Vistabel , powder for reconstitution, botulinum toxin- c is licensed for the temporary improvement of Injection

4 Vistabel , powder for reconstitution, botulinum toxin- c is licensed for the temporary improvement of Injection

haemagglutinin complex type A , net price 500-unit moderate to severe wrinkles between the eyebrows.

vial = £164.50

Xeomin c is licensed for the treatment of blepharospasm Vistabel and spasmodic torticollis. c (Allergan) A Injection , powder for reconstitution, botulinum toxin type A, net price 50-unit vial = £85.00

Xeomin c (Merz) TA Indications see notes above; preparations are not

BOTULINUM TOXIN TYPE A

Injection , powder for reconstitution, botulinum toxin interchangeable and should be used under specialist

type A, net price 100-unit vial = £119.90 supervision Cautions history of dysphagia or aspiration; neurolo- gical disorders (can lead to increased sensitivity and

BOTULINUM TOXIN TYPE B

exaggerated muscle weakness); pregnancy (Appendix Indications spasmodic torticollis (cervical dystonia)— 4); breast-feeding (Appendix 5)

specialist use only Specific cautions for blepharospasm or hemifacial

Cautions history of dysphagia or aspiration; inadver- spasm Caution if risk of angle-closure glaucoma; reduced blinking can lead to corneal exposure, persistent epithelial

tent injection into a blood vessel; tolerance may occur defect and corneal ulceration (especially in those with VIIth

Contra-indications neuromuscular or neuromuscular nerve disorders)—careful testing of corneal sensation in

junctional disorders; pregnancy (Appendix 4) and previously operated eyes, avoidance of injection in lower lid

breast-feeding (Appendix 5) area to avoid ectropion, and vigorous treatment of epithelial defect needed

Side-effects increased electrophysiologic jitter in Contra-indications generalised disorders of muscle

some distant muscles; dry mouth, dyspepsia, wor- activity (e.g. myasthenia gravis)

sening torticollis, neck pain, myasthenia, voice Side-effects increased electrophysiologic jitter in

changes, taste disturbances; very rarely exaggerated some distant muscles; misplaced injections may

muscle weakness, dysphagia, and aspiration (seek paralyse nearby muscle groups and excessive doses

medical attention if swallowing, speech, or respiratory may paralyse distant muscles; influenza-like symp-

disorders)

toms; rarely arrhythmias, myocardial infarction, sei-

Dose

zures, hypersensitivity reactions including rash, pru- . By intramuscular injection , initially 5000– ritus and anaphylaxis, antibody formation (substantial

10 000 units divided between 2–4 most affected deterioration in response), and injection-site reac-

muscles; adjust dose and frequency according to tions; very rarely exaggerated muscle weakness, dys-

response; important: not interchangeable with phagia, and aspiration (seek medical attention if

other botulinum toxin preparations swallowing, speech, or respiratory disorders)

NeuroBloc Specific side-effects for blepharospasm or hemifacial c (Eisai) A spasm Ptosis; keratitis, lagophthalmos, dry eye, irritation,

Injection , botulinum toxin type B 5000 units/mL, net photophobia, lacrimation; facial oedema; less commonly dry

price 0.5-mL vial = £111.20; 1-mL vial = £148.27; 2- mouth, facial weakness (including drooping), dizziness,

mL vial = £197.69 tiredness, ectropion, entropion, diplopia, visual disturbances,

Note May be diluted with sodium chloride 0.9%

BNF 57

4.10 Drugs used in substance dependence 275

4.10 Drugs used in substance

ACAMPROSATE CALCIUM

dependence Indications maintenance of abstinence in alcohol

dependence Cautions continued alcohol abuse (risk of treatment

This section includes drugs used in alcohol dependence,

failure)

cigarette smoking, and opioid dependence. Contra-indications severe hepatic impairment; renal The health departments of the UK have produced a

impairment (avoid if serum creatinine greater than report, Drug Misuse and Dependence which contains

120 micromol/litre; Appendix 3); pregnancy; breast- guidelines on clinical management.

feeding

Drug Misuse and Dependence , London, The Stationery Side-effects diarrhoea, nausea, vomiting, abdominal Office, 1999 can be obtained from:

pain; fluctuation in libido; pruritus, maculopapular The Publications Centre

rash; rarely bullous skin reactions PO Box 276

Dose

London, SW8 5DT . ADULT 18–65 years, body-weight 60 kg and over, Tel: (087) 0600 52

666 mg 3 times daily; body-weight less than 60 kg, Fax: (087) 0600 53

666 mg at breakfast, 333 mg at midday and 333 mg at or from The Stationery Office bookshops and through all

night Treatment course

good booksellers. Treatment should be initiated as soon as possible after alcohol withdrawal period and maintained if

It is important to be aware that people who misuse drugs patient relapses; recommended treatment period 1 year may be at risk not only from the intrinsic toxicity of the

drug itself but also from the practice of injecting pre- Campral EC c (Merck) A parations intended for administration by mouth. Exci-

Tablet , e/c, acamprosate calcium 333 mg, net price pients used in the production of oral dose forms are

168-tab pack = £28.92. Label: 21, 25 usually insoluble and may lead to abscess formation at the

Electrolytes Ca 0.8 mmol/tablet

site of injection , or even to necrosis and gangrene; more- over, deposits in the heart or lungs may lead to severe cardiac or pulmonary toxicity . Additional hazards include infection following the use of a dirty needle or an

unsterilised diluent.

DISULFIRAM

entral C

Indications adjunct in the treatment of chronic

alcohol dependence (under specialist supervision)

Alcohol dependence

Cautions ensure that alcohol not consumed for at least

nervous

24 hours before initiating treatment; see also notes alcohol dependence. It gives rise to extremely unplea-

Disulfiram is used as an adjunct to the treatment of

above; alcohol challenge not recommended on rou- sant systemic reactions after the ingestion of even a

tine basis (if considered essential—specialist units small amount of alcohol because it leads to accumula-

only with resuscitation facilities); hepatic or renal

syst

tion of acetaldehyde in the body. Reactions include impairment, respiratory disease, diabetes mellitus, flushing of the face, throbbing headache, palpitation,

epilepsy; interactions: Appendix 1 (disulfiram)

em

tachycardia, nausea, vomiting, and, with large doses of Alcohol reaction Patients should be warned of unpredict- alcohol, arrhythmias, hypotension, and collapse. Small

able and occasionally severe nature of disulfiram-alcohol interactions. Reactions can occur within 10 minutes and last

amounts of alcohol included in many oral medicines several hours (may require intensive supportive therapy— may be sufficient to precipitate a reaction (even toile-

oxygen should be available). Patients should not ingest tries and mouthwashes that contain alcohol should be

alcohol at all and should be warned of possible presence of avoided). It may be advisable for patients to carry a card

alcohol in liquid medicines, remedies, tonics, foods and even in toiletries (alcohol should also be avoided for at least 1

warning of the danger of administration of alcohol.

week after stopping)

Long-acting benzodiazepines (section 4.1) are used to Contra-indications cardiac failure, coronary artery attenuate withdrawal symptoms but they also have a

disease, history of cerebrovascular accident, hyper- dependence potential. To minimise the risk of depend-

tension, psychosis, severe personality disorder, sui- ence, administration should be for a limited period only

cide risk, pregnancy (Appendix 4), breast-feeding (e.g. chlordiazepoxide 10–50 mg 4 times daily, gradu-

(Appendix 5)

ally reducing over 7–14 days). Benzodiazepines should Side-effects initially drowsiness and fatigue; nausea, not be prescribed if the patient is likely to continue

vomiting, halitosis, reduced libido; rarely psychotic drinking alcohol.

reactions (depression, paranoia, schizophrenia, Clomethiazole (chlormethiazole) (section 4.1.1) should

mania), allergic dermatitis, peripheral neuritis, hepatic

be used for the management of withdrawal in an in-

cell damage

patient setting only. It is associated with a risk of