lSIDE-EFFECTS
▶Common or very commonArrhythmia supraventricular
(increased risk in patients with pre-existing arrhythmias).
headache.hypotension
▶UncommonAngina pectoris.chest pain.hypokalaemia.
thrombocytopenia.tremor
▶Rare or very rareAnaphylactic shock.bronchospasm.skin
eruption
▶Frequency not knownIntraventricular haemorrhage.renal
failure
lPREGNANCYManufacturer advises use only if potential
benefit outweighs risk.
lBREAST FEEDINGManufacturer advises avoid—no
information available.
lRENAL IMPAIRMENT
Dose adjustmentsUse half to three-quarters normal dose
and monitor response if estimated glomerularfiltration
rate less than 50 mL/minute/ 1. 73 m2
.
lMONITORING REQUIREMENTS
▶Monitor blood pressure, heart rate, ECG, central venous
pressure,fluid and electrolyte status, renal function,
platelet count and hepatic enzymes.
▶Monitor renal function.
lDIRECTIONS FOR ADMINISTRATIONAvoid extravasation.
Forintravenous infusiondilute with Glucose 5 %or
Sodium Chloride 0. 9 %orSodium Chloride and Glucose
intravenous infusion to a concentration of
200 micrograms/mL (higher concentrations of
400 micrograms/mL have been used).
Loading dose may be given undiluted iffluid-restricted.
lPRESCRIBING AND DISPENSING INFORMATION
Phosphodiesterase type- 3 inhibitors possess positive
inotropic and vasodilator activity and are useful in infants
and children with low cardiac output especially after
cardiac surgery. Phosphodiesterase type- 3 inhibitors
should be limited to short-term use because long-term
oral administration has been associated with increased
mortality in adults with congestive heart failure.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: solution for infusion
Solution for injection
▶Milrinone (Non-proprietary)
Milrinone 1 mg per 1 mlMilrinone 10 mg/ 10 ml solution for injection
ampoules| 5 ampouleP£ 35. 00 | 10 ampouleP£ 199. 06
▶Primacor(Sanofi)
Milrinone 1 mg per 1 mlPrimacor 10 mg/ 10 ml solution for injection
ampoules| 10 ampouleP£ 199. 066 Hyperlipidaemia
Lipid-regulating drugs
Cardiovascular disease risk factors
Atherosclerosis begins in childhood and raised serum
cholesterol in children is associated with cardiovascular
disease in adulthood. Lowering the cholesterol, without
hindering growth and development in children and
adolescents, should reduce the risk of cardiovascular disease
in later life.
The risk factors for developing cardiovascular disease
include raised serum cholesterol concentration, smoking,
hypertension, impaired glucose tolerance, male sex,
ethnicity, obesity, triglyceride concentration, chronic kidney
disease, and a family history of cardiovascular disease.
Heterozygous familial hypercholesterolaemia is the most
common cause of raised serum cholesterol in children;homozygous familial hypercholesterolaemia is very rare and
its specialised management is not covered inBNF for
Children. Familial hypercholesterolaemia can lead to a
greater risk of early coronary heart disease and should be
managed by a specialist.
Secondary causes of hypercholesterolaemia should be
addressed, these include obesity, diet, diabetes mellitus,
hypothyroidism, nephrotic syndrome, obstructive biliary
disease, glycogen storage disease, and drugs such as
corticosteroids.Management
The aim of management of hypercholesterolaemia is to
reduce the risk of atherosclerosis while ensuring adequate
growth and development. Children with
hypercholesterolaemia (or their carers) should receive advice
on appropriate lifestyle changes such as improved diet,
increased exercise, weight reduction, and not smoking;
Hypertension p. 98 should also be managed appropriately.
Drug therapy may also be necessary.
Hypothyroidism
Children with hypothyroidism should receive adequate
thyroid replacement therapy before their requirement for
lipid-regulating treatment is assessed because correction of
hypothyroidism itself may resolve the lipid abnormality.
Untreated hypothyroidism increases the risk of myositis with
lipid regulating drugs.Drug treatment in heterozygous familial
hypercholesterolaemia
Lifestyle modifications alone are unlikely to lower
cholesterol concentration adequately in heterozygous
familial hypercholesterolaemia and drug treatment is often
required. Lipid-regulating drugs should be considered by the
age of 10 years. The decision to initiate drug treatment will
depend on the child’s age, the age of onset of coronary heart
disease within the family, and the presence of other
cardiovascular risk factors. In children with a family history
of coronary heart disease in early adulthood, drug treatment
before the age of 10 years, and a combination of lipid-
regulating drugs may be necessary.
Drug treatment in secondary hypercholesterolaemia
If 6 – 12 months of dietary and other lifestyle interventions
has failed to lower cholesterol concentration adequately,
drug treatment may be indicated in children 10 years and
older (rarely necessary in younger children) who are at a high
risk of developing cardiovascular disease.Choice of drugs
Experience in the use of lipid-regulating drugs in children is
limited and they should be initiated on specialist advice.
Statinsare more effective than other classes of drugs in
lowering LDL-cholesterol but less effective than thefibrates
in reducing triglycerides. Statins also increase
concentrations of HDL-cholesterol. Statins reduce
cardiovascular disease events and total mortality in adults,
irrespective of the initial cholesterol concentration. They are
the drugs offirst choice in children and are generally well
tolerated; atorvastatin p. 132 and simvastatin p. 134 are the
preferred statins. Other lipid-regulating drugs can be used if
statins are ineffective or are not tolerated.
Evolocumab p. 134 is licensed for the treatment of
homozygous familial hypercholesterolaemia; it is used in
combination with other lipid-lowering therapies.
Ezetimibe p. 130 can be used alone when statins are not
tolerated, or in combination with a statin when a high dose
statin fails to control cholesterol concentration adequately.
Bile acid sequestrantsare also available but tolerability
of and compliance with these drugs is poor, and their use is
declining.
Fibratesmay reduce the risk of coronary heart disease in
those with low HDL-cholesterol or with raised triglycerides.
Evidence for the use of afibrate (bezafibrate p. 130 or
fenofibrate p. 131 ) in children is limited;fibrates should be128 Hyperlipidaemia BNFC 2018 – 2019
Cardiovascular system2