l URINE KETONES TESTING STRIPS
GlucoRx KetoRx Sticks 2GK testing strips (GlucoRx Ltd)
50 strip . NHS indicative price = £2.25 . Drug Tariff (Part IXr)
Ketostix testing strips (Ascensia Diabetes Care UK Ltd)
50 strip . NHS indicative price = £3.06 . Drug Tariff (Part IXr)
l URINE PROTEIN TESTING STRIPS
Albustix testing strips (Siemens Medical Solutions Diagnostics Ltd)
50 strip . NHS indicative price = £4.10 . Drug Tariff (Part IXr)
Medi-Test Protein 2 testing strips (BHR Pharmaceuticals Ltd)
50 strip . NHS indicative price = £3.27 . Drug Tariff (Part IXr)
Initially glucose p. 1041 10–20 g is given by mouth either in
liquid form or as granulated sugar or sugar lumps. If
necessary this may be repeated after 10–15 minutes. After
initial treatment, a snack providing sustained availability of
carbohydrate (e.g. a sandwich, fruit, milk, or biscuits) or the
next meal (if it is due) can prevent blood-glucose
concentration from falling again.
Proprietary products of quick-acting carbohydrate (e.g.
GlucoGel ®, Dextrogel ®, GSF-Syrup ®, Rapilose ® gel) are
available on prescription for patients to keep on hand in case
Alternatively, approximately 10 g of glucose is available
from 2 teaspoons of sugar, or from 3 sugar lumps, and also
from non-diet versions of the following soft drinks: 110 mL
of Lucozade ® Energy Original (also, see note below), 100 mL
of Coca-Cola ®, 19 mL of Ribena ® Blackcurrant (to be diluted).
Note: the carbohydrate content of some commercially
available glucose-containing drinks is currently subject
to change—individual product labels should be checked .
Patients should be aware that for a time, both old and new
bottles and cans may be available—individual product labels
Hypoglycaemia which causes unconsciousness is an
emergency. Glucagon below, a polypeptide hormone
produced by the alpha cells of the islets of Langerhans,
increases plasma-glucose concentration by mobilising
glycogen stored in the liver. In hypoglycaemia, if sugar
cannot be given by mouth, glucagon can be given by
injection. Carbohydrates should be given as soon as possible
to restore liver glycogen; glucagon is not appropriate for
chronic hypoglycaemia. Glucagon may be issued to close
relatives of insulin-treated patients for emergency use in
hypoglycaemic attacks. It is often advisable to prescribe on
an ‘if necessary’ basis to hospitalised insulin-treated
patients, so that it may be given rapidly by the nurses during
an hypoglycaemic emergency. If not effective in 10 minutes
intravenous glucose should be given.
Alternatively, glucose intravenous infusion 20% may be
given intravenously into a large vein through a large-gauge
needle; care is required since this concentration is irritant
especially if extravasation occurs. Glucose intravenous
infusion 10% may also be used but larger volumes are
needed. Glucose intravenous infusion 50% is not
recommended because of the higher risk of extravasation
injury and because administration is difficult. Close
monitoring is necessary in the case of an overdose with a
long-acting insulin because further administration of
glucose may be required. Patients whose hypoglycaemia is
caused by an oral antidiabetic drug should be transferred to
hospital because the hypoglycaemic effects of these drugs
See also, emergency management of hypoglycaemia in
dental practice for further advice.
Diazoxide p. 725, administered by mouth, is useful in the
management of patients with chronic hypoglycaemia from
excess endogenous insulin secretion, either from an islet cell
tumour or islet cell hyperplasia. It has no place in the
management of acute hypoglycaemia.
▶ BY SUBCUTANEOUS INJECTION, OR BY INTRAMUSCULAR
▶ Child 1 month–1 year: 500 micrograms
▶ Child 2–17 years (body-weight up to 25 kg):
500 micrograms, if no response within 10 minutes
intravenous glucose must be given
▶ Child 2–17 years (body-weight 25 kg and above): 1 mg, if no
response within 10 minutes intravenous glucose must
▶ Adult: 1 mg, if no response within 10 minutes
intravenous glucose must be given
Beta-blocker poisoning (cardiogenic shock unresponsive
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Child: 50–150 micrograms/kg (max. per dose 10 mg), to
be administered in glucose 5% (with precautions to
protect the airway in case of vomiting), followed by (by
intravenous infusion) 50 micrograms/kg/hour
▶ Adult: 2–10 mg, to be administered in glucose 5% (with
precautions to protect the airway in case of vomiting),
followed by (by intravenous infusion)
▶ BY INTRAVENOUS INJECTION, OR BY INTRAMUSCULAR
▶ Adult: (consult product literature)
DOSE EQUIVALENCE AND CONVERSION
▶ 1 unit of glucagon = 1 mg of glucagon.
l UNLICENSED USE Dose and indication for cardiogenic
shock unresponsive to atropine in beta-blocker overdose
l CONTRA-INDICATIONS Phaeochromocytoma
l CAUTIONS Glucagonoma . ineffective in chronic
hypoglycaemia, starvation, and adrenal insufficiency . insulinoma
l INTERACTIONS → Appendix 1: glucagon
▶ Common or very common Nausea
▶ Rare or very rare Abdominal pain . hypertension . hypotension .tachycardia
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children When administered by
continuous intravenous infusion, do not add to infusion
fluids containing calcium—precipitation may occur.
Medicines for Children leaflet: Glucagon for hypoglycaemia
www.medicinesforchildren.org.uk/glucagon-hypoglycaemia
724 Diabetes mellitus and hypoglycaemia BNF 78
l EXCEPTIONS TO LEGAL CATEGORY Prescription-only
medicine restriction does not apply where administration
is for saving life in emergency.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder and solvent for solution for injection
▶ GlucaGen Hypokit (Novo Nordisk Ltd)
Glucagon hydrochloride 1 mg GlucaGen Hypokit 1mg powder and
solvent for solution for injection | 1 vial P £11.52 DT = £11.52
Chronic intractable hypoglycaemia
▶ Adult: Initially 5 mg/kg daily in 2–3 divided doses,
adjusted according to response; maintenance
3–8 mg/kg daily in 2–3 divided doses
l INTERACTIONS → Appendix 1: diazoxide
l SIDE-EFFECTS Abdominal pain . albuminuria . appetite
decreased (long term use). arrhythmia . azotaemia . cardiomegaly . cataract. constipation . diabetic
retention . galactorrhoea . haemorrhage . headache . heart
failure . hirsutism . hyperglycaemia . hyperuricaemia (long
hypertension . skin reactions . sodium retention .taste
altered .thrombocytopenia .tinnitus . vision disorders . voice alteration (long term use). vomiting
l PREGNANCY Use only if essential; alopecia and
hypertrichosis reported in neonates with prolonged use;
may inhibit uterine activity during labour.
l BREAST FEEDING Manufacturer advises avoid—no
Dose adjustments Dose reduction may be required.
▶ Monitor white cell and platelet count during prolonged
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
▶ Eudemine (RPH Pharmaceuticals AB)
Diazoxide 50 mg Eudemine 50mg tablets | 100 tablet P £46.45
▶ Proglycem (Imported (Germany))
Diazoxide 25 mg Proglycem 25 capsules | 100 capsule P s
Osteoporosis is a progressive bone disease characterised by
low bone mass measured by bone mineral density (BMD),
and microarchitectural deterioration of bone tissue. This
leads to an increased risk of fragility fractures as a result.
Osteoporosis is considered severe if there have been one or
Osteoporosis occurs most commonly in postmenopausal
women, men over 50 years, and in patients taking long-term
oral corticosteroids (glucocorticoids). Risk factors for
osteoporosis include age, low body mass index (BMI),
cigarette smoking, excess alcohol intake, lack of physical
activity, vitamin D deficiency and low calcium intake, family
history of hip fractures, a previous fracture at a site
characteristic of osteoporotic fractures and early
menopause. Some diseases are also known to be associated
with osteoporosis such as rheumatoid arthritis and diabetes.
A combination of lifestyle changes and drug treatment aims
to prevent bone fractures in patients with osteoporosis.
g Patients should be encouraged to increase their level of
physical activity, stop smoking, maintain a normal BMI level
), and reduce their alcohol intake to
improve their bone health and reduce the risk of fragility
fractures. hFor guidance on stopping smoking, see
g Patients at risk of osteoporosis should also ensure an
adequate intake of calcium and vitamin D, preferably
through increasing dietary intake.
Elderly patients, especially those who are housebound or
live in residential or nursing homes, are at increased risk of
calcium and vitamin D deficiency and can benefit from
supplements. hElderly patients also have an increased risk
of falls (see Prescribing in the elderly p. 30).
The therapeutic options for the prevention and treatment of
osteoporosis in postmenopausal women are the same.
g Oral bisphosphonates, alendronic acid p. 727 and
risedronate sodium p. 730 are considered as first-line choices
for most patients with postmenopausal osteoporosis due to
their broad spectrum of anti-fracture efficacy. Alendronic
acid and risedronate sodium have been shown to reduce
occurrence of vertebral, non-vertebral and hip fractures.
Intravenous bisphosphonates (ibandronic acid p. 728 or
zoledronic acid p. 732), denosumab p. 734, or raloxifene
hydrochloride p. 754 are alternative options in women who
are intolerant of oral bisphosphonates or in whom they are
Hormone replacement therapy (HRT) is an additional
option. The use of HRT for osteoporosis is generally
restricted to younger postmenopausal women with
menopausal symptoms who are at high risk of fractures. This
is due to the risk of adverse effects such as cardiovascular
disease and cancer in older postmenopausal women and
women on long-term HRT therapy.
Teriparatide p. 734 is reserved for postmenopausal women
with severe osteoporosis at very high risk for vertebral
fractures. Its duration of treatment is limited to 24 months.
BNF 78 Disorders of bone metabolism 725
Glucocorticoid-induced osteoporosis
Glucocorticoid therapy is associated with bone loss and
increased risk of fractures. The greatest rate of bone loss
occurs early after initiation of glucocorticoids and increases
with dose and duration of therapy.g Bone-protection
treatment should be started at the onset of therapy in
patients who are at a high risk of fracture.
If glucocorticoid therapy is stopped, the need to continue
bone-protection treatment should be reviewed. However,
bone-protection treatment should be continued with longterm glucocorticoid therapy. Complex cases of
glucocorticoid-induced osteoporosis should be referred to a
Women aged 70 years or over, or with a previous fragility
fracture, or taking large doses of glucocorticoids
(prednisolone 7.5 mg daily or equivalent) are at high risk of
previous history of fracture or receiving high doses of
glucocorticoids can also be considered for bone-protection
The therapeutic options for prophylaxis and treatment of
glucocorticoid-induced osteoporosis are the same; oral
bisphosphonates, alendronic acid, or risedronate sodium are
first-line options. Intravenous zoledronic acid or teriparatide
are alternatives in patients intolerant of oral
bisphosphonates or in whom they are contra-indicated. h
g Oral bisphosphonates, alendronic acid or risedronate
sodium are recommended as first-line treatments for
osteoporosis in men. Intravenous zoledronic acid or
denosumab are alternatives in men who are intolerant of
oral bisphosphonates or in whom they are contra-indicated;
teriparatide is an additional option. h
Men having long-term androgen deprivation therapy for
prostate cancer have an increased fracture risk.g
Fracture risk should be assessed when starting this therapy.
A bisphosphonate can be offered to men with confirmed
osteoporosis; denosumab is an alternative if
bisphosphonates are contra-indicated or not tolerated. h
Bisphosphonates: treatment duration
g There is some evidence to suggest that patients can
benefit from a bisphosphonate-free period as their
therapeutic effects last for some time after cessation of
Bisphosphonate treatment should be reviewed after
5 years of treatment with alendronic acid, risedronate
sodium or ibandronic acid, and after 3 years of treatment
with zoledronic acid. Patients over 75 years of age, or with a
history of previous hip or vertebral fracture, or patients who
have had one or more fragility fractures during treatment, or
who are taking long-term glucocorticoid therapy can
continue bisphosphonates beyond this period. h
Compston, J. et al. The National Osteoporosis Guideline
Group (NOGG). (2017) UK clinical guidelines for the
prevention and treatment of osteoporosis. Arch Osteoporos
doi.org/10.1007/s11657-017-0324-5
Other drugs used for Disorders of bone metabolism
Osteoporosis in postmenopausal women (but not
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult (female): 50 mg every 3 weeks.
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l INTERACTIONS → Appendix 1: nandrolone
l SIDE-EFFECTS Clitoris enlarged . dysphonia . hepatic
retention . urine flow decreased . virilism (with high doses
including voice changes - sometimes irreversible)
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (discontinue treatment if hepatic
function worsens or if oedema, with or without congestive
l RENAL IMPAIRMENT Use with caution—may cause sodium
l LESS SUITABLE FOR PRESCRIBING Nandrolone injection is
less suitable for prescribing.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Arachis (peanut) oil, benzyl alcohol
▶ Deca-Durabolin (Aspen Pharma Trading Ltd)
Nandrolone decanoate 50 mg per 1 ml Deca-Durabolin 50mg/1ml
solution for injection ampoules | 1 ampoule P £3.17e
l DRUG ACTION Bisphosphonates are adsorbed onto
hydroxyapatite crystals in bone, slowing both their rate of
growth and dissolution, and therefore reducing the rate of
MHRA/CHM ADVICE: BISPHOSPHONATES: ATYPICAL FEMORAL
Atypical femoral fractures have been reported rarely
with bisphosphonate treatment, mainly in patients
receiving long-term treatment for osteoporosis.
The need to continue bisphosphonate treatment for
osteoporosis should be re-evaluated periodically based
on an assessment of the benefits and risks of treatment
for individual patients, particularly after 5 or more years
Patients should be advised to report any thigh, hip, or
groin pain during treatment with a bisphosphonate.
Discontinuation of bisphosphonate treatment in
patients suspected to have an atypical femoral fracture
should be considered after an assessment of the benefits
and risks of continued treatment.
MHRA/CHM ADVICE: BISPHOSPHONATES: OSTEONECROSIS OF THE
JAW (NOVEMBER 2009) AND INTRAVENOUS BISPHOSPHONATES:
OSTEONECROSIS OF THE JAW—FURTHER MEASURES TO MINIMISE
The risk of osteonecrosis of the jaw is substantially
greater for patients receiving intravenous
bisphosphonates in the treatment of cancer than for
patients receiving oral bisphosphonates for osteoporosis
726 Disorders of bone metabolism BNF 78
Risk factors for developing osteonecrosis of the jaw
that should be considered are: potency of
bisphosphonate (highest for zoledronate), route of
administration, cumulative dose, duration and type of
malignant disease, concomitant treatment, smoking,
comorbid conditions, and history of dental disease.
All patients should have a dental check-up (and any
necessary remedial work should be performed) before
bisphosphonate treatment, or as soon as possible after
starting treatment. Patients should also maintain good
oral hygiene, receive routine dental check-ups, and
report any oral symptoms such as dental mobility, pain,
or swelling, non-healing sores or discharge to a doctor
Before prescribing an intravenous bisphosphonate,
patients should be given a patient reminder card and
informed of the risk of osteonecrosis of the jaw. Advise
patients to tell their doctor if they have any problems
with their mouth or teeth before starting treatment, and
if the patient wears dentures, they should make sure
their dentures fit properly. Patients should tell their
doctor and dentist that they are receiving an intravenous
bisphosphonate if they need dental treatment or dental
Guidance for dentists in primary care is included in
Oral Health Management of Patients Prescribed
Bisphosphonates: Dental Clinical Guidance, Scottish
Dental Clinical Effectiveness Programme, April 2011
(available at www.sdcep.org.uk).
MHRA/CHM ADVICE: BISPHOSPHONATES: OSTEONECROSIS OF THE
EXTERNAL AUDITORY CANAL (DECEMBER 2015)
Benign idiopathic osteonecrosis of the external auditory
canal has been reported very rarely with bisphosphonate
treatment, mainly in patients receiving long-term
The possibility of osteonecrosis of the external
auditory canal should be considered in patients receiving
bisphosphonates who present with ear symptoms,
including chronic ear infections, or suspected
Risk factors for developing osteonecrosis of the
external auditory canal include: steroid use,
chemotherapy, infection, an ear operation, or cottonbud use.
Patients should be advised to report any ear pain,
discharge from the ear, or an ear infection during
treatment with a bisphosphonate.
illness . malaise . myalgia . nausea . oesophageal ulcer
▶ Rare or very rare Atypical femur fracture . StevensJohnson syndrome
Atypical femoral fractures Patients should be advised to
report any thigh, hip, or groin pain during treatment with
Osteonecrosis of the jaw During bisphosphonate treatment
patients should maintain good oral hygiene, receive
routine dental check-ups, and report any oral symptoms.
Osteonecrosis of the external auditory canal Patients should be
advised to report any ear pain, discharge from ear or an ear
infection during treatment with a bisphosphonate.
Treatment of postmenopausal osteoporosis
▶ Adult (female): 10 mg daily, alternatively 70 mg once
Treatment of osteoporosis in men
Prevention and treatment of corticosteroid-induced
osteoporosis in postmenopausal women not receiving
▶ Adult (female): 10 mg daily.
l CAUTIONS Active gastro-intestinal bleeding . atypical
femoral fractures . duodenitis . dysphagia . exclude other
causes of osteoporosis . gastritis . history (within 1 year) of
l INTERACTIONS → Appendix 1: bisphosphonates
▶ Common or very common Gastrointestinal disorders . joint
▶ Rare or very rare Femoral stress fracture . oropharyngeal
ulceration . photosensitivity reaction . severe cutaneous
SIDE-EFFECTS, FURTHER INFORMATION Severe oesophageal
reactions (oesophagitis, oesophageal ulcers, oesophageal
stricture and oesophageal erosions) have been reported;
patients should be advised to stop taking the tablets and to
seek medical attention if they develop symptoms of
oesophageal irritation such as dysphagia, new or
worsening heartburn, pain on swallowing or retrosternal
l BREAST FEEDING Manufacturer advises avoid—no
l RENAL IMPAIRMENT Avoid if eGFR less than
l MONITORING REQUIREMENTS Correct disturbances of
calcium and mineral metabolism (e.g. vitamin-D
deficiency, hypocalcaemia) before starting treatment.
Monitor serum-calcium concentration during treatment.
l DIRECTIONS FOR ADMINISTRATION Tablets should be
swallowed whole and oral solution should be swallowed as
a single 100 mL dose. Doses should be taken with plenty of
water while sitting or standing, on an empty stomach at
least 30 minutes before breakfast (or another oral
medicine); patient should stand or sit upright for at least
30 minutes after administration.
l PATIENT AND CARER ADVICE Patients or their carers should
be given advice on how to administer alendronic acid
Oesophageal reactions Patients (or their carers) should be
advised to stop taking alendronic acid and to seek medical
attention if they develop symptoms of oesophageal
irritation such as dysphagia, new or worsening heartburn,
pain on swallowing or retrosternal pain.
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