Treatment and prophylaxis of thrombotic episodes
following induction dose (if INR above 3. 5 )
▶BY MOUTH
▶Neonate (under expert supervision):Dose to be omitted.▶Child:Dose to be omitted
Treatment and prophylaxis of thrombotic episodes (usual
maintenance)
▶BY MOUTH
▶Neonate (under expert supervision):Maintenance
100 – 300 micrograms/kg once daily, doses up to
400 micrograms/kg once daily may be required
especially if bottle fed, to be adjusted according to INR.▶Child:Maintenance 100 – 300 micrograms/kg once
daily, doses up to 400 micrograms/kg once daily may be
required especially if bottle fed, to be adjusted
according to INRlUNLICENSED USENot licensed for use in children.IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: WARFARIN: REPORTS OF CALCIPHYLAXIS
(JULY 2016)
An EU-wide review has concluded that on rare occasions,
warfarin use may lead to calciphylaxis—patients should
be advised to consult their doctor if they develop a
painful skin rash; if calciphylaxis is diagnosed,
appropriate treatment should be started and
consideration should be given to stopping treatment
with warfarin. The MHRA has advised that calciphylaxis
is most commonly observed in patients with known risk
factors such as end-stage renal disease, however cases
have also been reported in patients with normal renal
function.lINTERACTIONS→Appendix 1 : coumarins
lPREGNANCYBabies of mothers taking warfarin at the time
of delivery need to be offered immediate prophylaxis with
intramuscular phytomenadione (vitamin K 1 ).
lBREAST FEEDINGNot present in milk in significant
amounts and appears safe. Risk of haemorrhage which is
increased by vitamin K deficiency.
lHEPATIC IMPAIRMENTAvoid in severe impairment,
especially if prothrombin time is already prolonged.
lRENAL IMPAIRMENTUse with caution in mild to moderate
impairment.
MonitoringIn severe renal impairment, monitor INR more
frequently.
lPRESCRIBING AND DISPENSING INFORMATION
Dietary differencesInfant formula is supplemented with
vitamin K, which makes formula-fed infants resistant to
warfarin; they may therefore need higher doses. In
contrast breast milk contains low concentrations of
vitamin K making breast-fed infants more sensitive to
warfarin.
lPATIENT AND CARER ADVICEAnticoagulant card to be
provided.
Medicines for Children leaflet: Warfarin for the treatment and
prevention of thrombosiswww.medicinesforchildren.org.uk/
warfarin-treatment-and-prevention-thrombosislMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension, oral solution
Oral suspension
CAUTIONARY AND ADVISORY LABELS 10
▶Warfarin sodium (Non-proprietary)
Warfarin sodium 1 mg per 1 mlWarfarin 1 mg/ml oral suspension
sugar free sugar-free| 150 mlP£ 108. 00 DT = £ 108. 00Tablet
CAUTIONARY AND ADVISORY LABELS 10
▶Warfarin sodium (Non-proprietary)
Warfarin sodium 500 microgramWarfarin 500 microgram tablets|
28 tabletP£ 1. 70 DT = £ 1. 27
Warfarin sodium 1 mgWarfarin 1 mg tablets| 28 tabletP£ 1. 16
DT = £ 0. 33 | 500 tabletP£ 5. 89
Warfarin sodium 3 mgWarfarin 3 mg tablets| 28 tabletP£ 1. 20
DT = £ 0. 37 | 500 tabletP£ 6. 61
Warfarin sodium 5 mgWarfarin 5 mg tablets| 28 tabletP£ 1. 29
DT = £ 0. 42 | 500 tabletP£ 7. 504 Blood pressure conditions
4.1 Hypertension
Hypertension
Overview
Hypertension in children and adolescents can have a
substantial effect on long-term health. Possible causes of
hypertension (e.g. congenital heart disease, renal disease
and endocrine disorders) and the presence of any
complications (e.g. left ventricular hypertrophy) should be
established. Treatment should take account of contributory
factors and any factors that increase the risk of
cardiovascular complications.
Serious hypertension is rare inneonatesbut it can present
with signs of congestive heart failure; the cause is often
renal and can follow embolic arterial damage.
Children (or their parents or carers) should be given advice
on lifestyle changes to reduce blood pressure or
cardiovascular risk; these include weight reduction (in obese
children), reduction of dietary salt, reduction of total and
saturated fat, increasing exercise, increasing fruit and
vegetable intake, and not smoking.
Indications for antihypertensive therapy in children
include symptomatic hypertension, secondary hypertension,
hypertensive target-organ damage, diabetes mellitus,
persistent hypertension despite lifestyle measures, and
pulmonary hypertension. The effect of antihypertensive
treatment on growth and development is not known;
treatment should be started only if benefits are clear.
Antihypertensive therapy should be initiated with a single
drug at the lowest recommended dose; the dose can be
increased until the target blood pressure is achieved. Once
the highest recommended dose is reached, or sooner if the
patient begins to experience side-effects, a second drug may
be added if blood pressure is not controlled. If more than one
drug is required, these should be given as separate products
to allow dose adjustment of individual drugs, butfixed-dose
combination products may be useful in adolescents if
compliance is a problem.
Acceptable drug classes for use in children with
hypertension includeACE inhibitors,alpha-blockers,
beta-blockers,calcium-channel blockers, andthiazide
diuretics. There is limited information on the use of
angiotensin-II receptor antagonistsin children. Diuretics
and beta-blockers have a long history of safety and efficacy
in children. The newer classes of antihypertensive drugs,
including ACE inhibitors and calcium-channel blockers have
been shown to be safe and effective in short-term studies in
children. Refractory hypertension may require additional
treatment with agents such as minoxidil p. 117 or clonidine
hydrochloride p. 102.Cardiovascular risk reduction
Aspirin p. 91 may be used to reduce the risk of cardiovascular
events; however, concerns about an increased risk of
bleeding and Reye’s syndrome need to be considered.98 Blood pressure conditions BNFC 2018 – 2019
Cardiovascular system2