Specialist Nurse. Indication Methotrexate is used in the treatment of adults with severe, active, classical or definite rheumatoid arthritis who are unresponsive or intolerant to conventional therapy and psoriatic arthritis (unlicensed) Dosage and Administration Supply only 2.5 mg strength tablets, as it reduces the risk of accidental overdose (see Specialist Pharmacy Service website). Issue the methotrexate monitoring booklet to all patients. Update with any dose changes Please note: Oral methotrexate 10 mg strength is not recommended for use in the BSSE health economy. BSR recommendation Typical dose: 7.5–25 mg ONCE weekly; starting dose may vary depending on the severity of the condition and patient characteristics such as age, renal function and other comorbid conditions. The initial dose may be 5–10 mg once weekly, increasing by 2.5–5 mg every 2–6 weeks until disease stabilised. The maximum licensed dose in RA is 25 mg/week. Rarely, the maximum dose can be 30 mg/week. Lower doses should be considered for frail elderly patients who often have poor renal function. If maximum oral dose is not effective or causes intolerance, consider i.m. or subcutaneous route of administration before discontinuation of the drug. Suggested regimen Starting dose 7.5 mg – 10 mg per week for two weeks Titration Dependent on tolerability and blood picture: • 10 mg per week for four weeks • Then 12.5 mg per week for four weeks Subsequent dosing in increments 2.5 mg every two to four weeks depending on response Range 2.5 mg to 20 mg as a single dose taken on the same day once a week. Spreading the dose over 24 hours helps reduce the risk of nausea NB: Dose can be increased to a maximum of 25 mg per week under specialist guidance (unlicensed) Folic acid 5 mg once a week taken 24 hours after dose of MTX can help reduce some minor side effects By injection Subcutaneous self injection by patient or carer may be used - hospital protocol applies Renal Impairment Methotrexate is contraindicated in the presence of severe/significant renal or significant hepatic impairment. Hepatic impairment Contra-indications / Special precautions Contraindications • Patients with a known allergic hypersensitivity to methotrexate should not receive methotrexate. • severe/significant renal renal impairment. • significant hepatic impairment. Liver disease including fibrosis, cirrhosis, recent or active hepatitis; active infectious disease; and overt or laboratory evidence of immunodeficiency syndrome(s) • Serious cases ...
Specialist Nurse. Indication For the treatment of the signs and symptoms of early-stage idiopathic Parkinson's disease as monotherapy (i.e. without levodopa) or in combination with levodopa, i.e. over the course of the disease, through to late stages when the effect of levodopa wears off or becomes inconsistent and fluctuations of the therapeutic effect occur (end of dose or 'on-off' fluctuations). Dosage and Administration Dosing in patients with early-stage Xxxxxxxxx'x disease: A single daily dose should be initiated at 2 mg/24 h and then increased in weekly increments of 2 mg/24 h to an effective dose up to a maximum dose of 8 mg/24 h. 4 mg/24 h may be an effective dose in some patients. For most patients an effective dose is reached within 3 or 4 weeks at doses of 6 mg/24 h or 8 mg/24 h, respectively. The maximum dose is 8 mg/24 h. Dosing in patients with advanced stage Xxxxxxxxx'x disease with fluctuations: A single daily dose should be initiated at 4 mg/24 h and then increased in weekly increments of 2 mg/24 h to an effective dose up to a maximum dose of 16 mg/24 h. 4 mg/24 h or 6 mg/24 h may be effective doses in some patients. For most patients an effective dose is reached within 3 to 7 weeks at doses of 8 mg/24 h up to a maximum dose of 16 mg/24 h. For doses higher than 8 mg/24 h multiple patches may be used to achieve the final dose e.g. 10 mg/24 h may be reached by combination of a 6 mg/24 h and a 4 mg/24 h patch. The patch should be applied to clean, dry, intact healthy skin on the abdomen, thigh, hip, flank, shoulder, or upper arm. Reapplication to the same site within 14 days should be avoided. Neupro should not be placed on skin that is red, irritated or damaged. Each patch is packed in a sachet and should be applied directly after the sachet has been opened. One half of the release liner should be removed and the sticky side should be applied and pressed firmly to the skin. Then, the patch is fold back and the second part of the release liner is removed. The sticky side of the patch should not be touched. The patch should be pressed down firmly with the palm of the hand for about 20 to 30 seconds, so that it sticks well. In the event that a patch should fall off, a new patch should be applied for the remainder of the 24 hour dosing interval. The patch should not be cut into pieces. Renal Impairment No dose adjustment is required Hepatic impairment Mild No dose adjustment is required Moderate Severe Caution is advised, may result in lower rotigotine cle...
Specialist Nurse. Indication Treatment of rheumatoid arthritis which has failed to respond to non-steroidal anti-inflammatory drugs (NSAIDs) Dosage and Administration Preparation Enteric Coated tablets improve gastrointestinal tolerability BSR recommendation Typical dose: 500 mg/day increasing by 500 mg weekly to 2.0–3.0 g/day. Occasionally doses above 3.0 g/day are prescribed Suggested regimen • 500 mg daily for first week • 500 mg bd for second week • 1 g mane 500 mg nocte for third week • Then 1 g bd maintenance dose Inadequate response on 2 g Increase to 3 g per day in divided doses Renal Impairment Sulfasalazine enteric coated should not be given to patients with impaired hepatic or renal function or with blood dyscrasias, unless the potential benefit outweighs the risk Hepatic impairment Contra-indications / Special precautions Contraindications Infants under the age of 2 years. Patients with a known hypersensitivity to sulfasalazine, its metabolites or any of the excipients as well as sulfonamides or salicylates. Patients with porphyria. Cautions Complete blood counts, including differential white cell count and liver function tests, should be performed before starting sulfasalazine, and every second week during the first three months of therapy. During the second three months, the same tests should be done once monthly and thereafter once every three months, and as clinically indicated. Assessment of renal function (including urinalysis) should be performed in all patients initially and at least monthly for the first three months of treatment. Thereafter, monitoring should be performed as clinically indicated. The patient should also be counselled to report immediately with any sore throat, fever, malaise, pallor, purpura, jaundice or unexpected non-specific illness during sulfasalazine treatment, this may indicate myelosuppression, haemolysis or hepatoxicity. Treatment should be stopped immediately while awaiting the results of blood tests. Sulfasalazine should not be given to patients with impaired hepatic or renal function or with blood dyscrasias, unless the potential benefit outweighs the risk. Sulfasalazine should be given with caution to patients with severe allergy or bronchial asthma. Use in children with the concomitant condition systemic onset juvenile rheumatoid arthritis may result in a serum sickness like reaction; therefore sulfasalazine is not recommended in these patients. Since sulfasalazine may cause haemolytic anaemia, it should be used with caut...
Specialist Nurse. Level 2 RN
Specialist Nurse. Indication For pre-operative treatment of moderate to severe symptoms of uterine fibroids in adult women of reproductive age. Dosage and Administration The treatment consists of one tablet of 5 mg to be taken orally once daily for up to 3 months. Treatments should always be started during the first week of menstruation. If a patient misses a dose, the patient should take ulipristal acetate as soon as possible. If the dose was missed by more than 12 hours, the patient should not take the missed dose and simply resume the usual dosing schedule. Renal Impairment Mild No dose adjustment required Moderate Severe Not recommended Hepatic impairment Mild No dose adjustment required Moderate Monitor patients closely Severe Contra-indications / Special precautions Contraindications Hypersensitivity to the active substance or to any of the excipients listed Pregnancy and breastfeeding. Genital bleeding of unknown aetiology or for reasons other than uterine fibroids. Uterine, cervical, ovarian or breast cancer. Cautions Ulipristal acetate should only be prescribed after careful diagnosis. Pregnancy should be precluded prior to treatment. Contraception Concomitant use of progestogen-only pills, a progestogen-releasing intrauterine device or combined oral contraceptive pills is not recommended. Although a majority of women taking a therapeutic dose of ulipristal acetate have anovulation, a non hormonal contraceptive method is recommended during treatment. Renal impairment Renal impairment is not expected to significantly alter the elimination of ulipristal acetate. In the absence of specific studies, ulipristal acetate is not recommended for patients with severe renal impairment unless the patient is closely monitored. Hepatic impairment There is no therapeutic experience with ulipristal acetate in patients with hepatic impairment. Hepatic impairment is expected to alter the elimination of ulipristal acetate, resulting in increased exposure. This is considered not to be clinically relevant for patients with mildly impaired liver function. Ulipristal acetate is not recommended for use in patients with moderate or severe hepatic impairement unless the patient is closely monitored. Concomitant treatments Co-administration of moderate (e.g. erythromycin, grapefruit juice, verapamil) or potent (e.g. ketoconazole, ritonavir, nefazodone, itraconazole, telithromycin, clarithromycin) CYP3A4 inhibitors and ulipristal acetate is not recommended Concomitant use of ulipristal acetat...
Specialist Nurse. Indication For treatment of the signs and symptoms of idiopathic Xxxxxxxxx’x disease, alone (without levodopa) or in combination with levodopa. Dosage and Administration The daily dose is administered in equally divided doses 3 times a day Doses should be increased gradually from a starting dose of 0.264 mg of base (0.375 mg of salt) per day and then increased every 5-7 days. Providing patients do not experience intolerable undesirable effects, the dose should be titrated to achieve a maximal therapeutic effect. If a further dose increase is necessary the daily dose should be increased by 0.54 mg of base (0.75 mg of salt) at weekly intervals up to a maximum dose of 3.3 mg of base (4.5 mg of salt) per day. However, it should be noted that the incidence of somnolence is increased at doses higher than 1.5 mg (of salt) per day. Maintenance treatment The individual dose of pramipexole should be in the range of 0.264 mg of base (0.375 mg of salt) to a maximum of 3.3 mg of base (4.5 mg of salt) per day. Further dose adjustments should be done based on the clinical response and the occurrence of adverse reactions. In advanced Xxxxxxxxx'x disease, pramipexole doses higher than 1.1 mg of base (1.5 mg of salt) per day can be useful in patients where a reduction of the levodopa therapy is intended. It is recommended that the dose of levodopa is reduced during both the dose escalation and the maintenance treatment with pramipexole, depending on reactions in individual patients. Treatment discontinuation Abrupt discontinuation of dopaminergic therapy can lead to the development of a neuroleptic malignant syndrome. Pramipexole should be tapered off at a rate of 0.54 mg of base (0.75 mg of salt) per day until the daily dose has been reduced to 0.54 mg of base (0.75 mg of salt). Thereafter the dose should be reduced by 0.264 mg of base (0.375 mg of salt) per day. Renal Impairment Creatinine clearance above 50 ml/min No dose adjusted required Creatinine clearance between 20 and 50 ml/min The initial daily dose of pramipexole should be administered in two divided doses, starting at 0.088 mg of base (0.125 mg of salt) twice a day (0.176 mg of base/0.25 mg of salt daily). A maximum daily dose of 1.57 mg pramipexole base (2.25 mg of salt) should not be exceeded Creatinine clearance less than 20 ml/min The daily dose of pramipexole should be administered in a single dose, starting at 0.088 mg of base (0.125 mg of salt) daily. A maximum daily dose of 1.1 mg pramipexole base (1.5 ...
Specialist Nurse. Indication Riluzole is indicated to extend life or the time to mechanical ventilation for patients with amyotrophic lateral sclerosis (ALS). Dosage and Administration Treatment should only be initiated by specialist physicians with experience in the management of motor neurone diseases. The recommended daily dose in adults or older people is 100 mg (50 mg every 12 hours) Renal Impairment Riluzole is not recommended for use in patients with impaired renal function Hepatic impairment Riluzole should be prescribed with care in patients with a history of abnormal liver function, or in patients with slightly elevated serum transaminases
Specialist Nurse. Level 3 RN Post graduate tertiary qualifications (Graduate Diploma level and above) in specialisation area - including Palliative Care, Diabetes, continence management, stomal therapy, dementia care, gerontology and Wound Management (Specialisation Area) and 5 years community nursing experience or other relevant nursing experience. 52.00 53.56 55.17 56.82
Specialist Nurse. Indication For the treatment of patients with Xxxxxxxxx'x disease and end-of-dose motor fluctuations not stabilised on levodopa/dopa decarboxylase inhibitor treatment. Dosage and Administration The optimum daily dose must be determined by careful titration of levodopa in each patient. The daily dose should be preferably optimised using one of the seven available tablet strengths (50 mg/12.5 mg/200 mg, 75 mg/18.75 mg/200 mg, 100 mg/25 mg/200 mg, 125 mg/31.25 mg/200 mg 150 mg/37.5 mg/200 mg, 175 mg/43.75 mg/200 mg or 200 mg/50 mg/200 mg levodopa/carbidopa/entacapone). Renal Impairment Renal impairment does not affect the pharmacokinetics of entacapone Severe Stalevo therapy should be administered cautiously to patients in severe renal impairment including those receiving dialysis therapy Hepatic impairment Mild It is advised that Stalevo should be administered cautiously to patients with mild to moderate hepatic impairment. Moderate Severe Not recommended Contra-indications / Special precautions Contraindication:- • Hypersensitivity to the active substances or to any of the excipients • Severe hepatic impairment. • Narrow-angle glaucoma. • Pheochromocytoma. • Coadministration of Stalevo with non-selective monoamine oxidase (MAO-A and MAO-B) inhibitors (e.g. phenelzine, tranylcypromine). • Coadministration witha selective MAO-A inhibitor and a selective MAO-B inhibitor • A previous history of Neuroleptic Malignant Syndrome (NMS) and/or non-traumatic rhabdomyolysis. Cautions:- • Stalevo is not recommended for the treatment of drug-induced extrapyramidal reactions • Stalevo therapy should be administered cautiously to patients with ischemic heart disease, severe cardiovascular or pulmonary disease, bronchial asthma, renal or endocrine disease, history of peptic ulcer disease or history of convulsions. • In patients with a history of myocardial infarction who have residual atrial nodal or ventricular arrhythmias; cardiac function should be monitored with particular care during the period of initial dose adjustments. • All patients treated with Stalevo should be monitored carefully for the development of mental changes, depression with suicidal tendencies, and other serious antisocial behaviour. Patients with past or current psychosis should be treated with caution. • Concomitant administration of antipsychotics with dopamine receptor-blocking properties, particularly D2 receptor antagonists should be carried out with caution, and the patient carefully observed f...
Specialist Nurse. Indication For the treatment of idiopathic Parkinson's disease (PD) as monotherapy (without levodopa) or as adjunct therapy (with levodopa) in patients with end of dose fluctuations.
