Diabetic neuropathy

6 Diabetic neuropathy

Endocrine Chronic hypoglycaemia

Optimal diabetic control is beneficial for the manage- ment of painful neuropathy in patients with type 1 dia-

Diazoxide, administered by mouth, is useful in the betes (see also section 4.7.3). Paracetamol or a non- management of patients with chronic hypoglycaemia

steroidal anti-inflammatory drug such as ibuprofen from excess endogenous insulin secretion, either from

(section 10.1.1) may relieve mild to moderate pain.

syst

an islet cell tumour or islet cell hyperplasia. It has no place in the management of acute hypoglycaemia.

The tricyclic antidepressants amitriptyline and nor-

em

triptyline (section 4.3.1) are the drugs of choice for painful diabetic neuropathy [unlicensed use]; amitripty- line is given in a dose of 25–75 mg daily (higher doses under specialist supervision). Other classes of anti- depressants do not appear to be effective. Gabapentin

(section 4.8.1) is licensed for the treatment of neuro- Indications chronic intractable hypoglycaemia (for

DIAZOXIDE

pathic pain and is an effective alternative to a tricyclic use in hypertensive crisis see section 2.5.1)

antidepressant.

Cautions ischaemic heart disease, pregnancy (Appen- Duloxetine (section 4.3.4) is licensed for the treatment dix 4), labour, impaired renal function (Appendix 3);

of diabetic neuropathic pain. monitor blood pressure; during prolonged use moni-

Carbamazepine and phenytoin [both unlicensed] (sec- tor white cell and platelet count, and in children,

tion 4.8.1) may be useful for shooting or stabbing pain, regularly assess growth, bone, and psychological

but adverse effects are common; carbamazepine 200– development; interactions: Appendix 1 (diazoxide)

800 mg daily in divided doses has been used. Side-effects anorexia, nausea, vomiting, hyperuric-

Capsaicin cream 0.075% (section 10.3.2) is licensed for aemia, hypotension, oedema, tachycardia, arrhyth-

painful diabetic neuropathy and may have some effect, mias, extrapyramidal effects; hypertrichosis on pro-

but it produces an intense burning sensation during the longed treatment

initial treatment period. Dose

Neuropathic pain may respond partially to some opioid . By mouth , ADULT and CHILD , initially 5 mg/kg daily in

analgesics, such as methadone, oxycodone and trama- 2–3 divided doses

dol, and they may have a role when other treatments have failed. Eudemine c (UCB Pharma) A In autonomic neuropathy diabetic diarrhoea can often be

Tablets , diazoxide 50 mg. Net price 20 = £9.29 managed by 2 or 3 doses of tetracycline 250 mg [unli- Injection , see section 2.5.1

censed use] (section 5.1.3). Otherwise codeine phos-

BNF 57 phate (section 1.4.2) is the best drug, but other anti-

6.1.6 Diagnostic and monitoring agents for diabetes mellitus

used for self-monitoring of blood glucose. In other European diarrhoeal preparations can be tried. An antiemetic

countries units of mg/100 mL (or mg/dL) are commonly used. which promotes gastric transit, such as metoclopramide

It is advisable to check that the meter is pre-set in the correct or domperidone (section 4.6), is helpful for gastropar-

units.

esis. In rare cases when an antiemetic does not help, If the patient is unwell and diabetic ketoacidosis is erythromycin (especially when given intravenously)

suspected, blood ketones should be measured accord- may be beneficial but this needs confirmation.

ing to local guidelines (section 6.1.3). Patients and their For the management of erectile dysfunction, see section

carers should be trained in the use of blood ketone

7.4.5. monitoring systems and to take appropriate action on the results obtained, including when to seek medical In neuropathic postural hypotension increased salt intake

attention.

and the use of the mineralocorticoid fludrocortisone 100–400 micrograms daily [unlicensed use] (section

Test strips

6.3.1) help by increasing plasma volume, but uncomfor- Active (Roche Diagnostics) table oedema is a common side-effect. Fludrocortisone

Reagent strips , for blood glucose monitoring, range 0.6– can also be combined with flurbiprofen (section 10.1.1)

33.3 mmol/litre, for use with Glucotrend and Accu-Chek and ephedrine hydrochloride (section 3.1.1.2) [both

D meters only. Net price 50-strip pack = £14.76 unlicensed]. Midodrine [unlicensed], an alpha agonist,

Active

Advantage Plus (Roche Diagnostics) may also be useful in postural hypotension.

Sensor strips , for blood glucose monitoring, range 0.6– 33.3 mmol/litre, for use with Accu-Chek Advantage D Gustatory sweating can be treated with an anti-

meter only. Net price 50-strip pack = £14.76 muscarinic such as propantheline bromide (section

Ascensia Autodisc (Bayer Diabetes Care) 1.2); side-effects are common. For the management of

Sensor discs , for blood glucose monitoring, range 0.6– hyperhidrosis, see section 13.12.

33.3 mmol/litre, for use with Ascensia Breeze D and

Ascensia Esprit

In some patients with neuropathic oedema, ephedrine

pack = £14.62

hydrochloride [unlicensed use] 30–60 mg 3 times daily Aviva tem (Roche Diagnostics) offers effective relief.

Sensor strips , for blood glucose monitoring, range 0.6–

sys

33.3 mmol/litre, for use with Accu-Chek Aviva D meter only. Net price 50-strip pack = £14.49

BM-Accutest (Roche Diagnostics)

ocrine

Reagent strips , for blood glucose monitoring, range 1.1– 33.3 mmol/litre, for use with Accutrend

D meters only.

End

Net price 50-strip pack = £14.31

6 6.1.6 Diagnostic and

Breeze 2 (Bayer Diabetes Care)

Sensor discs monitoring agents for , for blood glucose monitoring, range 0.6–

33.3 mmol/litre, for use with the Breeze 2 D meter only.

diabetes mellitus

Compact (Roche Diagnostics) Reagent strips , for blood glucose monitoring, range 0.6– 33.3 mmol/litre, for use with Accu-Chek Compact and Accu- Chek Compact Plus

Blood monitoring

pack = £14.88

Blood glucose monitoring using a meter gives a direct Contour (Bayer Diabetes Care) measure of the glucose concentration at the time of the

Sensor strips , for blood glucose monitoring, range 0.6– 33.3 mmol/litre, for use with Contour

D meter only. Net test and can detect hypoglycaemia as well as hyperglyc-

price 50-strip pack = £14.74 aemia. Patients should be properly trained in the use of

Note Formerly Ascensia Microfill blood glucose monitoring systems and to take appro-

(Abbott) priate action on the results obtained. Inadequate under-

FreeStyle

Sensor strips , for blood glucose monitoring, range 1.1– standing of the normal fluctuations in blood glucose can

27.8 mmol/litre, for use with FreeStyle D meters only. Net lead to confusion and inappropriate action.

price 50-strip pack = £14.62 For patients treated with insulin, it is ideal to observe

Freestyle Lite (Abbott) the ‘peaks’ and ‘troughs’ of blood glucose over 24 hours

Sensor strips , for blood glucose monitoring, range 1.1– and make adjustments to their insulin no more than

27.8 micromol/litre, for use with Freestyle Lite D meter only. Net price 50-strip pack = £14.62 once or twice weekly. Daily alterations to the insulin

dose are highly undesirable (except during illness). GlucoMen (Menarini Diagnostics) Sensor strips , for blood glucose monitoring, range 1.1– Self-monitoring of blood-glucose concentration is

33.3 mmol/litre, for use with GlucoMen Glyco´ D and appropriate for patients with type 2 diabetes:

GlucoMen

PC

D meters only. Net price 50-strip pack =

. who are treated with insulin; who are treated with oral hypoglycaemic drugs e.g.

GlucoMen LX (Menarini Diagnostics) .

Sensor strips , for blood glucose monitoring, range 1.1– sulphonylureas, to provide information on hypo-

33.3 mmol/litre, for use with GlucoMen LX D meter only. glycaemia;

Net price 50-strip pack = £14.33 .

to monitor changes in blood-glucose concentration GlucoMen Visio Sensor (Menarini Diagnostics) resulting from changes in lifestyle or medication,

Sensor strips , for blood glucose monitoring, range 1.1– and during intercurrent illness;

33.3 mmol/litre, for use with GlucoMen Visio D meter. Net price 50-strip pack = £14.53

. to ensure safe blood-glucose concentration during activities, including driving.

Hypoguard Supreme (Hypoguard) Reagent strips , for blood glucose monitoring, range 2.2– Note In the UK blood-glucose concentration is expressed in

27.7 mmol/litre, for use with Hypoguard Supreme D mmol/litre and Diabetes UK advises that these units should be

meters. Net price 50-strip pack = £12.00

BNF 57

6.1.6 Diagnostic and monitoring agents for diabetes mellitus 385

MediSense G2 (Abbott) Hypoguard Supreme (Hypoguard) D Sensor strips , for blood glucose monitoring, range 1.1–

Meters , for blood glucose monitoring (for use with 33.3 mmol/litre, for use with MediSense Precision QID D Hypoguard Supreme test strips). Hypoguard Supreme Plus

meter only. Net price 50-strip pack = £13.67 meter = £35.00; Hypoguard Supreme Extra meter = £45.00 MediSense Soft-Sense Plus (Abbott)

Sensor strips , for blood glucose monitoring, range 1.7– One Touch Ultra 2 (LifeScan)

Meter , for blood glucose monitoring (for use with One Touch 25 mmol/litre, for use with Optium Xceed meter only. Net price 50-strip pack = £14.52

Ultra sensor strips) = £12.99 One Touch (LifeScan)

One Touch UltraEasy (LifeScan) Reagent strips , for blood glucose monitoring, range 1.1–

Meter , for blood glucose monitoring (for use with One Touch 33.3 mmol/litre, for use with One Touch II, Profile and Basic

Ultra sensor strips) = £12.99 D meters only. Net price 50-strip pack = £14.37

One Touch UltraSmart (LifeScan) One Touch Ultra (LifeScan)

Meter , for blood glucose monitoring (for use with One Touch Sensor strips , for blood glucose monitoring, range 1.1–

Ultra sensor strips) = £19.99 33.3 mmol/litre, for use with One Touch Ultra , One Touch

Ultra 2 D, One Touch UltraSmart D, and One Touch One Touch Vita (LifeScan) UltraEasy

D meters only. Net price 50-strip pack = £14.53 Meter , for blood glucose monitoring (for use with One Touch

Vita sensor strips) = £16.99 One Touch Vita (LifeScan)

Sensor strips , for blood glucose monitoring, range 1.1- Optium Xceed (Abbott) D 33.3 mmol/litre for use with One Touch Vita

Meter , for blood glucose monitoring (for use with Med- Net price 50-strip pack = £14.53

D meter only.

iSense Soft-Sense , and Optium Plus test strips) and for blood ketone monitoring (for use with Optium b-ketone test

Optium b-ketone test strips (Abbott) strips). Net price starter pack = £9.00 Reagent Strips , for blood ketone monitoring, range 0– 8.0 mmol/litre, for use with Optium

Prestige (Home Diagnostics) D Xceed

D meters only. Net price 10-strip pack = £19.55 Meter , for blood glucose monitoring (for use with Prestige test strips) = £5.63

D or Optium

Optium Plus (Abbott) Sensor strips (formerly Medisense Optium Plus), for blood

TRUETrack (Home Diagnostics) D glucose monitoring, range 1.1–33.3 mmol/litre, for use with

Meter , for blood glucose monitoring (for use with Optium Xceed

D meter only. Net price 50-strip pack = PocketScan (LifeScan)

test strips) = £5.63 £14.53

TrueTrack

Sensor strips , for blood glucose monitoring, range 1.1–33.3 mmol/litre, for use with PocketScan

D meter only. Net

price 50-strip pack = £14.19

Urinalysis

Prestige (Home Diagnostics) Tests for glucose range from reagent strips specific to

Reagent strips , for blood glucose monitoring, range 1.4– glucose to reagent tablets which detect all reducing 33.3 mmol/litre, for use with Prestige

D meter only. Net

sugars. Few patients still use Clinitest c ; Clinistix c is

Endocrine

price 50-strip pack = £14.51 suitable for screening purposes only. Tests for ketones TRUEone (Home Diagnostics)

by patients are rarely required unless they become Sensor strips with meter , for blood glucose monitoring,

unwell—see section 6.1.6. range 1.1-33.3 mmol/litre. Meter built into top of sensor strip pot. Net price 50-strip and meter pack = £14.25

Microalbuminuria can be detected with Micral-Test

syst

II TRUETrack c (Home Diagnostics)

D or Microbumintest c D but this should be followed by confirmation in the laboratory, since false

em

Sensor strips , for blood glucose monitoring, range 1.1– 33.3 mmol/litre, for use with TrueTrack

positive results are common. price 50-strip pack = £14.25

D meter only. Net

Glucose

Meters Clinistix (Bayer Diabetes Care) Accu-Chek Aviva (Roche Diagnostics)

Reagent strips , for detection of glucose in urine. Net price Meter , for blood glucose monitoring (for use with Aviva test

50-strip pack = £3.25

strips). Accu-Chek Aviva system = £12.99 Clinitest (Bayer Diabetes Care) D Accu-Chek Compact Plus (Roche Diagnostics) Meter D Reagent tablets , for detection of glucose and other reducing , for blood glucose monitoring (for use with Compact

substances in urine. Net price 36-tab pack = £2.00 test strips). Accu-Chek Compact Plus system = £12.99

Diabur-Test 5000 (Roche Diagnostics) Breeze 2 (Bayer Diabetes Care) D Reagent strips , for detection of glucose in urine. Net price Meter , for blood glucose monitoring (for use with Breeze 2

50-strip pack = £2.79

Sensor discs) = £10.29 Diastix (Bayer Diabetes Care) Contour (Bayer Diabetes Care) Meter

D Reagent strips , for detection of glucose in urine. Net price , for blood glucose monitoring (for use with Ascensia

50-strip pack = £2.76

Microfill sensor strips) = £10.29 Freestyle (Abbott)

D (BHR) Medi-Test Glucose

Meters , for blood glucose monitoring (for use with Freestyle Reagent strips , for detection of glucose in urine. Net price and Freestyle Lite test strips). Freestyle Lite meter = £7.79;

50-strip pack = £2.30

Freestyle Freedom Lite meter = £5.99

Ketones

GlucoMen LX (Menarini Diagnostics) Ketostix (Bayer Diabetes Care) Meter , for blood glucose monitoring (for use with GlucoMen

Reagent strips , for detection of ketones in urine. Net price LX sensor strips) = £12.99

50-strip pack = £2.92 GlucoMen Visio (Menarini Diagnostics) D Ketur Test (Roche Diagnostics)

Meter , for blood glucose monitoring (for use with GlucoMen Reagent strips , for detection of ketones in urine. Net price Visio Sensor strips) = £12.99

50-strip pack = £2.68

6.2 Thyroid and antithyroid drugs BNF 57 Protein

Liothyronine sodium has a similar action to levothyr- Albustix (Bayer Diagnostics)

oxine but is more rapidly metabolised and has a more Reagent strips , for detection of protein in urine. Net price

rapid effect; 20 micrograms is equivalent to 100 micr- 50-strip pack = £4.10

ograms of levothyroxine. Its effects develop after a few Medi-Test Protein 2 (BHR)

hours and disappear within 24 to 48 hours of disconti- Reagent strips , for detection of protein in urine. Net price

nuing treatment. It may be used in severe hypothyroid 50-strip pack = £3.22

states when a rapid response is desired. Other reagent strips available for urinalysis

Liothyronine by intravenous injection is the treatment of include:

choice in hypothyroid coma. Adjunctive therapy includes Combur-3 Test

D (glucose and protein—Roche intravenous fluids, hydrocortisone, and treatment of Diagnostics), Clinitek Microalbumin

infection; assisted ventilation is often required. creatinine—Bayer Diagnostics), Ketodiastix

D (albumin and

D (glu-

cose and ketones—Bayer Diagnostics), Medi-Test Combi

2 D (glucose and protein—BHR), Micral-Test II

D (albumin—Roche Diagnostics), Microalbustix D

LEVOTHYROXINE SODIUM

(albumin and creatinine—Bayer Diagnostics), Micro- (Thyroxine sodium) bumintest

D (albumin—Bayer Diagnostics), Indications hypothyroidism; see also notes above Uristix

D (glucose and protein—Bayer Diagnostics) Cautions panhypopituitarism or predisposition to adrenal insufficiency (initiate corticosteroid therapy before starting levothyroxine), elderly, cardiovascular

Oral glucose tolerance test

disorders (including hypertension, myocardial insuf- ficiency or myocardial infarction, see Initial Dosage

The oral glucose tolerance test is now rarely needed for below), long-standing hypothyroidism, diabetes insi- the diagnosis of diabetes when symptoms of hyperglyc-

pidus, diabetes mellitus (dose of antidiabetic drugs tem aemia are present, though it is still required to establish

including insulin may need to be increased); the presence of gestational diabetes. This generally

sys pregnancy (Appendix 4); interactions: Appendix 1

involves giving anhydrous glucose 75 g (equivalent to (thyroid hormones) Glucose BP 82.5 g) by mouth to the fasting patient, and

Initial dosage Baseline ECG is valuable because changes measuring blood-glucose concentrations at intervals.

ocrine induced by hypothyroidism can be confused with ischaemia.

The appropriate amount of glucose should be given with If metabolism increases too rapidly (causing diarrhoea, ner-

End vousness, rapid pulse, insomnia, tremors and sometimes

200–300 mL fluid. Anhydrous glucose 75 g may alter- c anginal pain where there is latent myocardial ischaemia),

6 reduce dose or withhold for 1–2 days and start again at a natively be given as 113 mL Polycal (Nutricia Clinical) with extra fluid to administer a total volume of 200–

lower dose

300 mL. Contra-indications thyrotoxicosis Side-effects usually at excessive dosage (see Initial

Dosage above) include diarrhoea, vomiting, anginal pain, arrhythmias, palpitation, tachycardia, tremor, restlessness, excitability, insomnia; headache, flush- ing, sweating, fever, heat intolerance, weight-loss, muscle cramp, and muscular weakness; transient hair loss in children; hypersensitivity reactions including

6.2 rash, pruritus and oedema also reported Thyroid and antithyroid

Dose

drugs

. ADULT , initially 50–100 micrograms once daily, prefer- ably before breakfast, adjusted in steps of 25–

6.2.1 Thyroid hormones

50 micrograms every 3–4 weeks according to

6.2.2 response (usual maintenance dose 100–200 micr- Antithyroid drugs

ograms once daily); in cardiac disease, severe hypo- thyroidism, and patients over 50 years, initially

25 micrograms once daily, adjusted in steps of

25 micrograms every 4 weeks according to response;

6.2.1 usual maintenance dose 50–200 micrograms once Thyroid hormones

daily; CHILD under 12 years see BNF for Children (section 6.2.1)

Thyroid hormones are used in hypothyroidism (myx- . Congenital hypothyroidism and juvenile myxoedema, oedema), and also in diffuse non-toxic goitre, Hashimo-

see BNF for Children (section 6.2.1) to’s thyroiditis (lymphadenoid goitre), and thyroid carci-

noma. Neonatal hypothyroidism requires prompt Levothyroxine (Non-proprietary) treatment for normal development. Levothyroxine

A Tablets, levothyroxine sodium 25 micrograms, net sodium (thyroxine sodium) is the treatment of choice

price 28-tab pack = £1.80; 50 micrograms, 28-tab pack for maintenance therapy.

= £1.10; 100 micrograms, 28-tab pack = £1.22 In infants and children with congenital hypothyroidism

Brands include Eltroxin and juvenile myxoedema, the dose of levothyroxine

Oral solution , levothyroxine sodium 25 micrograms/ should be titrated according to clinical response, growth

5 mL, net price 100 mL = £42.75; 50 micrograms/ assessment, and measurements of plasma thyroxine and

5 mL, 100 mL = £44.90; 100 micrograms/5 mL, thyroid-stimulating hormone. See BNF for Children (sec-

100 mL = £52.75 tion 6.2.1) for suitable dosage regimens.

Brands include Evotrox (sugar-free)

BNF 57

6.2.2 Antithyroid drugs 387

LIOTHYRONINE SODIUM

treated with antihistamines without discontinuing ther- ( L -Tri-iodothyronine sodium)

apy; alternatively propylthiouracil can be substituted. All patients should be advised to report any sore throat

Indications see notes above immediately because of the rare complication of Cautions see under Levothyroxine Sodium; pregnancy

agranulocytosis (see CSM warning, above). (Appendix 4); breast-feeding (Appendix 5); interac- tions: Appendix 1 (thyroid hormones)

Propylthiouracil is given in a dose of 200 to 400 mg Contra-indications

daily in adults and this dose is maintained until the see under Levothyroxine Sodium

patient becomes euthyroid; the dose may then be gra- Side-effects see under Levothyroxine Sodium

dually reduced to a maintenance dose of 50 to 150 mg Dose

daily.

. By mouth , initially 10–20 micrograms daily gradu- Antithyroid drugs only need to be given once daily ally increased to 60 micrograms daily in 2–3 divided

because of their prolonged effect on the thyroid. Over- doses; ELDERLY smaller initial doses; CHILD , adult dose

treatment can result in the rapid development of hypo- reduced in proportion to body-weight

thyroidism and should be avoided particularly during . By slow intravenous injection , hypothyroid coma,

pregnancy because it can cause fetal goitre. 5–20 micrograms repeated every 12 hours or as often as every 4 hours if necessary; alternatively

A combination of carbimazole, 40 to 60 mg daily with

50 micrograms initially then 25 micrograms every 8 levothyroxine, 50 to 150 micrograms daily, may be used hours reducing to 25 micrograms twice daily

in a blocking-replacement regimen; therapy is usually given for 18 months. The blocking-replacement regimen Liothyronine sodium (Goldshield) A is not suitable during pregnancy.

Tablets , scored, liothyronine sodium 20 micrograms, net price 28-tab pack = £20.00

Iodine has been used as an adjunct to antithyroid drugs for 10 to 14 days before partial thyroidectomy; however, Triiodothyronine (Goldshield) A there is little evidence of a beneficial effect. Iodine

Injection , powder for reconstitution, liothyronine should not be used for long-term treatment because sodium (with dextran). Net price 20-microgram amp

its antithyroid action tends to diminish. = £37.92

Radioactive sodium iodide ( I) solution is used increas- ingly for the treatment of thyrotoxicosis at all ages, particularly where medical therapy or compliance is a problem, in patients with cardiac disease, and in patients who relapse after thyroidectomy.

Propranolol is useful for rapid relief of thyrotoxic

6.2.2 Antithyroid drugs

symptoms and may be used in conjunction with anti-

thyroid drugs or as an adjunct to radioactive iodine.

Endocrine

Antithyroid drugs are used for hyperthyroidism either to Beta-blockers are also useful in neonatal thyrotoxicosis prepare patients for thyroidectomy or for long-term

and in supraventricular arrhythmias due to hyper- management. In the UK carbimazole is the most com-

thyroidism. Propranolol has been used in conjunction monly used drug. Propylthiouracil may be used in

with iodine to prepare mildly thyrotoxic patients for patients who suffer sensitivity reactions to carbimazole

surgery but it is preferable to make the patient euthyroid

syst

as sensitivity is not necessarily displayed to both drugs. with carbimazole. Laboratory tests of thyroid function Both drugs act primarily by interfering with the synth-

are not altered by beta-blockers. Most experience in

em

esis of thyroid hormones. treating thyrotoxicosis has been gained with propranolol but nadolol is also used. For doses and preparations of

CSM warning (neutropenia and agranulocyto- beta-blockers see section 2.4. sis)

Thyrotoxic crisis (‘thyroid storm’) requires emergency Doctors are reminded of the importance of recog-

treatment with intravenous administration of fluids, nising bone marrow suppression induced by carbim-

propranolol (5 mg) and hydrocortisone (100 mg every azole and the need to stop treatment promptly.

6 hours, as sodium succinate), as well as oral iodine

1. Patient should be asked to report symptoms and solution and carbimazole or propylthiouracil which may signs suggestive of infection, especially sore

need to be administered by nasogastric tube. throat.

2. A white blood cell count should be performed if there is any clinical evidence of infection.

Pregnancy and breast-feeding Radioactive iodine

3. Carbimazole should be stopped promptly if therapy is contra-indicated during pregnancy. Propyl- there is clinical or laboratory evidence of neu-

thiouracil and carbimazole can be given but the block- tropenia.

ing-replacement regimen (see above) is not suitable. Both propylthiouracil and carbimazole cross the placen-

Carbimazole is given in a dose of 15 to 40 mg daily; ta and in high doses may cause fetal goitre and hypo- occasionally a larger dose may be required. This dose is

thyroidism—the lowest dose that will control the continued until the patient becomes euthyroid, usually

hyperthyroid state should be used (requirements in after 4 to 8 weeks and the dose is then gradually reduced

Graves’ disease tend to fall during pregnancy). Rarely, to a maintenance dose of 5 to 15 mg. Therapy is usually

carbimazole has been associated with congenital given for 12 to 18 months. Children may be given

defects, including aplasia cutis of the neonate. carbimazole in an initial dose of 250 micrograms/kg

Carbimazole and propylthiouracil appear in breast milk three times daily, adjusted according to response; treat-

but this does not preclude breast-feeding as long as ment in children should be undertaken by a specialist.

neonatal development is closely monitored and the Rashes and pruritus are common but they can be

lowest effective dose is used.

6.3 Corticosteroids BNF 57

CARBIMAZOLE

6.3 Corticosteroids

Indications hyperthyroidism

Cautions hepatic impairment (avoid if severe; Appen-

6.3.1 Replacement therapy

dix 2); pregnancy and breast-feeding (see notes above)

6.3.2 Glucocorticoid therapy

Contra-indications severe blood disorders Side-effects nausea, mild gastro-intestinal distur-

bances, taste disturbance, headache; fever, malaise; rash, pruritus, arthralgia; rarely myopathy, alopecia,

6.3.1 Replacement therapy

bone marrow suppression (including pancytopenia and agranulocytosis, see CSM warning above), and

The adrenal cortex normally secretes hydrocortisone jaundice

(cortisol) which has glucocorticoid activity and weak Counselling Warn patient to tell doctor immediately if sore

mineralocorticoid activity. It also secretes the minera- throat, mouth ulcers, bruising, fever, malaise, or non-specific

locorticoid aldosterone. illness develops Dose

In deficiency states, physiological replacement is best achieved with a combination of hydrocortisone (sec-

. See notes above tion 6.3.2) and the mineralocorticoid fludrocortisone;

Carbimazole hydrocortisone alone does not usually provide sufficient

(Non-proprietary) A Tablets , carbimazole 5 mg, net price 100-tab pack =

mineralocorticoid activity for complete replacement. £5.51; 20 mg, 100-tab pack = £19.12. Counselling,

In Addison’s disease or following adrenalectomy, hydro- blood disorder symptoms

cortisone 20 to 30 mg daily by mouth is usually required. This is given in 2 doses, the larger in the Neo-Mercazole c (Amdipharm) A morning and the smaller in the evening, mimicking

Tablets , both pink, carbimazole 5 mg, net price 100- the normal diurnal rhythm of cortisol secretion. The

tem

tab pack = £5.15; 20 mg, 100-tab pack = £19.12. optimum daily dose is determined on the basis of

sys

Counselling, blood disorder symptoms clinical response. Glucocorticoid therapy is supplemen- ted by fludrocortisone 50 to 300 micrograms daily.

In acute adrenocortical insufficiency, hydrocortisone is

ocrine IODINE AND IODIDE given intravenously (preferably as sodium succinate) in End doses of 100 mg every 6 to 8 hours in sodium chloride

Indications thyrotoxicosis (pre-operative) intravenous infusion 0.9%.

6 Cautions pregnancy, children; not for long-term

In hypopituitarism glucocorticoids should be given as in treatment

adrenocortical insufficiency, but since production of Contra-indications breast-feeding

aldosterone is also regulated by the renin-angiotensin Side-effects hypersensitivity reactions including cor-

system a mineralocorticoid is not usually required. yza-like symptoms, headache, lacrimation, con-

Additional replacement therapy with levothyroxine junctivitis, pain in salivary glands, laryngitis, bronch-

(section 6.2.1) and sex hormones (section 6.4) should itis, rashes; on prolonged treatment depression,

be given as indicated by the pattern of hormone defi- insomnia, impotence; goitre in infants of mothers

ciency.

taking iodides Dose

FLUDROCORTISONE ACETATE

. See under preparation Indications mineralocorticoid replacement in adre-

Aqueous Iodine Oral Solution

nocortical insufficiency (Lugol’s Solution), iodine 5%, potassium iodide 10% in

Cautions section 6.3.2; interactions: Appendix 1 purified water, freshly boiled and cooled, total iodine

(corticosteroids)

130 mg/mL. Net price 100 mL = £1.19. Label: 27 Contra-indications section 6.3.2 Dose 0.1–0.3 mL 3 times daily well diluted with milk or water

Side-effects section 6.3.2 Dose . 50–300 micrograms daily; CHILD

5 micrograms/kg

PROPYLTHIOURACIL

daily

Indications Florinef hyperthyroidism c (Squibb) A Cautions see under Carbimazole; hepatic impairment

Tablets , scored, fludrocortisone acetate 100 micr- (Appendix 2), renal impairment (Appendix 3)

ograms. Net price 100-tab pack = £5.36. Label: 10, Side-effects

steroid card

see under Carbimazole; leucopenia; rarely cutaneous vasculitis, thrombocytopenia, aplas- tic anaemia, hypoprothrombinaemia, hepatitis, encephalopathy, hepatic necrosis, nephritis, lupus

6.3.2 Glucocorticoid therapy

erythematous-like syndromes Dose

In comparing the relative potencies of corticosteroids in . See notes above