1. Withdraw the required dose.
2. The solution should be clear and colourless. Inspect visually for particulate matter or discolor-ation prior to administrdiscolor-ation and discard if present.
3. Give by IV injection over 30--60 seconds.
Intramuscular injection (less rapid response)
Preparation and administration1. Withdraw the required dose.
2. Give by deep IM injection.
Intermittent intravenous infusion
Preparation and administration1. Withdraw the required dose.
2. Add to a suitable volume of compatible infusion fluid (usually 100 mL NaCl 0.9%).
3. The solution should be clear and colourless. Inspect visually for particulate matter or discolor-ation prior to administrdiscolor-ation and discard if present.
4. Give by IV infusion over 15--30 minutes.
Technical information
Incompatible with No informationCompatible with Flush: NaCl 0.9%
Solutions: NaCl 0.9%, Gluc 5%
Y-site: No information
pH 8--9
Sodium content Negligible
Excipients Contains sulfites (may cause allergic reactions).
(continued) Betamethasone | 87
Technical information (continued )
Storage Store below 30C in original packaging.
Stability after preparation
Use prepared infusions immediately.
Monitoring
Measure Frequency Rationale
Serum Na, K, Ca Throughout treatment * May cause fluid and electrolyte disturbances.
Withdrawal symptoms and signs
During withdrawal and after stopping treatment
* During prolonged therapy with corticosteroids, adrenal atrophy develops and can persist for years after stopping. Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, #BP or death.
* The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in patients whose disease is unlikely to relapse. Full details can be found in the BNF.
Signs of infection During treatment Prolonged courses "susceptibility to infections and severity of infections. Serious infections may reach an advanced stage before being recognised.
Signs of chickenpox * Unless they have had chickenpox, patients receiving corticosteroids for purposes other than replacement should be regarded as being at risk of severe chickenpox.
* Confirmed chickenpox requires urgent treatment;
corticosteroids should not be stopped and dosage may need to be increased.
Exposure to measles * Patients should be advised to take particular care to avoid exposure to measles and to seek immediate medical advice if exposure occurs.
* Prophylaxis with IM normal immunoglobulin may be needed.
Additional information
Common and seriousundesirable effects
Immediate: Anaphylaxis and other hypersensitivity reactions have been reported.
Undesirable effects that may result from short-term use (minimise by using the lowest effective dose for the shortest time): "BP, Na and water retention, #K,
#Ca, "blood glucose, peptic ulceration and perforation, psychiatric reactions,
"susceptibility to infection, muscle weakness, tendon rupture, insomnia,
"intracranial pressure, #seizure threshold, impaired healing. For undesirable effects resulting from long-term corticosteroid use, refer to the BNF.
Pharmacokinetics Elimination half-life is 5.6 hours.
(continued) 88 | Betamethasone
Additional information (continued )
Significantinteractions
* The following may #corticosteroid levels or effect:
barbiturates, carbamazepine, phenytoin, primidone, rifabutin, rifampicin.
* Corticosteroids may "levels or effect of the following drugs (or "side-effects):
aldesleukin (avoid combination), amphotericin (risk of "K), anticoagulants (monitor INR), methotrexate ("risk of blood dyscrasias).
* Corticosteroids may #levels or effect of vaccines (#immunological response,
"risk of infection with live vaccines).
Action in case of overdose
Give supportive therapy as appropriate. Following chronic overdose the possibility of adrenal suppression should be considered.
Counselling Patients on long-term corticosteroid treatment should read and carry a Steroid Treatment Card.
Risk rating: GREEN Score ¼ 1
Lower-risk product: Risk-reduction strategies should be considered.
This assessment is based on the full range of preparation and administration options described in the monograph. These may not all be applicable in some clinical situations.
Bibliography
SPC Betnesol injection (accessed 1 October 2009).
Bivalirudin
250-mg dry powder vials
* Bivalirudin, an analogue of the peptide hirudin, is a direct thrombin inhibitor with actions similar to lepirudin.
* It is used as an anticoagulant in patients undergoing PCI, including those with, or at risk of, HIT. It is also licensed for use in the acute coronary syndromes (ACS): unstable angina and NSTEMI.
Pre-treatment checks
* Avoid in severe"BP; sub-acute bacterial endocarditis; active bleeding; bleeding disorders.
* Caution with previous exposure to lepirudin (theoretical risk from lepirudin antibodies), brachy-therapy procedures, and concomitant use of drugs that"risk of bleeding.
* Bivalirudin may be commenced 30 minutes after discontinuation of an unfractionated heparin IV infusion, or 8 hours after discontinuation of SC LMWH.
Betamethasone | Bivalirudin | 89
Biochemical and other tests (not all are necessary in an emergency situation) ACT
Blood pressure Bodyweight
FBC
Renal function: U, Cr, CrCl (or eGFR)
Dose
Patients undergoing PCI: 0.75 mg/kg by IV injection followed immediately by 1.75 mg/kg/hour by IV infusion for at least the duration of the procedure. This infusion may be continued for up to 4 hours post-PCI if necessary. After the 1.75 mg/kg/hour infusion has a finished, a reduced infusion of 0.25 mg/kg/hour may be continued for 4--12 hours as clinically necessary.
Treatment of ACS: 0.1 mg/kg by IV injection followed by 0.25 mg/kg/hour by IV infusion. Patients who are to be medically managed may continue the infusion for up to 72 hours.
ACS patients proceeding to PCI: an additional 0.5 mg/kg by IV injection is given before the procedure and the infusion increased as per PCI patients above.
ACS patients who proceed to coronary artery bypass graft (CABG) surgery off pump: the infusion is continued until the time of surgery. An additional 0.5 mg/kg by IV injection is given just prior to surgery followed by 1.75 mg/kg/hour by IV infusion for the duration of the surgery.
ACS patients who proceed to CABG surgery on pump: the infusion is continued until 1 hour prior to surgery then stopped and the patient treated with unfractionated heparin.
Dose in renal impairment: adjusted according to creatinine clearance:
* CrCl 30--59 mL/minute: loading dose remains unchanged but the IV infusion for patients under-going PCI (whether being treated for ACS or not) should be reduced to 1.4 mg/kg/hour.
* CrCl<30 mL/minute: do not use.