Medicines for Children leaflet: Diazepam (rectal) for stopping
seizures www.medicinesforchildren.org.uk/diazepam-rectalstopping-seizures-0
Medicines for Children leaflet: Diazepam for muscle spasm
www.medicinesforchildren.org.uk/diazepam-muscle-spasm-0
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Diazepam Tablets may be prescribed.
Diazepam Oral Solution 2 mg/5 mL may be prescribed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2, 19
Diazepam 2 mg Diazepam 2mg tablets | 28 tablet P £1.10 DT =
Diazepam 5mg tablets | 28 tablet P £1.12 DT =
Diazepam 10mg tablets | 28 tablet P £4.99 DT
▶ Diazemuls (Accord Healthcare Ltd)
Diazepam 5 mg per 1 ml Diazemuls 10mg/2ml emulsion for injection
ampoules | 10 ampoule P £9.05d
EXCIPIENTS: May contain Benzyl alcohol, ethanol, propylene glycol
Diazepam 5 mg per 1 ml Diazepam 10mg/2ml solution for injection
ampoules | 10 ampoule P £5.50–£7.20 DT = £5.50d
CAUTIONARY AND ADVISORY LABELS 2, 19
Diazepam 400 microgram per 1 ml Diazepam 2mg/5ml oral
suspension | 100 ml P £31.75 DT = £31.75d
CAUTIONARY AND ADVISORY LABELS 2, 19
Diazepam 400 microgram per 1 ml Diazepam 2mg/5ml oral
solution sugar free sugar-free | 100 ml P £42.81–£43.91 DT =
CAUTIONARY AND ADVISORY LABELS 2, 19
Diazepam 2 mg per 1 ml Diazepam 5mg RecTubes | 5 tube P £
Diazepam 10mg RecTubes | 5 tube P £
35d2.5ml rectal solution tube | 5 tube P £7.35 DT =
Diazepam 2 mg per 1 ml Stesolid 5mg rectal tube | 5 tube P £
6.89 DT = £5.85d Stesolid 10mg rectal tube | 5 tube P £8.78 DT = £7.35d
▶ Adult: 15–30 mg 3–4 times a day, for debilitated
▶ Elderly: 10–20 mg 3–4 times a day
Insomnia associated with anxiety
▶ Adult: 15–25 mg once daily (max. per dose 50 mg), dose
with depression). obsessional states . phobic states . respiratory depression
l CAUTIONS Muscle weakness . organic brain changes
▶ Paradoxical effects A paradoxical increase in hostility and
aggression may be reported by patients taking
benzodiazepines. The effects range from talkativeness and
excitement to aggressive and antisocial acts. Adjustment
of the dose (up or down) sometimes attenuates the
impulses. Increased anxiety and perceptual disorders are
l INTERACTIONS → Appendix 1: oxazepam
l BREAST FEEDING Benzodiazepines are present in milk, and
should be avoided if possible during breast-feeding.
Dose adjustments Start with small doses in severe
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
CAUTIONARY AND ADVISORY LABELS 2
Oxazepam 10 mg Oxazepam 10mg tablets | 28 tablet P £13.73
Oxazepam 15mg tablets | 28 tablet P £13.44
HYPNOTICS, SEDATIVES AND ANXIOLYTICS ›
NON-BENZODIAZEPINE HYPNOTICS AND
Short-term use in anxiety—not recommended
▶ Adult: 400 mg 3–4 times a day
▶ Elderly: Up to 200 mg 3–4 times a day
MHRA/CHM ADVICE: MEPROBAMATE: LICENCE TO BE CANCELLED
Following an EU-wide review of meprobamate, the UK
licence holder has ceased manufacturing and the licence
is due to be cancelled by December 2016. No new stock
will be released into the normal distribution chain after
31 December 2016, although existing stock placed on the
market before that date is likely to be dispensed until the
products approach their expiry date.
Prescribers should review the treatment of any patient
who is currently receiving a meprobamate-containing
medicine with a view to switching them to an alternative
treatment, and not start any new patients on medicines
l CONTRA-INDICATIONS Acute porphyrias p. 1058 . acute
pulmonary insufficiency .respiratory depression
l CAUTIONS Abrupt withdrawal (may precipitate
periods)—increased risk of dependence . epilepsy (may
induce seizures). history of alcohol dependence . history of
drug dependence . muscle weakness .respiratory disease
l INTERACTIONS → Appendix 1: meprobamate
l SIDE-EFFECTS Agitation . agranulocytosis . anal
inflammation . ataxia . blood disorder. bone marrow
syndrome . stomatitis .thrombocytopenia . vomiting . withdrawal syndrome
l PREGNANCY Avoid if possible.
l BREAST FEEDING Avoid. Concentration in milk may
exceed maternal plasma concentrations fourfold and may
l HEPATIC IMPAIRMENT Elimination may be prolonged in
l RENAL IMPAIRMENT Increased cerebral sensitivity.
Dose adjustments Start with small doses in severe
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. driving); effects of
l LESS SUITABLE FOR PRESCRIBING Meprobamate is less
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Meprobamate (Non-proprietary)
Meprobamate 400 mg Meprobamate 400mg tablets | 84 tablet P £197.63 DT = £197.63c
Attention deficit hyperactivity
Attention deficit hyperactivity disorder (ADHD) is a
behavioural disorder characterised by hyperactivity,
impulsivity and inattention, which can lead to functional
impairment such as psychological, social, educational or
impulsive, while others are principally inattentive.
Symptoms typically appear in children aged 3–7 years, but
may not be recognised until after 7 years of age, especially if
hyperactivity is not present. ADHD is more commonly
diagnosed in males than in females.
ADHD is usually a persisting disorder and some children
continue to have symptoms throughout adolescence and
into adulthood, where inattentive symptoms tend to persist,
and hyperactive-impulsive symptoms tend to recede over
time. ADHD is also associated with an increased risk of
disorders such as oppositional defiant disorder (ODD),
conduct disorder, and possibly mood disorders such as
depression, mania, and anxiety, as well as substance misuse.
The aims of treatment are to reduce functional impairment,
severity of symptoms, and to improve quality of life.
g Patients should be advised about the importance of a
balanced diet, good nutrition and regular exercise. h
Environmental modifications are changes made to the
physical environment that can help reduce the impact of
ADHD symptoms on a person’s day-to-day life.g The
modifications should be specific to the person’s
circumstances, and may involve changes to seating
arrangements, lighting and noise, reducing distractions,
346 Mental health disorders BNF 78
optimising work or education by having shorter periods of
focus with movement breaks, and reinforcing verbal requests
with written instructions. These changes should form part of
the discussion at the time of diagnosis of ADHD and be
trialled and reviewed for effectiveness before drug treatment
ADHD focused psychological interventions which may
involve elements of, or a complete course of cognitive
behavioural therapy (CBT) may be effective in patients who
have refused drug treatment, have difficulty with adherence,
are intolerant of, or unresponsive to drug treatment. In
patients who have benefited from drug treatment, but whose
symptoms are still causing significant impairment in at least
one area of function (such as interpersonal relationships,
education and occupational attainment, and risk awareness),
consider a combination of non-drug treatment with drug
g Drug treatment should be initiated by a specialist
trained in the diagnosis and management of ADHD.
Following dose stabilisation, continuation and monitoring of
drug treatment can be undertaken by the patient’s general
practitioner under a shared care arrangement. Treatment
should be started in patients with ADHD whose symptoms
are still causing significant impairment in at least one area of
function, despite environmental modifications. Patients with
ADHD and anxiety disorder, tic disorder, or autism spectrum
disorder should be offered the same treatment options as
Lisdexamfetamine mesilate p. 351 or methylphenidate
hydrochloride p. 348 are recommended as first-line
treatment. If symptoms have not improved following a
p. 350 [unlicensed] can be tried if the patient is having a
beneficial response to lisdexamfetamine mesilate but cannot
tolerate its longer duration of effect.
Modified-release preparations of stimulants are preferred
because of their pharmacokinetic profile, convenience,
improved adherence, reduced risk of drug diversion (drugs
being forwarded to others for non-prescription use or
misuse), and the lack of need to be taken to work.
Immediate-release preparations can be given when more
flexible dosing regimens are required, or during initial dose
be used to extend the duration of effect. The magnitude,
duration of effect, and side-effects of stimulants vary
In patients who are intolerant to both methylphenidate
hydrochloride p. 348 and lisdexamfetamine mesilate, or who
have not responded to separate 6-week trials of both drugs,
treatment with the non-stimulant atomoxetine below can be
Advice from, or referral to a tertiary specialist ADHD
service should be considered if the patient is unresponsive to
one or more stimulant drugs (e.g. methylphenidate
hydrochloride p. 348 and lisdexamfetamine mesilate) and
atomoxetine below. A specialist service should also be
consulted for advice before starting treatment with
guanfacine p. 352 [unlicensed], or an atypical antipsychotic
sustained orthostatic hypotension or fainting episodes occur
with guanfacine p. 352 treatment, the dose should be
reduced or an alternative treatment offered. h
Other treatment options such as bupropion hydrochloride
p. 498, modafinil p. 492, tricyclic antidepressants, and
venlafaxine p. 368 [all unlicensed] have been used in the
management of ADHD, but due to limited evidence their use
is not recommended without specialist advice.
g Patients should be monitored for effectiveness of
medication and side-effects, as well as changes in sleep
pattern, sexual dysfunction (associated with atomoxetine
below), and stimulant diversion or misuse. If the patient
develops new, or has worsening of existing seizures, review
drug treatment and stop any drug that might be contributing
to the seizures; treatment can be cautiously reintroduced if
it is unlikely to be the cause. Monitor patients for the
development of tics associated with stimulant use. If tics are
stimulant related, consider a dose reduction, stopping
treatment, or changing to a non-stimulant drug. If there is
worsening of behaviour, consider adjusting drug treatment
Treatment should be reviewed by a specialist at least once
a year and trials of treatment-free periods, or dose
reductions considered where appropriate. h
Attention deficit hyperactivity disorder: diagnosis and
management. National Institute for Health and Care
Excellence. Clinical guideline 87. March 2018.
CNS STIMULANTS › CENTRALLY ACTING
Attention deficit hyperactivity disorder (initiated by a
▶ Child 6–17 years (body-weight up to 70 kg): Initially
500 micrograms/kg daily for 7 days, dose is increased
according to response; maintenance 1.2 mg/kg daily,
total daily dose may be given either as a single dose in
the morning or in 2 divided doses with last dose no
later than early evening, high daily doses to be given
under the direction of a specialist; maximum 1.8 mg/kg
per day; maximum 120 mg per day
▶ Child 6–17 years (body-weight 70 kg and above): Initially
40 mg daily for 7 days, dose is increased according to
response; maintenance 80 mg daily, total daily dose
may be given either as a single dose in the morning or
in 2 divided doses with last dose no later than early
evening, high daily doses to be given under the
direction of a specialist; maximum 120 mg per day
▶ Adult (body-weight up to 70 kg): Initially
500 micrograms/kg daily for 7 days, dose is increased
according to response; maintenance 1.2 mg/kg daily,
total daily dose may be given either as a single dose in
the morning or in 2 divided doses with last dose no
later than early evening, high daily doses to be given
under the direction of a specialist; maximum 1.8 mg/kg
per day; maximum 120 mg per day
▶ Adult (body-weight 70 kg and above): Initially 40 mg daily
for 7 days, dose is increased according to response;
maintenance 80–100 mg daily, total daily dose may be
given either as a single dose in the morning or in
2 divided doses with last dose no later than early
evening, high daily doses to be given under the
direction of a specialist; maximum 120 mg per day
l UNLICENSED USE Atomoxetine doses in BNF may differ
from those in product literature.
▶ In children Doses above 100 mg daily not licensed.
▶ In adults Dose maximum of 120 mg not licensed.
l CONTRA-INDICATIONS Phaeochromocytoma . severe
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