lSIDE-EFFECTS
▶Common or very commonAbscess.alopecia.anaemia.
asthenia.asthma.bone fracture.chest discomfort.
depression.dizziness.fever.gastrointestinal discomfort.
gastrointestinal disorders.gastrointestinal inflammatory
disorders.headache.hypersensitivity.hypertension.
increased risk of infection.insomnia.nausea.
paraesthesia.respiratory disorders.skin reactions.
stomatitis
▶UncommonArrhythmia.balance impaired.bone marrow
disorders.breast disorder.cholelithiasis.constipation.
eye inflammation.eye irritation.flushing.goitre.
hyperthyroidism.hypothyroidism.leucopenia.liver
disorder.menstrual disorder.myocardial ischaemia.
neoplasms.sepsis.thrombocytopenia.thrombosis.
thyroid disorder.vision disorders
▶Rare or very rareBladder disorder.congestive heart failure
.demyelination.healing impaired.hepatitis B
reactivation.lupus-like syndrome.Raynaud’s
phenomenon.renal disorder.sarcoidosis.taste altered.
vasculitis
SIDE-EFFECTS, FURTHER INFORMATIONAssociated with
infections, sometimes severe, including tuberculosis,
septicaemia, and hepatitis B reactivation.
lCONCEPTION AND CONTRACEPTIONManufacturer advises
adequate contraception during treatment and for at least
6 months after last dose.
lPREGNANCYUse only if essential.
lBREAST FEEDINGManufacturer advises avoid during and
for at least 6 months after treatment—present in milk in
animalstudies.
lHEPATIC IMPAIRMENTManufacturer advises caution—no
information available.
lPRE-TREATMENT SCREENING
TuberculosisPatients should be evaluated for tuberculosis
before treatment.
lMONITORING REQUIREMENTSMonitor for infection before,
during, and for 5 months after treatment.
lDIRECTIONS FOR ADMINISTRATION
Missed doseIf dose administered more than 2 weeks late,
subsequent doses should be administered on the new
monthly due date.
lPATIENT AND CARER ADVICEAn alert card should be
provided.
TuberculosisAll patients and their carers should be advised
to seek medical attention if symptoms suggestive of
tuberculosis (e.g. persistent cough, weight loss, and fever)
develop.
Blood disordersPatients and their carers should be advised
to seek medical attention if symptoms suggestive of blood
disorders (such as fever, sore throat, bruising, or bleeding)
develop.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Solution for injection
CAUTIONARY AND ADVISORY LABELS 10
▶Simponi(Merck Sharp & Dohme Ltd)
Golimumab 100 mg per 1 mlSimponi 50 mg/ 0. 5 ml solution for
injection pre-filled disposable devices| 1 pre-filled disposable
injectionP£ 762. 97
Simponi 50 mg/ 0. 5 ml solution for injection pre-filled syringes| 1 pre-
filled disposable injectionP£ 762. 97
Simponi 100 mg/ 1 ml solution for injection pre-filled pen| 1 pre-filled
disposable injectionP£ 1 , 525. 942 Neuromuscular disorders
Neuromuscular disorders
Drugs that enhance neuromuscular transmission
Anticholinesterases are used asfirst-line treatment inocular
myasthenia gravisand as an adjunct to immunosuppressant
therapy forgeneralised myasthenia gravis.
Corticosteroids are used when anticholinesterases do not
control symptoms completely. A second-line
immunosuppressant such as azathioprine p. 518 is
frequently used to reduce the dose of corticosteroid.
Plasmapheresis or infusion of intravenous
immunoglobulin [unlicensed indication] may induce
temporary remission in severe relapses, particularly where
bulbar or respiratory function is compromised or before
thymectomy.
Anticholinesterases
Anticholinesterase drugs enhance neuromuscular
transmission in voluntary and involuntary muscle in
myasthenia gravis. Excessive dosage of these drugs can
impair neuromuscular transmission and precipitate
cholinergic crises by causing a depolarising block. This may
be difficult to distinguish from a worsening myasthenic
state.
Muscarinic side-effects of anticholinesterases include
increased sweating, increased salivary and gastric secretions,
increased gastro-intestinal and uterine motility, and
bradycardia. These parasympathomimetic effects are
antagonised by atropine sulfate p. 810.
Neostigmine p. 648 produces a therapeutic effect for up to
4 hours. Its pronounced muscarinic action is a disadvantage,
and simultaneous administration of an antimuscarinic drug
such as atropine sulfate or propantheline bromide p. 63 may
be required to prevent colic, excessive salivation, or
diarrhoea. In severe disease neostigmine can be given every
2 hours. In infants, neostigmine by either subcutaneous or
intramuscular injection is preferred for the short-term
management of myasthenia.
Pyridostigmine bromide p. 649 is less powerful and slower
in action than neostigmine but it has a longer duration of
action. It is preferable to neostigmine because of its
smoother action and the need for less frequent dosage. It is
particularly preferred in patients whose muscles are weak on
waking. It has a comparatively mild gastrointestinal effect
but an antimuscarinic drug may still be required. It is
inadvisable to use excessive doses because acetylcholine
receptor down regulation may occur. Immunosuppressant
therapy may be considered if high doses of pyridostigmine
bromide are needed.
Neostigmine and pyridostigmine bromide should be given
to neonates 30 minutes before feeds to improve suckling.
Neostigmine is also used to reverse the actions of the non-
depolarising neuromuscular blocking drugs.
Immunosuppressant therapy
A course ofcorticosteroidsis an established treatment in
severe cases of myasthenia gravis and may be particularly
useful when antibodies to the acetylcholine receptor are
present in high titre. Short courses of high-dose (’pulsed’)
methylprednisolone p. 441 followed by maintenance therapy
with oral corticosteroids may also be useful.
Corticosteroid treatment is usually initiated under
specialist supervision. Transient but very serious worsening
of symptoms can occur in thefirst 2 – 3 weeks, especially if
the corticosteroid is started at a high dose. Once remission
has occurred (usually after 2 – 6 months), the dose of
prednisolone p. 442 should be reduced slowly to the
minimum effective dose.646 Neuromuscular disorders BNFC 2018 – 2019
Musculoskeletal system10