/l: Halve dose Reduce dose i...
Dose and Administration. 60mg given by subcutaneous injection every 6 months. The initial dose will be given whilst the patient is in hospital. Subsequent injections will be given in primary care. The patient should be assessed prior to each injection to ensure that bisphosphonate therapy is not appropriate. Patients should be adequately supplemented with calcium and vitamin D. Adverse effects The most common adverse effects reported with denosumab are constipation, abdominal discomfort, urinary tract infection, upper respiratory tract infection, pain in extremities, musculoskeletal pain, sciatica, cataracts* and rash and eczema (between 1 in 10 and 1 in 100). Other less commonly reported adverse effects include diverticulitis, cellulitis and ear infection (between 1 in 100 and 1 in 1000). Osteonecrosis of the jaw, hypocalcaemia, atypical femoral fractures and hypersensitivity have been reported rarely with denosumab (between 1 in 1000 and 1 in 10000). See contraindications and warnings. * In a single phase III placebo-controlled clinical trial in patients with prostate cancer receiving androgen deprivation therapy (ADT) an imbalance in cataract adverse events was observed (4.7% denosumab, 1.2% placebo). No imbalance was observed in postmenopausal women or men with osteoporosis or in women undergoing aromatase inhibitor therapy for non-metastatic breast cancer. Drug Interactions There are no known pharmacodynamic or pharmacokinetic drug interactions. Contraindications and warnings • Hypocalcaemia Denosumab is contraindicated in hypocalcaemia, which should be corrected by adequate intake of calcium and vitamin D before initiating therapy. Patients with severe renal impairment (eGFR <30 ml/min) or receiving dialysis are at greater risk of developing hypocalcaemia with denosumab. Clinical monitoring of calcium levels is recommended for patients predisposed to hypocalcaemia. Patients should be advised to report symptoms of hypocalcaemia to their doctor (e.g. muscle spasms, twitches, cramps, numbness or tingling in the fingers, toes or around the mouth). • Hypersensitivity Denosumab is contraindicated in patients with hypersensitivity to the active substance or any excipients. • Patients with rare hereditary problems of fructose intolerance should not use denosumab. • Osteonecrosis of the jaw (ONJ) Denosumab is associated with a risk of ONJ. Most cases have been reported in cancer patients; however some have occurred in patients with osteoporosis. Before initiating denosumab prescriber...
Dose and Administration. In this trial a low dose of Magtrace® 28mg/ml (0.1ml) will be injected intracutaneously at one time-point. This is different from the recommendation of 1-2 mL in the subcutaneous tissue. The rationale is that the lymphatic outflow from an intracutaneous injection is much higher, and a lower dose is then needed. This is the same type of injection that is currently used with Tc99 and blue dye. The injection should be done slowly with a thin needle in the most superficial part of the skin, so that the tip of the needle is visible and that the Magtrace® creates a small spider web in the skin as it enters the lymphatic vessels.
Dose and Administration. 1 - 1.5 mg/kg daily, although some patients may respond to a lower starting dose of 0.75 mg/kg daily. Dosage may need to be reduced in renal or hepatic impairment. Mercaptopurine is available as 50 mg scored tablets. Monitoring: Specialist baseline and annual: FBC, ESR, CRP, U&Es, creatinine, LFTs, TPMT (thiopurine methyltransferase) genetic testing or enzyme levels at discretion of specialist. Ask about oral ulceration/sore throat, unexplained rash or unusual bruising at every consultation. GP: FBC & LFTs weekly for at least 8 weeks, or until stable. When stable monthly thereafter. When the disease, dose and blood monitoring is stable the FBC and LFT can be reduced to every 3 months. U&E, creatinine at 4, 12 & 26 weeks, then annually. CRP & ESR every 3 months. Ask about oral ulceration/sore throat, unexplained rash or unusual bruising at every consultation. Contra- indications: previous hypersensitivity to azathioprine or mercaptopurine. TPMT deficiency - avoid if deficient or reduce dose if low levels.
