inadequate response after 12 weeks of treatment, to be
administered into the thigh, abdomen or upper arm
Homozygous familial hypercholesterolaemia in patients
on apheresis (in combination with other lipid-lowering
therapies)
▶BY SUBCUTANEOUS INJECTION
▶Child 12–17 years: 420 mg every 2 weeks, to correspond
with apheresis schedule, to be administered into the
thigh, abdomen or upper armlSIDE-EFFECTS
▶Common or very commonArthralgia.back pain.increased
risk of infection.nausea.skin reactions
lPREGNANCYManufacturer advises avoid unless
essential—limited information available.
lBREAST FEEDINGManufacturer advises avoid—no
information available.
lHEPATIC IMPAIRMENTManufacturer advises monitor in
moderate impairment—possible reduced efficacy; use with
caution in severe impairment—no information available.
lRENAL IMPAIRMENTManufacturer advises caution if
estimated glomerularfiltration rate less than
30 mL/minute/ 1. 73 m^2 —no information available.
lHANDLING AND STORAGEManufacturer advises store in a
refrigerator ( 2 – 8 °C)—consult product literature for further
information regarding storage outside refrigerator.
lPATIENT AND CARER ADVICEPatients and their carers
should be given training in subcutaneous injection
technique.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Solution for injection
▶Repatha(Amgen Ltd)A
Evolocumab 140 mg per 1 mlRepatha 140 mg/ 1 ml solution for
injection pre-filled syringes| 1 pre-filled disposable injectionP
£ 170. 10
▶Repatha SureClick(Amgen Ltd)A
Evolocumab 140 mg per 1 mlRepatha SureClick 140 mg/ 1 ml
solution for injection pre-filled disposable devices| 2 pre-filled
disposable injectionP£ 340. 20
7 Myocardial ischaemia
NITRATES
Nitrates
Overview
Nitrates are potent coronary vasodilators, but their principal
benefit follows from a reduction in venous return which
reduces left ventricular work. Unwanted effects such as
flushing, headache, and postural hypotension may limit
therapy, especially if the child is unusually sensitive to the
effects of nitrates or is hypovolaemic. Glyceryl trinitrate
below is also used in extravasation.
Nitrates f
lCONTRA-INDICATIONSAortic stenosis.cardiac tamponade
.constrictive pericarditis.hypertrophic cardiomyopathy.
hypotensive conditions.hypovolaemia.marked anaemia.
mitral stenosis.raised intracranial pressure due to
cerebral haemorrhage.raised intracranial pressure due to
head trauma.toxic pulmonary oedema
lCAUTIONSHeart failure due to obstruction.hypothermia.
hypothyroidism.hypoxaemia.malnutrition.metal-
containing transdermal systems should be removed before
magnetic resonance imaging procedures, cardioversion, or
diathermy.recent history of myocardial infarction.
susceptibility to angle-closure glaucoma.tolerance.
ventilation and perfusion abnormalities
CAUTIONS, FURTHER INFORMATION
▶ToleranceChildren receiving nitrates continuously
throughout the day can develop tolerance (with reduced
therapeutic effects). Reduction of blood-nitrate
concentrations to low levels for 4 to 8 hours each day
usually maintains effectiveness in such patients.
lSIDE-EFFECTS
▶Common or very commonArrhythmias.asthenia.cerebral
ischaemia.dizziness.drowsiness.flushing.headache.
hypotension.nausea.peripheral oedema.vomiting
▶UncommonAnorectal disorder.cardiac disorder.
circulatory collapse.cyanosis.diarrhoea.gastrointestinal
discomfort.haemorrhage.skin reactions.syncope
▶Rare or very rareAngioedema.angle closure glaucoma.
hypoxia.methaemoglobinaemia.myalgia.respiratory
disorders.restlessness.Stevens-Johnson syndrome
▶Frequency not knownDrug tolerance.hyperhidrosis.
palpitations.tongue blistering.vertigo
lALLERGY AND CROSS-SENSITIVITYContra-indicated in
nitrate hypersensitivity.
lBREAST FEEDINGNo information available—
manufacturers advise use only if potential benefit
outweighs risk.
lHEPATIC IMPAIRMENTCaution in severe impairment.
lRENAL IMPAIRMENTManufacturers advise use with
caution in severe impairment.
lMONITORING REQUIREMENTSMonitor blood pressure and
heart rate during intravenous infusion.
lTREATMENT CESSATIONAvoid abrupt withdrawal.eiiiiFaboveGlyceryl trinitrate 09-Mar-2018
lINDICATIONS AND DOSE
Hypertension during and after cardiac surgery|Heart
failure after cardiac surgery|Coronary vasoconstriction
in myocardial ischaemia|Vasoconstriction in shock
▶BY CONTINUOUS INTRAVENOUS INFUSION
▶Neonate: 0. 2 – 0. 5 microgram/kg/minute, adjusted
according to response, maintenance
1 – 3 micrograms/kg/minute (max. per dose
10 micrograms/kg/minute).▶Child:Initially 0. 2 – 0. 5 microgram/kg/minute, adjusted
according to response, maintenance
1 – 3 micrograms/kg/minute (max. per dose
10 micrograms/kg/minute); maximum
200 micrograms/minutelUNLICENSED USENot licensed for use in children.
lINTERACTIONS→Appendix 1 : nitrates
lPREGNANCYNot known to be harmful.
lDIRECTIONS FOR ADMINISTRATION
▶With intravenous useForcontinuous intravenous infusion,
dilute to max. concentration of 400 micrograms/mL (but
concentration of 1 mg/mL has been used via a central
venous catheter) with Glucose 5 % or Sodium Chloride
0. 9 %.Neonatal intensive care, dilute 3 mg/kg body-weight
to afinal volume of 50 mL with Glucose 5 % or Sodium
Chloride 0. 9 %; an intravenous infusion rate of 1 mL/hour
provides a dose of 1 microgram/kg/minute; max.
concentration of 400 micrograms/mL (but concentration of
1 mg/mL has been used via a central venous catheter).
▶With intravenous useGlass or polyethylene apparatus is
preferable; loss of potency will occur if PVC is used.
Glyceryl trinitrate 1 mg/ml to be diluted before use orBNFC 2018 – 2019 Myocardial ischaemia 135
Cardiovascular system2