Oxford handbook of Clinical Pharmacy

Table 27.2  Common drugs

Drug Therapeutic range Ideal sampling time Ind

Carbama­ 4–10mg/L Trough measurement before Ini
zepine 17–42micromol/L dose me
Ciclosporin Ch
Digoxin Varies with indication Trough measurement before au
Generally 100–200 dose Lo
micrograms/L As
Int
0.8–2 micrograms/L Sampling 8–24h after last dose int
Reference range is valid
for specimens taken Tra
6–8h post-dose the
Adults, 1.0–2.6nmol/L Gr
Ch
lat
Ch
As
Int
int

Ini
As
Int
int
Ch

dication for drug monitoring Type of sample 760
required
itiation of therapy: 3wks (induces own Serum or plasma—SST 670 Chapter 27  Therapy-related issues: miscellaneous
etabolism). (orange) or PST heparin
hange of dose: 3–5 days, before maximal (green)
uto-induction 1–3wks
oss of seizure control: immediately Whole blood—EDTA
ssess toxicity or compliance: immediately (lavender)
troduction or withdrawal of a potentially
teracting drug: 1–2wks later Serum or plasma—SST
(orange) or PST heparin
ansplant surgery: initially every 2 days until (green)
erapeutic level achieved
raft vs host disease: immediately
hange in the route of administration: 2–3 days
ter
hange in dose: 2 days later
ssess toxicity or compliance: immediately
troduction or withdrawal of a potentially
teracting drug: 2–3 days later

itiation of dose: 8 days (if renal function normal)
ssess toxicity or compliance: immediately
troduction or withdrawal of a potentially
teracting drug: 8 days later
hanging renal function: immediately

Lithium Minimum effective 12h post-dose Ini
concentration in Su
Phenytoin mania prophylaxis is eve
Phenobarbital 0.5–1.2mmol/L Ch
Theophylline/ As
aminophylline Toxic conc. >1.5mmol/L Int
Tacrolimus int
Not in lithium heparin Ch
tube Please measure
maintenance range 12h Ini
after last dose Ch
Lo
10–20mg/L Trough measurement before As
40–80micromol/L dose Int
int
15–40mg/L Trough measurement before
60–160micromol/L dose Ini
Ch
10–20mg/L (1) D uring a continuous infusion, Lo
55–110micromol/L preferably at 6h and 24h As
Int
(2) SR preparation— pre-dose int

5–15ng/mL Trough measurement before dose Ini
Su
Ini
As

NA

itiation of therapy: 7 days Serum–SST (orange) 6 71
ubsequent levels weekly until stabilized and then
very 3 months Therapeutic drug monitoring (TDM) in adults 671
hange in dose: 7 days
ssess toxicity or compliance: immediately
troduction or withdrawal of a potentially
teracting drug: 7 days later
hange in sodium of fluid intake: 12h after previous dose

itiation of therapy: 2–4wks Serum or plasma—SST
hange of dose or oral formulation: 2–4wks (orange) or PST heparin
oss of seizure control: immediately (green)
ssess toxicity or compliance: immediately
troduction or withdrawal of a potentially Serum or plasma—SST
teracting drug: 2–4wks later (orange) or PST heparin
(green)
itiation of therapy: 3wks
hange of dose or oral formulation: 3wks Serum or plasma—SST
oss of seizure control: immediately (orange) or PST heparin
ssess toxicity or compliance: immediately (green)
troduction or withdrawal of a potentially Blood—EDTA (lavender)
teracting drug: 3wks later

itiation of IV therapy: 6h
ubsequent levels for IV therapy every 24h
itiation of oral therapy 2–4 days
ssess toxicity: immediately

A

Table 27.3  Antimicrobials

Drug Therapeutic range (mg/L) Ideal sampling time
Trough level 18–24h
Gentamicin, once daily 20 first dose (ideal <1.

Gentamicin, conventional Trough <2 Trough
dosing Peak 5–10 Peak—1h post-dose
Amikacin
Trough <10 Trough
Peak 20–30 Peak–1h post admin

Vancomycin Trough 10-20 Pre-dose before fou

Teicoplanin Trough 10–20 Trough

Tobramycin Trough <2 For tobramycin bein
Peak 5–10 in multiple daily dos
1h post-administrati
trough( immediately
next dose) are usefu
determine dose and
interval

h after the Comments Type of sample required 762
.0mg/L) Most patients only need one dose. Blood SST (orange)
e Consult microbiologist advice if >1 672 Chapter 27  Therapy-related issues: miscellaneous
nistration dose needed Blood SST (orange)
urth dose Peak for endocarditis if having Blood SST
synergistic therapy 3–5mg/L
ng given Blood SST (orange)
ses peak Further usually twice weekly Blood SST (orange).
ion and pre-dose levels if no dose changes Blood SST
y before and normal renal function
ul to Further monitoring usually twice
d dose weekly
>20mg/L (<60mg/L) for deep
seated infection
Samples should be taken pre and
post fourth dose, depending on
renal function

7 36

Ophthalmology principles 673

Ophthalmology principles

It is helpful for pharmacists to be familiar with the terminology of the eye
structure, which is detailed as follows.
Eye structure
• Conjunctiva—transparent membrane covering the sclera and the eyelids.
• Cornea—transparent curved layer in front of the iris and pupil, provides

protection to the internal ocular structures and refracts light as it enters
the eye working with the lens to focus light onto the retina.
• Iris—coloured area at the front of the eye surrounding the pupil,
controls the amount of light entering the pupil by contacting and
relaxing.
• Lens—flexible disc sitting behind the iris which focuses light onto the
retina. Thickens to focus on nearby objects and thins to focus on those
far away.
• Optic disc—the part of the optic nerve closest to the eye; the
photoreceptors in the retina convert images into electrical impulses
which are carried to the brain by the optic nerve.
• Orbit—pear-shaped bony cavity containing the eyeball, muscles, nerves,
and blood vessels.
• Pupil—black dot in the middle of the eye, able to constrict and dilate as
the lighting conditions change.
• Retina—situated at the back of the eye and contains photoreceptors
which are most densely packed in the macula, responsible for converting
light into electrical signals. Photoreceptors are either rods or cones,
rods are sensitive to dim light and cones are sensitive to colour and
enable us to see in daylight.
• Sclera—outer white-coloured covering of the eyeball.
• Anterior segment—the front section of the eye from the inside of the
cornea to the front surface of the lens, filled with aqueous humour.
• Posterior segment—the back section of the eye extending from the back
of the lens to the retina, filled with vitreous humour which gives the eye
its shape and provides nutrients.
There are many ocular conditions that may be seen on general wards or in
general practice. Some examples of the most common conditions and their
treatment are detailed in this section.
Glaucoma
Glaucoma refers to a group of eye diseases which can lead to optic neurop-
athy causing visual loss. Damage to the optic nerve is due to i intraocular
pressure (IOP). In the Western world, glaucoma is present in 3% of those
>70yrs and it is the leading cause of irreversible blindness.
Open-angle glaucoma
Optic nerve neuropathy leads to peripheral vision loss followed by central
vision loss. There is usually, but not always, an i in IOP (>21mmHg).

746

674 Chapter 27  Therapy-related issues: miscellaneous

Risk factors
• Age >40yrs
• Ethnicity—more common and often more severe in Afro-Caribbean

populations
• Family history—first-degree relative i risk to 71 in 8
• Steroid use (can i IOP)
• Vascular disease—e.g. diabetes and hypertension.
Treatment (define target for reduction in IOP, e.g. >20%)
Royal College of Ophthalmology guidelines recommend treatment for
patients >60yrs with IOP >25mmHg. Treatment should be reviewed 6wks
post initiation to consider whether target IOP has been reached and whether
the patient has experienced any systemic or local side effects. Thought
should also be given to whether the treatment should be continued.
First line—prostaglandin analogues
• Prostaglandin analogues i uveoscleral outflow and subsequently

reduce IOP.
• Latanoprost is a prostaglandin analogue, it is available generically and it

has few systemic side effects.
• Counselling points—educate patient that prostaglandin analogues may

cause brown pigmentation to iris, and lengthening/thickening/darkening
of eyelashes.
• If patients are not responding to treatment, their adherence and
drop-instillation technique should be checked (including nasolacrimal
occlusion).
• If patients are not able to tolerate prostaglandin analogues, consider
if the patient is intolerant of the preservative; if so, switch to a
preservative-free formulation.
Second line—alpha- or beta-blocker
• If prostaglandin analogues are not appropriate, patients may be
switched to an alternative agent—e.g. α-blocker or β-blocker.
• In circumstances where some reduction in IOP has been seen with
a prostaglandin analogue, but the target has not been reached, then
a combination of topical agents may be needed—e.g. prostaglandin
analogue with a β-blocker.
• Combination products are available, but should only be used to improve
compliance or adherence.
Third line
• For patients in which pharmacological treatment is inadequate and two
or more agents have been tried, surgical or laser intervention may be
indicated.

Angle-closure glaucoma
The anterior chamber angle (where the cornea and iris join) in the eye
becomes closed or narrowed preventing the drainage of aqueous humour
leading to a rapid i in IOP (>50mmHg). Patients can present with a red
eye, headache, plus nausea/vomiting. Angle-closure glaucoma is an ocular
emergency. The pressure must be lowered urgently to prevent optic nerve
damage which can lead to blindness.

56 7

Ophthalmology principles 675

Risk factors
• Age >40 years
• Ethnicity—more common in Chinese, south east Asians, and Inuit

populations.
Treatment
Aims to control i IOP and reverse angle closure.
Immediate
• Acetazolamide IV 500mg stat then PO 250mg four times a day
• Topical—β-blocker (timolol 0.5%) stat, wait 1min then

• Sympathomimetic (apraclonidine 1%) stat, wait 1min then
• Pilocarpine 2% one drop every 15min for two doses, wait 1min after

the first dose then
• Steroid (prednisolone 1%) stat then 0.5–1-hourly.
In addition treat associated symptoms—e.g. pain/nausea with analgesia and
antiemetics.
Intermediate
Check IOP hourly. If not improving consider mannitol 20% IV 1–1.5g/kg or
glycerol PO 1g/kg.
Definitive
Surgical intervention—e.g. laser peripheral iridotomy to create a small hole
in the iris to allow outflow of aqueous humour.

Ocular infections
Conjunctivitis
The direct translation of conjunctivitis is inflammation of conjunctiva, the
mucous membrane lining the inside of the eyelids and covering the globe
of the eye. Infectious conjunctivitis is usually caused by bacteria but may be
viral. Non-infectious conjunctivitis may be caused by an allergic reaction.
Bacterial conjunctivitis is typically associated with a thick or coloured dis-
charge. The most common causative organisms include Staph. epidermidis,
Staph. aureus, Strep. pneumoniae, and H. influenza. Allergic or viral conjunc-
tivitis is more associated with a watery discharge. Conjunctivitis is a very
common, self-limiting infection; however, topical antibiotic treatment may
reduce the duration of symptoms. Patients often present with one or two
red and discharging eyes.

When diagnosing, ensure more severe, sight-limiting eye conditions are
ruled out first—e.g. acute angle-closure glaucoma or infectious keratitis.
Look out for ‘red flag’ symptoms:
• Reduction in vision
• Ciliary flush (redness more pronounced in a ring)
• Photophobia
• Sensation of a foreign body
• Corneal opacity
• Fixed pupil
• Severe headache ± nausea.

76

676 Chapter 27  Therapy-related issues: miscellaneous

Treatment
• First-line (bacterial) non-contact lens wearers—chloramphenicol 0.5%

drops start 1–2-hourly and wean as condition improves. Treat for
7–10 days. Ointment may also be used, but only requires four-times-a-
day dosing. Chloramphenicol drops may be used in paediatric patients
and neonates; however, more serious ocular infections in neonates may
require systemic antibiotics.
• First-line (bacterial) contact lens wearers—fluoroquinolone, e.g. ofloxacin
or levofloxacin drops due to the high incidence of pseudomonas
infections. Advise patient not to wear lenses until treatment is
completed and there has been no discharge from the eye for 24h.
• In patients not responding to therapy within 1–2 days consider tak-

ing conjunctival swabs and sending for MC&S and tailor therapy to
results.
• General advice to patients (bacterial and viral cases)—avoid rubbing the
eye, avoid sharing towels to prevent spread, and encourage frequent
handwashing.
• Viral conjunctivitis often does not require direct treatment, some
patients may find symptomatic relief from antihistamines (topical or
oral) or topical nasal decongestants.
Bacterial keratitis
Keratitis presents as infection and inflammation of the cornea and is con-
sidered an emergency. It can be a sight-threatening condition, however it is
usually treatable. Visual loss can occur if treatment is delayed, inappropriate
therapy is given, or there is no follow up. Prolonged wear or inappropri-
ate contact lens hygiene can be a causative factor, but keratitis can also be
seen in patients with other ocular disorders (e.g. dry eye or nasolacrimal
diseases).
Early corneal scrapes should be performed, and if the patient is a contact
lens wearer, the lenses, storage pots, and solutions should also be sent for
culture.
Treatment
• Stop contact lens wear.
• Intensive topical antibiotics—hourly dual therapy with broad-spectrum
antibiotics, e.g. cefuroxime (Gram-positive cover) and levofloxacin
(Gram-negative cover). Gentamicin 1.5% may be used in place of
levofloxacin. Use preservative-free preparations due to frequency of
instillation.
• Consider systemic antibiotics if corneal perforation—e.g. ciprofloxacin
750mg twice a day.
• Cyclopentolate 1% two to three times a day if photophobia or
ciliary spasm.
• Oral analgesia if needed.
• Patients require daily monitoring.
• As the eye starts to improve, reduce frequency of topical antibiotics,
and consider switching to a preserved formulation.
• Add ocular lubricants to promote healing and consider topical steroids
to reduce inflammation.

7 6

Ophthalmology principles 677

Viral keratitis
The most common causative organism of viral keratitis is herpes simplex
virus which can lead to visual loss due to corneal scarring and opacity. The
infection is characterized by infection in the superficial layer of the cornea
with the presence of dendritic lesions. The majority of cases are unilateral
and can be reoccurring.
Treatment
• Topical antivirals—e.g. aciclovir 3% eye ointment (if unavailable,

ganciclovir 0.15% eye gel may be substituted), apply five times a day until
healing occurs then continue three times a day for up to 1wk.
• Systemic antivirals—e.g. aciclovir 400mg five times/day may also be
used. Oral antivirals have been found to be equally as effective as
topical agents in randomized controlled trials and may often be used
in preference due to the convenience. However, there has been
no reported benefit in using the topical and systemic treatment in
conjunction. Aciclovir at lower doses (e.g. 400mg twice a day) may
be continued long term as suppressive treatment in those patients
particularly at risk of corneal scarring and visual loss, or those who
present with frequent episodes.
• Administration of topical steroid treatment without concurrent topical
antiviral treatment can lead to worsening of the infection if inflammation
is due to active infection rather than immune response to previous
infection. Steroid use is contraindicated in the presence of dendritic
ulcers.
Acanthamoeba keratitis
Protozoal keratitis caused by Acanthamoeba species remains rare; how-
ever, the incidence is rising due to i contact lens use. It is often resistant to
broad-spectrum, first-line antibiotics.
Risk factors
• Poor contact lens hygiene.
• Swimming or showering with lens in situ.
• Corneal trauma with soil contamination.
Treatment
• Stop contact lens wear.
• Topical antiamoeba agents—e.g. polyhexamethylene biguanide 0.02% or
chlorhexidine 0.02% hourly plus propamidine isethionate 0.1% hourly.
• Cyclopentolate 1% two or three times a day—prevents photophobia
and treats pain associated with ciliary muscle spasm.
• Analgesia.
• Topical steroids to prevent corneal scarring (may be initiated once eye
starts to improve, and after at least 2wks of antiamoeba therapy).
• Taper treatment according to clinical response, patients will often need
prolonged courses of treatment to fully eradicate the amoeba (upwards
of 6 months).

876

678 Chapter 27  Therapy-related issues: miscellaneous

Endophthalmitis
Endophthalmitis is a deeper infection in the eye involving the aqueous and/
or vitreous humours (the liquid part of the eye which provides its shape).
Cases may be exogenous, e.g. following trauma, surgery (e.g. cataract,
occurs within 6wks) or intravitreal injection to the eye; or endogenous with
no preceding insult to the eye which may be also associated with bacterae-
mia or endocarditis. In cases of endogenous endophthalmitis, blood cultures
should be taken prior to starting antibiotic therapy. Acute endophthalmitis is
vision-threatening and should be treated as an emergency, including referral
to ID/micro and ophthalmology.
Diagnosis
• Aqueous or vitreous biopsy.
• Send for MC&S, the most common causative organism is

coagulase-negative staphylococci.
Treatment
• Intravitreal antibiotics—vancomycin 2mg in 0.1mL plus ceftazidime 2mg

in 0.1mL or amikacin 0.4mg in 0.1mL (amphotericin 0.01mg in 0.1mL
may be added if fungi are suspected). These may be repeated after 48h
if inflammation/vision is not improving.
• Systemic antibiotics—usually quinolone, e.g. moxifloxacin 400mg once a
day or ciprofloxacin 500–750mg twice a day.
• Surgical intervention—e.g. vitrectomy to debride the affected vitreous.
• Tailor antibiotic therapy to sensitivity test result from biopsy
once known.
• All cases of exogenous endophthalmitis following surgical intervention
or intravitreal injection are investigated with a root cause analysis in line
with infection control procedures.

  679
769

Appendix

Supplementary data

Sodium content of parenteral drugs  680
Pathology ranges and interpretation  684
Normal ranges  691
Paediatric normal laboratory values  692
Useful websites  695
In vitro activity of antibacterials  698

860

680 Appendix   Supplementary data

Sodium content of parenteral drugs

The sodium content of drugs
A number of parenteral and enteral formulations contain a significant
amount of sodium ions (Table A1). At maximum daily doses of some prepa-
rations, the amount of sodium ingested could exceed the maximum recom-
mended daily amount (for adults: 7100mmol). This sodium load is unlikely
to be important in most patients, other than potentially contributing to total
daily intake being higher than the recommended level. However, in patients
who have conditions exacerbated by high sodium levels (e.g. hypertension,
heart failure, liver or renal impairment), or in neonates, this could be clini-
cally significant. Occasionally, the sodium load from drug therapy will be the
cause of, or contribute to, a high serum sodium level.
Intravenous medicines
Several factors should be taken into account when assessing the sodium
content of IV medicines:
• Use the summary of product characteristics (SPC) for the correct brand

of product to check how much sodium is in the product; this is usually
listed in the ‘qualitative and quantitative composition section’ or ‘list of
excipients’.
• If the SPC does not give enough information, consider checking the
National Injectable Medicines Guide (MEDUSA1) or contacting the
manufacturer directly.
• Check whether the drug is further diluted for administration, each
additional 100mL of sodium chloride 0.9% increases the sodium load by
15mmol.
Oral medicines
Similar principles apply to oral medicines as to IV medicines:
• Use the SPC and BNF to check for the sodium content of oral
medicines.
• Soluble, effervescent, or dispersible tablets often have a high sodium
content.
• Some antacids contain high amounts of sodium; the BNF annotates
antacids with a low sodium as ‘low Na’.
• Orodispersible preparations usually do not contain significant amounts
of sodium.
If a reduction in sodium load is required, consider:
• Is the medicine really necessary?
• Can it be given by an alternative route (e.g. switch from IV to oral or
NG)?
• Can the infusion volume be safely reduced (e.g. give undiluted via a
central line)?
• For infusions, can a diluent other than sodium chloride 0.9% be used?
• For oral preparations, can an alternative form be used (e.g. suspension
instead of soluble tablet)?
• Does the drug increase serum sodium by its pharmacological effect?

 
861

Sodium content of parenteral drugs 681

Other sources that quote the sodium content
of parenteral formulations

Barber N, Wilson A (2006). Clinical Pharmacy (2nd ed). Edinburgh: Churchill Livingstone.
Pharmacy Department, University College London Hospitals (2010). UCL Hospitals Injectable Drug

Administration Guide (3rd ed). Chichester: John Wiley and Son.
electronic Medicines Compendium (eMC). ‘Summaries of Product Characteristics’ M www.emc.

medicines.org.uk

Table A1  Sodium content of parenteral drugs

Name Vial/ampoule size Sodium content per vial (mmol)

Acetylcysteine 2g 12.78
Aciclovir 250mg 1

Addiphos® 20mL 30
Amoxicillin 250mg 0.7
Amphotericin lipid 100mg 3.13
complex (Abelcet®)
Amphotericin liposomal 50mg <0.5
(AmBisome®)

Ampicillin 250mg 0.7
Atenolol 5mg 1.3–1.8

Benzylpenicillin 600mg 1.68
Cefotaxime 500mg 1.1
Ceftazidime 500mg 1.2
Ceftriaxone 1g 3.6
Cefuroxime 50mg 1.8
Chloramphenicol sodium 1g 3.14
succinate
Ciprofloxacin 200mg 15.4
Clomethiazole 500mL 15–16
Co-amoxiclav 600mg 1.6

Co-trimoxazole 480mg 1.7
Desmopressin 4 micrograms 0.15
Diazoxide 300mg 15
Disodium hydrogen 10mL 12
phosphate

Ertapenem 1g 6
Flucloxacillin 250mg 0.5
Fluconazole 200mg 15

(Continued)

862

682 Appendix   Supplementary data

Table A1  (Contd.) Vial/ampoule size Sodium content per vial (mmol)
Name 2.5g 34.44
Flucytosine 15mg 0.2
Folinic acid 1g 15.6
Foscarnet 250mg 1
Furosemide 500mg 2
Ganciclovir 3mg 1.17
Granisetron 25000IU/mL 0.625–0.8
Heparin 100mL 100–160 (check label for
Human albumin solution exact amount)
(all concentrations) 100mg
Hydrocortisone: 100mg 0.66
  Sodium phosphate 500mg 0.37
  Sodium succinate 500mg 1.72
Imipenem 1g 15.4
Levofloxacin 10mg 3.9
Meropenem 500mg 0.27
Metoclopramide 200mg 13–14.55
Metronidazole 15.4
Ofloxacin 15mg
Pamidronate: 30mg 0.1
 Dry powder 90mg 0.2
15mg 0.3
 Solution 30mg 1.1
250mg 1.1
Phenytoin 4.5g 1.1
Piperacillin + tazobactam 300mg 9.4
Rifampicin 600mg <0.5
1.26% <0.5
Sodium bicarbonate 4.2% 150/L
8.4% 500/L
Sodium chloride 0.9% 1000/L
Sodium nitroprusside 50mg 150/L
Sodium valproate 400mg 0.34
Sotalol 40mg 2.41
0.5

 
638

Sodium content of parenteral drugs 683

Table A1  (Contd.) Vial/ampoule size Sodium content per vial (mmol)
Name 200mg <0.5
Teicoplanin 400mg <0.5
500 micrograms 0.15
Terbutaline 500mg 23.26
Thiopental sodium 3.2g 16
Ticarcillin + clavulanic acid 5mg 0.3
Verapamil
Vitamins B and C: 1+2 ampoules 2.95
  Pabrinex® 1+2 ampoules 2.92

high-potency IV
  Pabrinex®

high-potency  IM

Reference

1.‘MEDUSA’, website, M www.medusa.wales.nhs.uk

Pathology ranges and interpretation

See Table A2.

Table A2  Pathology ranges and interpretation

Levels i by L

Sodium (Na+) Water depletion, nephrogenic diabetes insipidus, W
135–145mmol/L (e.g. lithium toxicity), mineralocorticoid excess (e.g. (e
Cushing’s syndrome), corticosteroids, Secondary lo
aldosteronism (e.g. CCF), nephritic syndrome, d
hepatic cirrhosis, and uraemia p
Symptoms: dry skin, postural hypotension, oliguria. h
Cerebral dehydration l thirst, confusion, and c
eventually coma S
c
Potassium (K+) Mineralocorticoid deficiency (e.g. Addison’s a
3.5–5.0mmol/L thyroid deficiency) ACE inhibitors, K+-sparing
diuretics, renal failure, severe tissue damage (e.g. T
burns), hypoaldosteronism, diabetic ketoacidosis, il
excess K+ therapy, NSAIDs, β-blockers, heparin th
infusions, and sodium depletion (very rare) sy
Symptoms: muscle weakness and abnormal cardiac a
conduction (e.g. ventricular fibrillation, and S
asystole) m

Levels d by Comments 864
Regulated by aldosterone
Water excess, mineralocorticoid deficiency (ADH) 684 Appendix   Supplementary data
e.g. Addison’s, thyroid deficiency), thiazide and
oop diuretics, burns, SIADH, excess sweating, Regulated by aldosterone,
diarrhoea, vomiting, aspiration, atypical insulin/glucose. For
pneumonia, haemodilution caused by cardiac, hypokalaemia, if
hepatic or renal failure, oedema, infection, and on diuretics, then i
carcinoma bicarbonate is the
Symptoms: headache, nausea, hypertension, best indication that
cardiac failure, cramps, confusion, convulsions, hypokalaemia is likely
and overhydration to be longstanding.
Magnesium might be low
Thiazide and loop diuretics, vomiting, diarrhoea, and hypokalaemia is often
leostomy, fistula, steroids, glucose and insulin difficult to correct until
herapy, mineralocorticoid excess (e.g. Cushing’s magnesium is normalized
yndrome), β-agonists, aspiration and metabolic
alkalosis
Symptoms: hypotonia, cardiac arrhythmias,
muscle weakness, and paralytic ileus

Levels i by L

Chloride (Cl–) Excess ingestion and dehydration V
95–105mol/L Symptoms: non-specific n
Bicarbonate S
(2H4–C3O0m3−)mol/L Excessive antacid use, thiazide and loop diuretics, D
Glucose metabolic alkalosis, bicarbonate, hypokalaemia, m
3.0–8.0mmol/L vomiting, and Cushing’s syndrome h
Symptoms: vomiting S
Magnesium (Mg2+) se
0.70–1.10mmol/L Diabetes mellitus, severe stress, occasionally In
after CVA, corticosteroids, thiazides, relative e
insulin deficiency caused by i growth hormone, S
i glucocorticoids or placental lactogen during ta
pregnancy (glucagonaemia)
Symptoms: polyuria, polydipsia and ketoacidosis S
Renal failure and excessive antacids d
Symptoms: loss of muscle tone, lethargy and h
respiratory depression S
a
Zinc (Zn2+) 11–24µ Zinc therapy h
C
n
m
S
a

Levels d by Comments  
865
Vomiting, diarrhoea, diuretics, dehydration and Cl– follows Na+
nephropathy movement Pathology ranges and interpretation 685
Symptoms: non-specific Reflects renal, metabolic,
and respiratory functions
Diarrhoea, renal failure, diabetes mellitus,
metabolic acidosis, respiratory alkalosis, and
hyperventilation
Symptoms: headache, drowsiness, and coma in
evere acidosis

nsulin overdose, sulphonylureas especially in the
elderly, insulinoma, alcohol, and hepatic failure
Symptoms: dizziness, lethargy, sweating,
achycardia, agitation, and coma

Severe diarrhoea, fistula, alcohol abuse, diuretics, Deficiency can exacerbate
diabetes mellitus, TPN, hyper-aldosteronism, digitalis toxicity and Mg2+
hepatic cirrhosis, and malabsorption is excreted by the kidneys
Symptoms: tetany, paraesthesiae, cramps,
arrhythmias, neuromuscular excitability, and
hypoparathyroidism

Cirrhosis, diarrhoea, alcoholism, drugs, parenteral
nutrition, inadequate diet, steroids, diuretics,
malabsorption syndrome, and rarely genetic
Symptoms: poor wound healing and growth,
alopecia, infertility, and poor resistance to infection

(Continued)

Table A2  (Contd.) Levels i by L
Calcium (Ca2+) Paget’s disease, vitamin A overdose, T
2.20–2.60mmol/L hyper-parathyroidism, vitamin D overdose, re
(Determine thiazides, oestrogen, lithium, tamoxifen, excess a
corrected calcium milk ingestion, excess calcium absorption, S
level in hypoal­ Hodgkin’s disease, and myeloma c
buminaemia and Symptoms: nausea, vomiting, constipation, abdominal n
hyperalb­ uminaemia) pain, renal stones, cardiac arrhythmias, headache,
P0.h8o–s1p.h4amtem(oPl/OL43−) depression, mental fatigue, and psychosis O
Urea 2.5–7.0mmol/L Renal failure, hypoparathyroidism, diabetic a
ketoacidosis, and i vitamin D a
Creatinine i
20–110µmol/L (Cr/ Renal failure, elderly (caused by d renal function), p
Cl 80–139mL/min urinary tract obstruction, CCF, dehydration, li
(not considered corticosteroids, high-protein diet, i catabolism o
impaired unless (e.g. starvation), sepsis, and GI bleed P
<50mL/min)) Dehydration, renal failure, d GFR, urinary tract
obstruction, and i meat/vitamin C

Levels d by Comments 86
Apparent hypocalcaemia
Thyroid surgery, hypoparathyroidism, alkalosis, might be caused by 686 Appendix   Supplementary data
enal failure, osteomalacia, vitamin D deficiency hypoalbuminaemia.
and acute pancreatitis Regulated by parathyroid
Symptoms: i nervous excitability, tetany, hormone calcitonin
convulsions, muscle cramps, spasms, tingling, (1,25-dihydroxychole-calc
numbness of fingers, and ECG changes iferol)

Osteomalacia (starvation), hyperparathyroidism, mCae2t+abanodlisPmOc4l3o- sely linked
alcohol abuse, d vitamin D, Al(OH)3 therapy,
and septicaemia Derived from amino-acid
metabolism in the liver;
i GFR, pregnancy, excessive IV infusion, low indicator of kidney
protein intake, anabolic states or synthesis, function
iver failure, diabetes insipidus, diuresis, and Derived from muscle
overhydration. mass, determined by lean
body mass, and indication
Pregnancy and chronic muscle wasting of glomerular insufficiency

Levels i by L

Alkaline Renal failure, cholestasis, liver cell H
phosphatase damage, osteomalacia and bone disease,
<125IU/L hyper-parathyroidism (e.g. Paget’s disease) S
and metastases. Also during third trimester of h
Creatine kinase pregnancy, post menopause, carcinoma of liver/ p
32–184IU/L prostrate, and drug-induced (e.g. chlorpromazine) d
Haemoglobin ♂: MI, skeletal muscle damage (even IM injection), c
135–180g/L♀: muscular dystrophy, acute psychotic episodes, D
115–160g/L head injury, surgery, hypothyroidism, alcoholism, re
White cell count and neonates le
4.0–11.0 × 109/L Polycythaemia and dehydration a
Haematocrit or A
packed cell volume Drugs (e.g. steroids), infection, septicaemia,
♂: 0.4–5.0L/L ♀: malignancy, sulphonamides, bacterial infection,
0.37–0.47L/L alcohol hepatitis, and cholecystitis
Addison’s thyroid deficiency, dehydration,
polycythaemia and pregnancy

Levels d by Comments  
Hypothyroidism and growth retardation 750% bone-related, 750% 867
hepatic fraction, and
72–3% intestinal fraction Pathology ranges and interpretation 687

Found in heart, skeletal
and smooth muscle, and
brain

Sickle cell disease, thalassaemia, GI bleed,
haemorrhage (acute/chronic) deficient RBC
production, iron deficiency, bone marrow
depression, renal failure, d haemolysis and
chronic liver disease

Drugs, bacterial infections, HIV, hypersensitivity Produced in bone
eactions, surgery, trauma, burns, haemorrhage, marrow and stimulated
eukaemia, radiation, cytotoxics, d vitamin B12, by GSF
and d folate Relative measure of cells
in blood and packed cell
Anaemia and haemorrhage volume

(Continued)

Table A2  (Contd.) Levels i by L
Platelets 150–400 Inflammatory disorders, bleeding, malignancy, d
× 109/L splenectomy, and polycythaemia su
d
Prothrombin Severe liver damage, cholestasis causing i
time 10–14s malabsorption of vitamin K and warfarin g
INR—0.8–1.2
D
Thrombin time Heparin and DIC C
12–15s Heparin, haemophilia, and liver failure L
APPT d
sy
Fibrinogen Nephrotic syndrome, Hodgkin's, and PE S
1.7–4.1g/L n
Total protein Mineralocorticoid deficiency (e.g. Addison’s b
60–80g/L thyroid deficiency) and myeloma
Albumin 35–50g/L Dehydration and shock
t½=20–26 days

Levels d by Comments 86
d production: bone-marrow failure/ Derived from
uppression, leukaemia, drugs (notably cytotoxic megakaryocytes in bone 688 Appendix   Supplementary data
drugs), megaloblastic anaemia, SLE, heparin. marrow and destroyed
i consumption: DIC, splenomegaly, furosemide, in spleen
gold, idiopathic thrombocytopenia.
Used to monitor
anticoagu­lant therapy
(not DOACs) and assess
liver function

Used to monitor heparin
therapy

DIC and massive blood transfusion

Catabolic states (e.g. septicaemia)

Lost through skin (e.g. burns and psoriasis) liver
disease, mal-nutrition, septicaemia, nephrotic
yndrome, and late pregnancy
Symptoms: oedema and toxic effects of drugs
normally bound to albumin (e.g. calcium,
bilirubin, and phenytoin)

Levels i by L

Bilirubin—total Hepatocellular damage (e.g. viral hepatitis— R
<17µmol/L inability to conjugate bilirubin), cholestasis (e.g. H
Bilirubin— by phenothiazines and flucloxacillin) gallstones,
conjugated (bound inflammation, malignancy, Gilbert’s syndrome,
to albumin) haemolysis, methyldopa, GI bleed, extensive
<4µmol/L bruising, and sulphonamides (displace bilirubin
from albumin)
γ-glutamyl Symptoms: jaundice
transpeptidase Cholestasis (e.g. carcinoma of pancreas or
♂: 11–51IU/L ♀: biliary tract), liver cell damage (e.g. hepatitis
7–33IU/L and cirrhosis). Enzyme inducers (e.g. alcohol,
Aspartate phenytoin, and phenobarbital) and alcoholism
transaminase
5–35IU/L Hepatocellular damage, cirrhosis, viral hepatitis,
Amylase <180U/ severe haemolytic anaemia, myocardial injury (e.g.
dL random urine MI), cholestasis, trauma, or surgery
<650IU/L Acute pancreatitis, abdominal trauma, diabetic
ketoacidosis, chronic renal failure, cholecystitis,
intestinal obstruction, mumps, ruptured ectopic
pregnancy, post-MI ruptured DU, and morphine

Fibrin degradation DIC and adult respiratory distress syndrome
products <10
micrograms/mL

Levels d by Comments  
Derives from breakdown 869
of RBCs by monocyte
macrophage system Pathology ranges and interpretation 689

Renal failure and vitamin B deficiency Found in liver, kidneys,
Hepatitis and pancreatic insufficiency pancreas and prostate;
released by tissue damage

Found in liver, heart,
kidneys, skeletal muscle,
and erythrocytes
Found in parotid glands
and pancreas. Smaller
amounts in ovaries,
intestine, and skeletal
muscle

(Continued)

Table A2  (Contd.) Levels i by L
Cholesterol Diabetes mellitus, familial hypercholesterolaemia S
3.9–6mmol/L excess alcohol, hypothyroidism, and hepatic and fi
pH 7.35–7.45 renal diseases
Vomiting, K+ loss, burns, hyperventilation, stroke, R
SAH, anxiety, hyperthyroidism, excess antacids, re
aspirin overdose, fever, and uncompensated p
alkalosis a

PaO2 >10.6kPa Artificial over-ventilation with O2 C
P2Tao4C–ta3Ol0C2mO4m.72o–l6.0kPa COAD, hypoventilation, respiratory acidosis and c
ARDS-compensated metabolic alkalosis H
a
m
n

Levels d by Comments 960
Severe illness, severe weight loss, and MI (during Treatment will depend on
first 2wks) other risk factors 690 Appendix   Supplementary data

Respiratory failure, hypoventilation, diarrhoea, Reflects ratio of acid to
enal failure, ketoacidosis, trauma, shock, high base and not absolute
plasma lactate (e.g. liver failure), hypoxia, concentration. Therefore
anaemia, and uncompensated acidosis it might mask a defect
for which the body has
COAD, respiratory failure, ARDS, and compensated
cardiogenic pulmonary oedema Indicator of respiratory
Hyperventilation, respiratory alkalosis, CVA, function
anxiety, aspirin overdose, compensated
metabolic acidosis, pulmonary embolism, and
non-cardiogenic ARDS

 
619

Normal ranges 691

Normal ranges

See Table A3.

Table A3  Normal ranges

Sodium 135–145mmol/L White cell count 4.0–11 × 109/L
Potassium 3.5–5.0mmol/L PCV/haematocrit ♂=0.4–0.54L/L
Chloride 95–105mmol/L PCV/haematocrit ♀=0.37–0.47L/L
Bicarbonate 24–30mmol/L Platelets 150–400 × 109/L
Glucose (fasting) 3.5–5.5mmol/L INR 0.8–1.2
Magnesium 0.75–1.05mmol/L KCR 0.8–1.2
Phosphate 0.8–1.4mmol/L Thrombin time Ratio <1.2
Zinc 11–24µmol/L Fibrinogen 1.7–4.1g/L
Calcium 2.12–2.65mmol/L Albumin 35–50g/L
FDP <10 micrograms/mL Total protein 60–80g/L
Urea 2.5–6.7mmol/L Bilirubin (total) 3–17µmol/L
Creatinine 70–150µmol/L Bilirubin <4µmol/L
(conjugated)
Cr/Cl 80–139mL/min GGT ♂: 11–40IU/L
♀: 7–33IU/L
Alk phos <150IU/L AST 5–35IU/L
Creatine kinase ♂: 25–195IU/L
♀: 25–170IU/L Amylase <180IU/L
Haemoglobin ♂=135–180g/L Amylase (random <650IU/L
Haemoglobin ♀=115–160g/L urine)
PaO2 >10.6kPa
Cholesterol 3.9–6mmol/L PaCO2 4.7–6.0kPa
pH 7.35–7.45

926

692 Appendix   Supplementary data

Paediatric normal laboratory values

The values given in Tables A4–A10 are a guide; local laboratories may differ.
Check normal values with the laboratory you use. You will find here tables
on biochemistry (Table A4), haematology (Table A5), respiratory rate
(Table A6), blood pressure (Table A7), urinary output (Table A8), hypogly-
caemia (Table A9), and electrolyte requirements (Table A10).

Table A4  Biochemistry

Alanine Newborn–1 month ≤70IU/L
aminotransferase Infants and children 15–55IU/L

Albumin Preterm Day 1 25–45g/L
Newborn (term) Day 2 25–50g/L
Alkaline 1–3 months Days 3–5 30–42g/L
phosphatase 3–12 months >1 month 27–50g/L
Amylase 1–15yrs 32–50g/L
Aspartate Newborn ♂
amino-transferase 6 months–9yrs ♀ 150–600U/L
Bilirubin 250–800U/L
Full term ♂
♀ 70–300IU/L
Calcium Preterm
Chloride Infants <45IU/L
Creatine kinase >1yr
<65µmol/L
Creatinine Newborn <115µmol/L
1 month <155µmol/L
Creatinine 1yr <10µmol/L
clearance Children
1.5–2.5mmol/L
0–2yrs 2.25–2.75mmol/L
2–6yrs 2.25–2.6mmol/L
6–12yrs
>12yrs 95–105mmol/L

<37wks’ gestation <600IU/L
Neonate <400IU/L
1–2wks <30IU/L
2–4 months <190IU/L
6–125 months <130IU/L
12 months to adult
20–50µmol/L
25–60µmol/L
30–80µmol/L
65–120µmol/L
50–110µmol/L

<15mL/min/m2
10–20mL/min/m2
20–35mL/min/m2
35–45mL/min/m2
45–60mL/min/m2
50–85mL/min/m2

 
963

Paediatric normal laboratory values 693

Table A4  (Contd.)

C-reactive protein <20mg/L

γ-glutaryl Newborn <200IU/L
transferase
1 month–1yr <150IU/L
>1yr <30IU/L

Glucose Newborn–3 days 2–5mmol/L
>1wk 2.5–5mmol/L

Lactate 0.7–1.8mmol/L

Magnesium Newborn 0.7–1.2mmol/L
Child 0.7–1mmol/L

Phosphate Pre-term first month 1.4–3.4mmol/L
Full-term newborn 1.2–2.9mmol/L
1yr 1.2–2.2mmol/L
2–10yrs 1–1.8mmol/L
>10yrs 0.7–1.6mmol/L

Potassium 0–2wks 3.7–6mmol/L
2wks–3 months 3.7–5.7mmol/L
>3 months 3.5–5mmol/L

Protein (total) 1 month 50–70g/L
1yr 60–80g/L
1–9yrs 60–81g/L

Sodium 135–145mmol/L

Urea 0–1yr 2.5–7.5mmol/L
1–7yrs 3.3–6.5mmol/L
7–16yrs ♂ 2.6–6.7mmol/L
♀ 2.5–6mmol/L

Table A5  Haematology

Age Hb (g/L) MCV (fL) WBC Reticulocyte
Mean (range) Mean (range) (× 109/L) range (%) range

Birth 185 (145–215) 108 (95–116) 5–26 3–7

1 month 140 (100–165) 104 (85–108) 6–15 0–1

6 months 110 (850–135) 88 (80–96) 6–15 0–1

1yr 120 (105–135) 78 (70–86) 6–15 0–1

6yrs 125 (115–140) 81 (75–88) 6–15 0–1

12yrs 135 (115–145) 86 (77–94) 5–15 0–1

Note: an artefactual high neonate WBC may be reported because automatic cell counters may
wrongly include in the WBC the many normoblasts (red cell precursors) in the neonate.

649

694 Appendix   Supplementary data

Table A6  Respiratory rate

Newborn 30–60 breaths/min Heart rate is usually four
6 months 30–45 breaths/min times the respiratory rate
1–2yrs 25–35 breaths/min
3–6yrs 20–30 breaths/min
>7yrs 20–25 breaths/min

Table A7  Blood pressure

Mean (mmHg)

Systolic BP Diastolic BP

Newborn to 2yrs 95 55

3–6yrs 100 65

7–10yrs 105 70

11–15yrs 115 70

Table A8  Urinary output mL/day
250–600
Infant 500–1000
Child 500–1500
Adolescent 500–2000
Adult

Table A9  Hypoglycaemia Serum glucose (mmol/L)
<1.4
Pre-term <2.0
Term <2.5
Child

Table A10  Electrolyte requirements

Na+ 2–4mmol/kg body weight/24h
K+ 1–3mmol/kg body weight/24h
Cl− 3–5mmol/kg body weight/24h
Ca2+ 1mmol/kg body weight/24h
Mg2+ 0.15mmol/kg body weight/24h

 
659

Useful websites 695

Useful websites

See Table A11.

Table A11  Useful websites E Web address (URL)
Description http://www.asco.org
American Society of Clinical Oncology
(ASCO) http://www.hematology.org
American Society of Hematology (ASH) http://www.ashp.org
American Society of Health-System
Pharmacists http://www.annals.org
Annals of Internal Medicine http://www.tga.gov.au
Australian Therapeutic Goods
Administration http://www.bnf.org
BNF http://www.bcshguidelines.com
British Committee for Standards in
Haematology (BCSH) guidelines http://www.bmj.com
British Medical Journal (BMJ) http://www.bopawebsite.org
British Oncology Pharmacy Association
(BOPA) http://www.b-s-h.org.uk
British Society for Haematology (BSH) http://www.nlm.nih.gov/hsrinfo/
Canadian Health Technology Assessment evidence_based_practice.html
Programme http://www.improvement.nhs.
Cancer Improvement uk/cancer
http://www.cancerresearchuk.org
Cancer Research UK http://www.corec.org.uk
COREC http://www.
Counterfeit drugs pharmacistscombatcounterfeiting.
org
CPD for Pharmacists http://www.uptodate.org.uk
Cytotoxic guidelines http://www.marchguidelines.com
Department of Health http://www.dh.gov.uk
Drugs in breast milk http://www.ukmicentral.nhs.uk
Electronic Medicines Compendium http://www.medicines.org.uk/emc
European Society for Medical Oncology http://www.esmo.org
(ESMO)
Evidence in Health and Social Care http://www.evidence.nhs.uk
Gene Therapy Advisory Committee http://www.dh.gov.uk/ab/GTAC/
(GTAC) index.htm?ssSourceSiteId=en

(Continued)

96

696 Appendix   Supplementary data

Table A11  (Contd.) E Web address (URL)
Description http://www.pharmacyregulation.org
General Pharmaceutical Council http://www.hse.gov.uk/
Health and Safety Executive (HSE) http://www.herbmed.org
Herbal medicines—includes evidence for
efficacy, ADRs and drug interactions http://www.isopp.org
International Society of Oncology Pharmacy
Practitioners (ISOPP) http://www.jco.org
Journal of Clinical Oncology (JCO) http://www.jama.ama-assn.org
Journal of the American Medical Association
(JAMA) http://www.thelancet.com
Lancet http://www.macmillan.org.uk
Macmillan Cancer Information http://www.malariahotspots.co.uk
Malaria advice (no prophylaxis advice) http://www.mhra.gov.uk
Medicines and Healthcare products
Regulatory Agency (MHRA) http://www.ukmi.nhs.uk
Medicines information http://www.pharmalife.co.uk
Medicines management and pharmaceutical
care http://www.merck.com/mmpe/
Merck manual full-text online index.html
http://www.library.nhs.uk
National Electronic Library for Health http://www.nice.org.uk
National Institute for Health and Care
Excellence (NICE) http://www.npc.co.uk
National Prescribing Centre http://www.nta.nhs.uk
National Treatment Centre for Substance
Misuse http://www.nejm.org
New England Journal of Medicine http://ohcm.oxfordmedicine.com
Oxford Handbook of Clinical Medicine http://www.palliativedrugs.com
Palliative care http://www.pharmweb.net/
Paracetamol Information Centre (includes paracetamol.html
guidelines on treatment of overdose) http://www.nelm.nhs.uk/en/
Patient-group directions Communities/NeLM/PGDs
http://www.pjonline.com
Pharmaceutical Journal http://www.renal.org/home.aspx
Renal Association http://www.rpharms.com
RPSGB http://www.sign.ac.uk
Scottish Intercollegiate Guideline Network
(SIGN)

(Continued)

 
967

Useful websites 697

Table A11  (Contd.) E Web address (URL)
Description http://www.dh.gov.uk/en/
TB information in various languages Publicationsandstatistics/
Publications/
Travel advice, specific to destination— PublicationsPolicyAndGuidance/
includes vaccinations and malaria prop DH_116689
Travel shop, includes travel health http://www.fitfortravel.scot.nhs.uk
information and medical supplies
Travel—health information (subscription http://www.nomadtravel.co.uk
required, free NHS Scotland)
WHO Action Programme on Essential http://www.travax.scot.nhs.uk
Drugs
http://www.who.int/dap

In vitro activity of antibacterials

See Table A12

Table A12  In vitro activity of antibacterials ? = variab

= usually sensitive

Note: These are generalizations. There are major differences between countries, areas, and hospitals. Che
not be licensed to treat the bacteria for which they are active.

Gram positives

Staphylococcus aureus MSSA
Staphylococcus aureus MRSA
Staphylococcus epidermidis
Haemolytic streptococci
(Strep A, C, G and Strep B)
Enterococcus faecalis
Enterococcus faecium
Streptococcus pneumoniae
Listeria monocytogenes

Penicillins ×× ×   ? × 
Phenoxymethylpenicillin  ?  
Benzylpenicillin ×× ×   ?  
Ampicillin/Amoxicillin  ? × 
Co-amoxiclav ×× ×  × × × ×
Flucloxacillin  ? ×
Pip+tazobactam ×   

Cephalosporins × ? 
Cefradine/Cefalexin
× ? 

× ?  × × × ×

ble sensitivity X = usually resistant or 968
   inappropriate therapy
698 Appendix   Supplementary data
eck local Public Health or Microbiology laboratories for local sensitivity patterns. Antibacterials may

Anaerobes Gram negatives Atypicals

Clostridium perfringens
Clostridium difficile
Bacteroides fragilis
Neisseria meningitidis
Neisseria gonorrhoeae
Haemophilus influenzae
Escherichia coli
Klebsiella spp
Proteus mirabilis
Proteus vulgaris
Pseudomonas aeruginosa
Moraxella catarrhalis
Legionella spp
Mycoplasma pneumoniae
Chlamydia spp

 × × × ? × ×× ×× × × ×× ×

 × ×  ? × ×× ×× × × ×× ×

 × ×  ? ? ? ×  × × × × ×

 × × ?  ?  ×  × × ×

× × × × × × ×× ×× × × ×× ×

 ×       × × × × ×

× × × × × × ? × × × × × ×

Gram positives

Staphylococcus aureus MSSA
Staphylococcus aureus MRSA
Staphylococcus epidermidis
Haemolytic streptococci
(Strep A, C, G and Strep B)
Enterococcus faecalis
Enterococcus faecium
Streptococcus pneumoniae
Listeria monocytogenes

Cefotaxime × ?  × × × ×

Cefuroxime × ?  × × × ×
× × × ×
Ceftriaxone × ?  × ×? × ×

Ceftazidime ? ×? 

Carbapenems

Ertapenem ×   ? × ? 

Meropenem/Imipenem ×   ? ?× 

Macrolides/Lincosamides

Azithromycin × ×  × × × 
× × × ×
Erythromycin × ?  × × × 
× × × 
Clarithromycin × × 

Clindamycin × × 

Aminoglycosides

Amikacin  ? × 1 × × 1 ×
1 1 × 1 ×
Gentamicin  ? ×

Diaminopryimidines and sulphonamides

Co-trimoxazole ? ? ? × × × ×
×
Trimethoprim ?? ? ?  ×? ×

× × ×  ?    ?  × × × Clostridium perfringens Anaerobes
× × × × ?    ×  × × ×
× × ×      ?  × × × Clostridium difficile Gram negatives
× × × ? ?      × × × Bacteroides fragilis
Neisseria meningitidis Atypicals
 ×       ×  × × × Neisseria gonorrhoeae
 ×         × × × Haemophilus influenzae
Escherichia coli
 × ×  ?  ×× × × ×    Klebsiella spp
× × ×  ? ? ×× × × ×    Proteus mirabilis
 × × × ?  ×× × × ×    Proteus vulgaris
 × × × × ×× ×× × × ×× × Pseudomonas aeruginosa
Moraxella catarrhalis
× × × × ×      × × Legionella spp
× × × × ×      × × Mycoplasma pneumoniae
Chlamydia spp
× × ×  ? ?  × ×  × 
× × × ? × ?  × × × × × ×

(Continued)

In vitro activity of antibacterials 699

 
96

Table A12  (Contd.)

Gram positives

Staphylococcus aureus MSSA
Staphylococcus aureus MRSA
Staphylococcus epidermidis
Haemolytic streptococci (Strep
A, C, G and Strep B)
Enterococcus faecalis
Enterococcus faecium
Streptococcus pneumoniae
Listeria monocytogenes

Quinolones

Ciprofloxacin ×  × × ×× × ×
 ?  × × 
Levofloxacin ×    ? × 

Moxifloxacin ×    ?  
?   ?  
Glycopeptides
× × × ×× × 
Vancomycin (IV) 
     
Teicoplanin 
× ? × ×  
Nitromidazoles
×  ? ?× ?
Metronidazole ××   ×   

Oxazolidinones

Linezolid 

Tetracyclines

Doxycycline ?

Miscellaneous

Chloramphenicol ?×

Quinupristin/dalfopristin(Synercid®)  

1Sensitive if used synergistically with penicillins/glycopeptides.

2 IV vancomycin ineffective for Clostridium difficile.

? ?  × ? × × ? ×× ×× × × ××  ?   × × × ×× ×× × × ×× ×  ×2 × × × × × × × × × × × × × × × ×          Clostridium perfringens
 × × × × × ×× ×× × × ×× ×  × ×      ?   
× ? ×     ? ? × ×?  × ?      ?    Clostridium difficile Anaerobes
Bacteroides fragilis
×× × × ×    ? ? ×    ×× ×× × × ××  Neisseria meningitidis Gram negatives
Neisseria gonorrhoeae
Haemophilus influenzae Atypicals
Escherichia coli
Klebsiella spp
Proteus mirabilis
Proteus vulgaris
Pseudomonas aeruginosa
Moraxella catarrhalis
Legionella spp
Mycoplasma pneumoniae
Chlamydia spp

70

700 Appendix   Supplementary data

07 1 701

Index

5-H​ T3 receptor additive drug interactions  25 determination of
antagonists 535 adherence causality 20

A antiretroviral failure to report, ‘seven
treatment  476–7​ deadly sins’  22
abacavir, HLA-B*5701
status 476 assessment of  5 to herbal
children  210–​11 medicines 145, 146
abatacept 603
abbreviations  43–​8 making medicines more information provision  10
ABC (Airway, Breathing, palatable 211 new drugs  244
predisposing factors  20
Circulation) 367 ‘pill school’  212–1​ 3 reporting 22, 260
abciximab COM-​B model  3, 4 risk communication  21
definition 2 risk in older
in NSTE-​ACS  365 importance of  2
in PCI  358 influencing factors  2–4​ people 214, 216
abiraterone role of health coaching  14 when to report  288–9​
dosage 529 TB treatment  480 aggressive patients  66–​7,
frequency of adherence
84–5​
administration 529 consultations  8–​10 limit setting  67
absorption four E’s triangle  9 agomelatine,
information checklist  10
in children  205 adherence support  2, 6–7​ hepatotoxicity 420
drug interactions  23 practical strategies  7 AIDS 473
effect of diarrhoea  302 administration of medication
in older people  215 cytotoxic drugs  520–​1 see also HIV
acamprosate 660 air, clinical uses  158
acanthamoeba keratitis  677 intrathecal  541–3​ alanine aminotransferase
acarbose 487 in enteral nutrition  589–​91
accountable officer, con- risk management  64–​5 (ALT) 173
safety issues  285 normal range, paediatric
trolled drugs  118 see also intravenous drug
Accuhaler® inhaler  387 values 692
ACE inhibitors  see administration albumin administra-
administration sets  554–​5
angiotensin-c​ onverting tion, in hepatorenal
enzyme inhibitors burette sets  554 syndrome 179
acetazolamide, in changing 554 albumin levels  173
glaucoma 675 peripheral venous access normal range  691
aciclovir, in keratitis  677 paediatric values  692
acitretin 627 devices 555 range and
aconite 146 adolescents
perioperative interpretation 688
non-a​ dherence  211 alcohol dependence, liver
considerations 153 see also children
activated charcoal  302 adrenaline disease 174
activated partial thrombo- in anaphylaxis  29 alcohol poisoning  661
alcohol withdrawal
plastin time (APPT)  688 doses 30
active transport  572 in cardiac arrest  370 nutrition  659–6​ 0
acute commissioning  278 emergency adminis- at discharge  660
acute coronary syndrome thiamine deficiency  659
tration without a thiamine
(ACS) 354 prescription 30 replacement  659–6​ 0
see also myocardial adrenaline auto-​injectors  29
adrenal insufficiency  394 relapse prevention  660
infarction; non-S​ T advanced life suggested regimen
segment elevation support  369–​70
myocardial infarction; drug administration 658–9​
ST-s​ egment elevation 370–​1 alcohol withdrawal
myocardial infarction; adverse drug reactions
unstable angina (ADRs) 18, 288 syndrome (AWS)  658
adalimumab 601 classification of  19 aldosterone receptor
in psoriasis  628 Common Terminology
addiction  see drug misusers Criteria for Adverse antagonists
Events (CTCAE)  540 in heart failure  331
secondary prevention of

CVD 362
alemtuzumab  444–5​
alendronic acid  608
alginates 314

072

702 INDEX

alginate wound anaesthesia, regional  405 avoidance in
dressings 617 anakinra 603 pregnancy 512
analgesia
alkaline phosphatase in heart failure  331
(ALP) 173 acute pain management in hypertension  336–​8
NNT league table secondary prevention of
normal range  691 of acute pain
paediatric values  692 treatments 404 CVD  325–6​ , 362
NSAIDs and angiotensin II receptor
range and non-o​ pioids  404–5​
interpretation 687 opioids 405 antagonists (ARBs)
regional anaesthesia  405 avoidance in
allergic contact topical agents  405
dermatitis  619–2​ 2 pregnancy 512
in acute porphyria  201 in heart failure  332
allergies 54 cancer pain  406–7​ in hypertension  336–8​
anaphylaxis prevention  32 secondary prevention of
egg allergy  196–​7 breakthrough pain  407
to penicillin and spinal opioids  407 CVD  325–​6
cephalosporins 458 chronic pain angle-c​ losure
see also anaphylaxis;
desensitization management 411 glaucoma  674–5​
drug compatibilities  409 animal insulins  489
allodynia  398–9​ equianalgesic doses for ankylosing spondylitis  605
allopurinol 611
alpha-​blockers opioids 408 biologic therapies  601–​2
in liver failure  178 anorexia 630
in glaucoma  674 in neuropathic pain  412 antacids 314
in hypertension  337, 339 opioid and NSAID antagonistic drug
alpha-​glucosidase
combinations 407 interactions 25
inhibitors 487 in patients who misuse anterior segment of the
alteplase  359–​60
ambulatory infusion drugs  221–​2 eye 673
WHO analgesic anthracyclines, extravasation
pumps 558
ambulatory oxygen ladder 406 management 550
analogue insulins  489 antibiotics  see antimicrobials
therapy  168–9​ AnaPen® 29 anticoagulants
amikacin, therapeutic drug anaphylaxis
alternatives to
monitoring 672 causative agents  28 warfarin 353
amino acid solutions, for late sequelae  31
prevention of  32 drug interactions
children 583 recognition of  28 with herbal
aminoglycosides, mode of symptoms and signs  28 medicines 151, 152
treatment  29–3​ 1
action 451 and liver disease  174
aminophylline adrenaline 29, 30 in PCI  358
adrenaline perioperative
drug interactions with
herbal medicines  152 auto-​injectors  29 considerations 227
chlorphenamine 30 prevention of venous
therapeutic drug hydrocortisone 30
monitoring 671 symptomatic and sup- thromboembo-
lism  342–4​
aminotransferases 173 portive care  30 in renal replacement
amiodarone, in cardiac angina pectoris therapy  656–7​
risk factors for
arrest  370–1​ causes 322 bleeding 344
amitriptyline, in chronic clinical features  322 safety issues  286
definition 322 secondary prevention of
pain 411 management 322 CVD 363
amlodipine, angina treatment of acute
of acute attacks  323 DVT  344–​5
prevention 324 prevention of warfarin
amount strengths  231 counselling patients  348–9​
amylase levels attacks  323–​5 dosing 346
secondary monitoring  346–​7, 349
normal range  691 reversal  350–​1
paediatric values  692 prevention  325–6​ anticoagulation clinics  352
tolerance to nitrate anticonvulsants
range and in acute porphyria  201
interpretation 689 therapy 327 in chronic pain  411
types of  322 drug interactions  509–​10
anaemia  639–​42 unstable 354 with herbal
causes 639 see also unstable angina
folate deficiency  641–2​ angiotensin-​converting medicines 152
haematological
investigations 639 enzyme (ACE) inhibitors
iron deficiency  640
plasma iron studies  641
signs and symptoms  639
vitamin B12 deficiency  641

 037

INDEX 703

antidepressants 413 in specific perioperative
adverse effects  415, conditions  455–​7 considerations 227
416–​18, 420
hyponatraemia  418–1​ 9 combined therapy  457–​8 antiretroviral
serotonin syndrome in conjunctivitis  676 treatment  472–​4
415 in endophthalmitis  678
in bipolar flow chart of selection and adherence  476–​7
disorder 431, 434 drug classes and
classification of  414 use 459
discontinuation and hormonal mechanisms of
syndrome 419 action 475
initiation of treatment contraception 510 drug interactions  477–8​ ,
415 inclusion in PGDs  256 509–1​ 0
in neuropathic pain  412 in infective diarrhoea  302 with herbal medicines  152
in obsessive–​compulsive in keratitis  676 effects 476
disorder 435 modes of action  451–​2 monitoring  475–​6
monitoring therapy  458 patient counselling  478
antiemetics 308 Outpatient Parenteral as prevention  474
in acute porphyria  201 resistance 477
for chemotherapy-​ Antimicrobial Therapy antisecretories, drug
induced nausea and (OPAT)  592–​6 compatibilities 637
vomiting  531–9​ penicillin and cephalosporin antivirals, in keratitis  677
antiemetics for failure of hypersensitivity 458 anxiolytics
control 538 prophylactic use  460 drug compatibilities  637
oral drug reasons for treatment perioperative
combinations  536–7​ failure  458–​9 considerations 227
prescription with TB treatment  479 anxious patients  68
chemotherapy  535–6​ therapeutic drug apixaban 353
recommended IV monitoring 672 perioperative
doses 538 topical 616 considerations 227
recommended oral treatment decisions  453 appetite stimulants  630
doses 537 treatment duration  457 aprepitant 535
in refractory emesis  538 antimicrobial aqueous cream  620
contraindications  309–1​ 0 stewardship  278, 461–​2 arachis oil  305
doses  309–1​ 0 prescription reviews ARBs  see angiotensin II
drug compatibilities  637 462 receptor antagonists
in hyperemesis strategies  461–2​ Area Prescribing
gravidarum 513 antimotility drugs  302 Committees
in malignant bowel antiplatelet drugs (APCs)  277–​8
obstruction 636 drug interactions with aripiprazole, long-​acting
herbal medicines  152 formulation 427
antihypertensives in NSTE-​ACS  364–​5 arnica 146
in acute porphyria  201 low-​risk disease  365–6​ arrhythmias
see also hypertension in PCI  357–​9 bradycardia  370–1​
perioperative torsades de pointes  371
anti-L​ INGO-1​   445 considerations  226–7​ ventricular fibrillation  370
antimicrobial prescribing secondary prevention of arthritis
CVD  325–6​ , 361 ankylosing spondylitis
guidelines  463–5​ antipsychotics 605
authors 464 adverse osteoarthritis 606
content  464–​5 effects  425–6​ , 428–​9 psoriatic 605
monitoring and audit  465 in bipolar disorder  430 septic 456
target audience  464 classification of  423–​4 see also gout; rheumatoid
type and format of clozapine  427–​8 arthritis
adverse effects  428–​9 asparaginase, dose
guidance  463–4​ missed doses  429 calculation 529
updating 465 monitoring 428, 429 aspartame 197
antimicrobial and smoking  429 aspartate transferase
in delirium  647 (AST) 173
resistance  466–​8 depots and long-a​ cting normal range  691
implications  466–​7 injections 424, 427 paediatric values  692
measurement 467 initiation of treatment  424 range and
mechanisms 466 lower risk treatment interpretation 689
preventive strategies  468 options 426 aspiration risk, enteral
risk factors for  467–8​ monitoring  424–​6, feeding 588
in TB 479 428, 429
antimicrobials
choice of therapy  453–4​

074

704 INDEX

aspirin beclomethasone dipropion- of mania/​
perioperative ate (BDP)  375 hypomania 430
considerations  226–​7 benzodiazepines, in alcohol
pre-e​ clampsia withdrawal  658–​9 valproate  432–3​
prophylaxis  511–1​ 2 bestloaw2 -a​rgeolenaisstes bisacodyl suppositories  305
secondary prevention of formulations 377 bisacodyl tablets  305
CVD  325–​6, 361 see aaglsoonliostnsg(-L​aActBinAgsβ);2 bismuth chelate
thromboprophylaxis 342 short-​acting β2 agonists
beta-b​ lockers (tripotassium
aspirin allergy  32 angina prevention  323 dicitratobismuthate) 315
assertiveness 84 in glaucoma  674, 675 bisoprolol
in heart failure  330 angina prevention  323
definition 84 acute management  333 secondary prevention of
examples of  85 in hypertension  337,
non-​assertive 338, 339 CVD  361–2​
in hyperthyroidism  500 bisphosphonates
behaviour  84–5​ perioperative
strategies 85 considerations 226 in hypercalcaemia of
assist control ventilation secondary prevention of malignancy  632–3​
CVD  361–​2
(ACV) 652 in STEMI  360 in osteoporosis  608
asthma betahistine 308 bivalirudin
dose and
management aims  374 contraindications 309 in NSTE-​ACS  364–5​
omalizumab  378–9​ bevacizumab, dose in PCI  358
personalized asthma action calculation 529 black cohosh  147
bicarbonate levels drug interactions  151
plans  374–​9 normal range  691 bladder dysfunction, man-
stepping down range and
interpretation 685 agement in MS  439
treatment 378 bile, composition of   570 bleeding
stepwise approach  374 bilevel positive airway
pressure (BiPAP)  652 upper gastrointesti-
initial add-o​ n bilirubin levels  173 nal  313–1​ 4, 317–​18
therapy  376–​7 normal range  691
paediatric values  692 warfarin reversal  350–​1
oral range and bleeding time  340–1​
corticosteroids  377–8​ interpretation 689 bleomycin
binary data  129
persistent poor biologic therapies cumulative dose  529
control 377 in ankylosing spondylitis  605 dose calculation  529
in cancer  530 blinding of clinical trials  109
regular preventer emetic risk  532–​3 blood glucose levels
therapy 375 extravasation diagnosis of diabetes  485
classification 548 monitoring diabetes  490
SABAs  374–5​ cautions  598–​604 normal range  691
steroid-s​ paring in psoriasis  628
in psoriatic arthritis  605 paediatric values  693
treatments 379 in rheumatoid range and
see also inhalers arthritis  598–6​ 04
atenolol bipolar disorder  430–​4 interpretation 685
angina prevention  323 monitoring 431 recording results  491
secondary prevention of suicide risk  433 target values  490
treatment blood glucose meters  491
CVD  361–2​ antidepressants 434 finger-p​ ricking devices and
atopic eczema  619–​22 of depression  431
atropine, in lamotrigine  433–4​ lancets 491
lithium  431–​4 test strips  491
bradycardia  370–1​ maintenance blood ketone levels, moni-
audit  see clinical audit therapy 431
autoimmune hypothyroid- toring in diabetes  492–3​
blood loss, fluid
ism (Hashimoto’s
thyroiditis) 502 replacement 570
awake intubation  651 blood pressure  335
azathioprine, in rheumatoid
arthritis 599 children 694
treatment targets in
B
hypertension 339
baclofen, in chronic pain  411 see also hypertension
bacteria  see blood transfusion  640
body language  87
micro-​organisms body mass index (BMI)  574
bactericidal versus bacterio- body surface area  see

static drugs  454–7​ surface area
basal metabolic rate (BMR) borage 146
bowel obstruction,
calculation 575
basic life support  367, 368 malignant 636

57 0

INDEX 705

bowel preparation, stoma calcium supplements, in cardiotoxicity, herbal
patients 320 osteoporosis 608 medicines 146

brain abscess  455 calculations care plans  55–6​
brand name use  50 concentrations  231–2​ case presentations  100–2​
breakthrough pain  407 dose calculations
breastfeeding  192–5​ cytotoxic drugs  528–9​ framework  100–​2
medicines for categorical scales, pain
factors affecting drug trans- children  208–9​
fer into milk  192–3​ for drug infusions  237 assessment 400
flow rate calculations  238 cavity wounds  615
general moles and
considerations  194–5​ millimoles  233–​4 dressings 617
preparing dilutions  235–​6 CCR5 receptor
general principles of drug
use 192 calendula 146 antagonists 475
Calvert equation  529 cellulitis 456
infant factors  193–4​ cancer pain  406–​7 central venous
interruption of  195
TB treatment  481 breakthrough pain  407 catheters 593
budesonide, BDP equiva- drug compatibilities  409 extravasation of cytotoxic
spinal opioids  407
lence ratio  375 cannula care  555 drugs 551
budget statements  75, 76 cannula sizes  555 for parenteral
bulk-​forming capsule identification,
nutrition 579
laxatives 304, 305 TICTAC 661 cephalosporins
buprenorphine, capsule swallowing, ‘pill
hypersensitivity to 458
opioid-​replacement school’  212–1​ 3 mode of action  451
therapy  220–1​ , 222 carbamazepine certolizumab 602
discharge chamomile 146, 147
in chronic pain  411 drug interactions  151
prescriptions 223 therapeutic drug perioperative
business conduct
monitoring 670 considerations 153
standards  271–2​ carbapenemase-​producing chaparral 146
chemotherapy  see
C Enterobacteriaceae
(CPE) 467 cytotoxic drugs
cachexia 630 carbimazole  499–5​ 01 chest compressions,
calamus 146 adverse effects  500
calcineurin inhibitors, carbohydrate requirements, cardiopulmonary
children 582 resuscitation 367
topical 622 carbon dioxide children
calcipotriol 626 clinical uses  158 adherence  210–1​ 1
calcitonin, in hypercalcaemia cylinder data  163 making medicines more
carbon dioxide/​air mixture,
of malignancy  632–​3 cylinder data  164 palatable 211
calcium acetate, in carbon dioxide/​oxygen mix- age groupings  204
tures, cylinder data  163 alcohol poisoning  661
hyperphosphataemia 562 carboplatin blood pressure  694
calcium carbonate, in dose calculation  529 creatinine clearance  183
frequency of dose calculations  208–​9
hyperphosphataemia 562 electrolyte
calcium-c​ hannel blockers administration 529
cardiac arrest  see cardiopul- requirements 694
angina prevention  323–​4 extravasation of cytotoxic
in hypertension  337, 338 monary resuscitation
secondary prevention of cardiac enzymes, changes drugs  551–​2
fingertip units  621
CVD 363 after acute MI  355 hypoglycaemia,
calcium chloride, in cardiac cardiopulmonary
definition 694
arrest 371 resuscitation licensing of medicines
calcium gluconate, in advanced life
for 207
hypermagnesaemia 560 support  369–​70 medication safety  287
calcium imbalance  see hyper- drug normal laboratory values

calcaemia; hypocalcaemia administration  370–​1 biochemistry 692
calcium levels basic life support  367, 368 haematology 693
emergency drug box nutritional
normal range  566–​7, 691
paediatric values  692 contents 371, 372 requirements  581–3​
management after success- amino acid solutions
range and
interpretation 686 ful resuscitation  371 583
carbohydrates 582
calcium requirements  576 electrolytes 584
children 694 lipids  582–​3
nitrogen 583
calcium solutions  566
administration of  567
dilution 566

076

706 INDEX

children (contd.) stages of  390 Clinical Trials Regulation  111
parenteral nutrition  581 use of inhaled clinical versus statistical
administration 585
complications 585 therapies 393 significance 126
indications for  581 see also inhalers clinical work
monitoring 585 chronotropes  653–4​
pharmacodynamics 206 ciclesonide, BDP equivalence medical hierarchy  39
pharmacokinetics  205–​6 medical notes  41–2​
‘pill school’  212–​13 ratio 375
respiratory rate  694 ciclosporin clerking  41–​2
urinary output  694 commonly used
Chinese herbal drug interactions, with
medicine 146, 150 herbal medicines  152 abbreviations  43–8​
chloramphenicol, mode of patient etiquette  37–9​
action 451 in psoriasis  627 prescription
chlordiazepoxide, in alcohol in rheumatoid arthritis  600
withdrawal  658–​9 therapeutic drug endorsement 51
cautions 659 dose endorsement  50–​1
chloride levels monitoring 670 drug chart review  49–5​ 0
normal range  691 cinnarizine 308 pharmacy annotation
paediatric values  692
range and dose and section 51
interpretation 685 contraindications 309 starting work on a new
chloride requirements,
children 694 ciprofloxacin, adminis- ward 37
chlorinated desloughing tration with enteral ward etiquette  37
agents 617 nutrition 590 working with medical
chlorphenamine, in
anaphylaxis 30 cirrhosis, definition  172 staff   39–4​ 0
cholestasis citalopram, QT interval clomethiazole 659
definition 172 clomipramine, in obsessive–​
effect on drug prolongation 420
clearance  176–7​ citation styles  297–8​ compulsive disorder  435
liver function tests  173 clonazepam, in chronic
parenteral nutrition-​ Harvard style  297
associated 585 Vancouver style  297–8​ pain 411
cholesterol levels citrate, in renal replacement clopidogrel
normal range  691
range and therapy 657 drug interactions  315
interpretation 690 clinical audit  292 in NSTE-​ACS  364–5​
chronic (type C) in PCI  357–9​
reactions 19 audit cycle  292 perioperative
chronic bronchitis  see of home IV therapy  596
chronic obstructive clinical information  42 considerations  226–7​
pulmonary disease clinical management secondary prevention of
chronic obstructive
pulmonary disease plans 258 CVD 361
(COPD)  390–5​ clinical medication reviews  61 Clostridium difficile-​associ-
inhaled clinical trials
corticosteroids  392–​3 ated diarrhoea, risk
long-a​ cting βm2uasgcoarniinsitcs  392 assessment of randomized factors for  315
long-a​ cting studies  136–7​ clotting cascade
antagonists 392 activation 657
methylxanthines 392 critical assessment of clozapine  427–​8
mucolytics 394 papers  139–​41 adverse effects  428–​9
oral corticosteroids  394 missed doses  429
oxygen therapy  395–​6 design of  109 monitoring 428, 429
short-a​ cting β392 1–​2 development phases  108 perioperative
agonists  emergencies,
short-a​ cting muscarinic considerations 227
antagonists 392 management of  109 and smoking  429
smoking cessation  391–2​ European Clinical Trials coagulation
laboratory tests  340–1​
Directive  110–1​ 1 mechanisms of  340–1​
of gene therapy  267–8​ coagulation factors  340
on herbal products  154 coagulation pathways  341
hierarchy of coal tar  624
Cochrane reviews, herbal
evidence  124–5​
hospital pharmacy drugs 145, 155
Cockcroft and Gault
guidance
charges 113 equation 182, 183
documentation and codeine phosphate, in

records 113 diarrhoea 302
labelling, packaging, and Code of Conduct for NHS

stability 112 Managers 2002  271–​2
receipt of supplies  112 cognitive behavioural
storage and handling  112
licensing 107 therapy (CBT)  435
premarketing  244–​8
regulations 106