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CONTINUING PROFESSIONAL DEVELOPMENT
Page 58
Non-medical
prescribing multiple
choice questionnaire

Page 59
Read Gill Knotts
practice profile on
liver cirrhosis

Page 60
Guidelines on how to
write a practice profile

Non-medical prescribing using

the British National Formulary
NS426 Kaufman G (2008) Non-medical prescribing using the British National Formulary.
Nursing Standard. 22, 20, 51-56. Date of acceptance: October 26 2007.

Summary
This article explores how to maximise efficient use of the
British National Formulary (BNF) within the context of non-medical
prescribing. It provides an overview of the layout of the BNF
and identifies how the publication can be used to detect
contraindications and potential drug interactions. The detection,
recording and reporting of adverse drug reactions are also explored.
In addition, prescription writing standards and the meaning of
unlicensed and off label medicines are discussed.

Author
Gerri Kaufman is lecturer, University of York, York.
Email: gk8@york.ac.uk

Keywords
Adverse drug reactions and interactions; British National
Formulary; Prescribing; Yellow card reporting
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.

Aims and intended learning outcomes

This article aims to give nurses and other health
professionals an insight into using the British
National Formulary (BNF). After reading this
article you should be able to:

Describe how drugs are listed in the BNF and
explain what is meant by indications, cautions,
side effects and contraindications.

Use the BNF to identify contraindications and
potential drug interactions.

Explain the detection, recording and reporting
of adverse drug reactions.
NURSING STANDARD

Explain what is meant by unlicensed and off

label medicines and discuss the implications
for their use.

Discuss national and local prescription writing
standards and write a prescription that is clear
and unambiguous.

Introduction
The BNF is a joint publication of the British
Medical Association (BMA) and the Royal
Pharmaceutical Society of Great Britain
(RPSGB). It is published biannually under the
authority of a Joint Formulary Committee, which
comprises representatives of professional bodies
(BMA and the RPSGB) and UK health
departments. The BNF aims to provide
prescribers, pharmacists and other healthcare
professionals with thorough, up-to-date
information on the use of medicines. When
prescribing drugs it is an important reference
guide to ensure that the correct doses are given,
that no predictable interactions will occur and
that no known contraindications are overlooked.
Therefore, understanding how to use the
publication is an essential skill for medical and
non-medical prescribers. When making
prescribing decisions it is vital to use the most
recent edition of the BNF (2007). The BNF is also
available online at: http://BNF.org
The BNF comprises 15 chapters, each of which
is related to a particular system of the body or to an
aspect of medical care, for example, chapter one in
the BNF (Number 54) (2007) relates to the
gastrointestinal system, and chapter three relates to
the respiratory system. Each chapter is further
divided into sections, and the information
provided within the sections includes concise
summaries of clinical conditions, as well as
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relevant drugs and preparations. Individual drugs
are listed alongside others that are similar, either
in chemical structure or clinical indication. These
notes are intended to provide information to
medical and non-medical prescribers, as well as
other healthcare professionals to facilitate the
selection of appropriate treatment.

Time out 1
Use the index of the BNF to
locate the drug atenolol. Note
that the drug can be sold as
atenolol or Tenormin. Note the
price differences between the two drugs.

Nomenclature of drugs
All drugs within the BNF are listed in identical
fashion. The drug name is followed by
indications, cautions, contraindications, side
effects and dose (BNF 2007). This is usually
followed by the drug listed under its generic
(non-proprietary) and trade (proprietary) names
(Galbraith et al 2007). It is important to be aware
that drugs that are used to treat more than one
condition will be listed in various chapters of the
BNF, for example, the drug methotrexate, which
is used in the treatment of malignant disease,
rheumatic disease and skin disease, is listed in
chapters eight, ten and 13 (BNF 2007). When
searching for a drug, the most efficient method is
to turn straight to the index and look up the name
of the drug (Jones 2001a).
Most drugs have at least three different names
by which they can be recognised. These include a
chemical name, a generic name and a trade name
(Galbraith et al 2007). Atenolol is a drug
belonging to the group of beta blockers, a class of
drugs used primarily in cardiovascular disease.
Atenolols chemical name is 2- [4-[2-hydroxy-3-(1methylethylamino)propoxy] phenyl]ethanamide.
The name is an unambiguous description of the
drugs structure, however, it would be
cumbersome to use and remember. Consequently
chemical names are rarely used. Generic names are
simplified chemical names, which make drugs
easier to remember (Galbraith et al 2007). The
generic name for the compound mentioned above
is atenolol. Trade or brand names are like
trademarks and are the property of the company
manufacturing the drug. Tenormin is a trade
name for atenolol. When a company first sells a
drug it is usually sold by its trade name under
patent. The company holding the patent has
exclusive rights to manufacture and sell the drug
52 january 23 :: vol 22 no 20 :: 2008

until the patent protection lapses. In the UK,

patent protection is valid for 20 years. The
purpose of patenting is to give the developer of the
drug exclusive rights to manufacture and the
opportunity to recover the expensive costs of the
drugs development. With the lapse of a drugs
patent other companies may then make the
product. Generic medicines are in the main copies
of pharmaceutical products that are no longer
protected by patent.
The production of generic drugs leads to
competition resulting in lower costs. Using generic
drugs contributes to reducing the overall cost of
medicines to the health service. Therefore generic
prescribing is favoured over brand name
prescribing (Simonsen et al 2006). Atenolol is an
example of a generic drug that is lower in cost than
the branded product Tenormin. However,
controversy exists over whether all drugs should be
prescribed and supplied by a generic name. One
fear relating to the use of generic preparations
is that they may not be interchangeable or
bioequivalent. In other words, they may not be
absorbed or act in the same way on administration.
While generic drug versions are carefully evaluated
for comparable effects on absorption and clinical
response with the original patented drug, there are
some exceptions where bioavailability problems
are important and the patient should always
receive the same brand. Some examples include
carbamazepine, theophylline and modified-release
nifedipine (Lloyd and Faulding 2005).

Time out 2
Use the most recent edition of
the BNF (2007) to identify the
meaning of the terms indications,
cautions, side effects and
contraindications. Choose three drugs
that are used regularly within your
specialty or clinical area. Use the BNF to
identify the indications for their use and note
any cautions and contraindications.

Adverse drug reactions and interactions

Indications provide details of uses for a particular
drug, for example, the indications for digoxin
include heart failure and supraventricular
arrhythmias, particularly atrial fibrillation (BNF
2007). However, the benefits of prescribing any
medicine need to be considered in relation to the
risks involved. Cautions and contraindications
alert prescribers to potential dangers in
prescribing a drug and may refer the healthcare
professional to the appendices at the end of the
BNF, which provide further information to
inform a prescribing decision. Appendix 1 in the
BNF is an alphabetical list of drug interactions
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where the symbol has been placed against

interactions that are potentially hazardous.
Adverse drug interactions occur when two or
more drugs interact in such a way that the
effectiveness or toxicity of one or more of the
drugs is altered. An interaction can also be said
to occur if the effects of a drug are altered by the
presence of food, drink or herbal medicines
(Reddy 2006a). Any patient receiving two or more
drugs is at potential risk of a drug interaction. The
interaction may or may not lead to a clinically
significant effect. Drug interactions that are
clinically significant can be beneficial but they can
also be harmful. Adverse drug interactions can be
harmful if the toxicity of the drug is increased or if
its efficacy is reduced (Reddy 2006a). One example
of an interaction that increases drug toxicity occurs
when a statin (for example, simvastatin), which is
given to decrease blood lipid levels is administered
with an imidazole antifungal agent, for example,
ketoconazole. The outcome of this interaction is an
increase in statin toxicity. This can increase the risk
of severe muscle damage, which is a rare but
significant side effect of the statins (BNF 2007).
A reduction in the effectiveness of a drug can
be as serious as an increase in toxicity and can
compromise a patients health. For example,
patients taking the anticoagulant warfarin who
are given the anti-tuberculous drug rifampicin
will require extra warfarin to maintain an
adequate anticoagulant effect (Reddy 2006a).
The two examples above demonstrate unwanted
effects of drug-to-drug interactions. However,
there are examples of beneficial drug interactions
where drugs with different pharmacological
actions but similar therapeutic effects are used
together because of their additive effect. A good
example is in the treatment of hypertension where
guidelines recommend the use of moderate doses
of two or more different anti-hypertensives rather
than a maximum dose of a single drug
(McGavock 2007).
Some patients are more at risk of drug
interactions than others. The more drugs a patient
takes, the more likely he or she is to experience an
interaction. Because older people are often on
multiple medications they are more susceptible to
drug interactions. Other risk factors for drug
interactions include impaired renal and hepatic
function (Cossey 2004). The first step in
minimising adverse drug interactions is to be aware
of patients who are taking drugs that could
potentially interact. Before prescribing for a
patient, the prescriber must ensure that he or she
establishes every drug the patient is taking. This
should include prescribed medicines, those bought
over the counter, herbal and homeopathic remedies.
It is important to remember that adverse drug
interactions can occur if herbal medicines are
taken with conventional drugs. St Johns Wort is
NURSING STANDARD

a popular, unlicensed, herbal remedy for treating

mild depression. Some serious interactions with
conventional drugs have been identified, for
example, if the remedy is taken in conjunction with
the anti-epileptic agents, carbamazepine and
phenytoin, the blood concentration of these
drugs is reduced, which could put the patient at
risk of seizures (BNF 2007). Prescribers also need
to be aware of the potential for drug-to-food
interactions, for example, drinking large volumes
of grapefruit juice can increase levels of the lipidlowering drug simvastatin in the bloodstream,
potentially leading to toxicity (Reddy 2006a).

Time out 3
In Appendix 1 of the BNF locate the section on
coumarins. Coumarins are anticoagulants which
include warfarin and acenocoumarol. According to
information contained within the appendix, what are
the implications of taking cranberry juice and
anticoagulants together? What recommendation does
the BNF make about the concomitant use of both substances?
What are the implications of taking the herbal remedy
St Johns Wort and the oral contraceptive pill?
If the potential hazards of prescribing two drugs
together outweigh the benefits then another drug
should be used instead. If the result of the
interaction is to increase or reduce the effect of a
drug then the dose can be adjusted to prevent
adverse effects. If an interacting drug combination
has to be given the patient should be monitored
regularly for adverse effects. It is impossible to
remember every potential drug interaction, but it is
useful for prescribers to know where they can
access information about adverse drug interactions
(Reddy 2006a). The list of drug interactions in the
BNF is important in helping a prescriber to decide
which interactions could be clinically significant in
individual patients (Cossey 2004). Sources of
further information on drug interactions can be
obtained from drug information centres or
specialist text books. Additionally, in primary care,
most GP computer systems will usually flag up a
drug interaction. However, it is important not to be
too reliant on these systems as they may not detect
every possible interaction (Reddy 2006a).
It is essential that prescribers are aware of the
contraindications of the drugs prescribed and
their potential implications for the patient. To
reduce the risk of prescribing substances that are
contraindicated it is important to explore a
patients health history before prescribing. A
health history should include an exploration
of the patients past medical history and current
problems. In the UK, the Committee on Safety
of Medicines (CSM) registers and collates all
information regarding adverse events and the
adverse effects of drugs (Simonsen et al 2006).
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Time out 4
Use the index at the back of the BNF to locate the
drug bupropion (Zyban). The indication for use of
bupropion is to aid smoking cessation in
combination with motivational support. In which
groups of patients is the use of bupropion
contraindicated? What is the initial starting dose
of the drug and over what period of time is the initial starting
dose given? What is the maximum daily dose of the drug?
What recommendations are made in Appendices 2 and 3
of the BNF in relation to the use of bupropion in patients with
liver disease and renal impairment?
Under cautions and contraindications within the
BNF reference may be made to CSM advice
and warnings. Where the CSM provides advice
about the use of drugs and a warning about
contraindications it is usually displayed within a
blue box such as the advice given about the use of
bupropion in patients with a history of seizures
(BNF 2007). In the section on cautions and
contraindications reference may also be made
to Appendices 2 and 3, which give further
information on prescribing for patients with
hepatic and renal impairment respectively. The
liver and the kidneys are the most important
organs for eliminating the majority of drugs
(Simonsen et al 2006). Disease in the organ that
eliminates a drug can result in an increased
concentration of the substance in the
bloodstream, which may result in toxicity.
Consequently, smaller doses of a drug may be
required in patients with hepatic and renal
impairment. Appendices 2 and 3 of the BNF
include tables of drugs to be avoided or used
with caution in patients with liver and kidney
disease, for example, dose modification to half
the adult dose is recommended for the use of
bupropion in patients with renal and hepatic
impairment (BNF 2007).

Time out 5
Marilyn, who is 24 years old, sprained her ankle a
couple of days ago while playing squash. She
bought some ibuprofen for pain relief
and is taking 400mg three times daily. She is not
taking any other medicines. Generally she is fit and well.
She has no allergies. She had mild asthma as a child but
has no history of other medical problems. Since starting
the ibuprofen Marilyn has experienced chest tightness
and breathlessness. Based on the information on non-steroidal
anti-inflammatory drugs in the BNF, what do you suspect
is happening to Marilyn?
54 january 23 :: vol 22 no 20 :: 2008

No drug is completely risk free. Any

medication can cause an unexpected adverse
reaction. An adverse drug reaction can be defined
as an unwanted or harmful reaction experienced
following the administration of a drug or
combination of drugs under normal conditions
of use, and is suspected to be related to the drug
(Lewis and Allen 2003). Adverse drug reactions
can be divided into two types type A and type B.
Type A reactions Type A adverse drug reactions
are common and predictable and result from the
pharmacological or physiological actions of a
drug. Postural hypotension in a patient on
anti-hypertensive medication is an example of a
type A reaction reflecting nothing more than the
normal pharmacological effect of the drug (Jones
2001b). An exacerbation of asthma in a patient
taking non-steroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen, which block the
prostanoid production necessary to stimulate
bronchodilation (McGavock 2007) is an example
of a type A reaction resulting from the physiological
actions of a drug. For type A reactions the
management is a reduction in the dose or complete
withdrawal of the medication (Jones 2001b).
Type B reactions Type B adverse drug reactions
are uncommon and they cannot be predicted
from a drugs known pharmacology. They are
associated with high mortality but these adverse
reactions are rare (Mc Gavock 2007, Jones
2001b). Immunological interactions such as
allergy, hypersensitivity, anaphylaxis and
idiosyncrasy are included in this category
(Kanneh 2004). Idiosyncrasy is a term referring
to an inherent, qualitative, abnormal reaction
to a drug. Some patients are more at risk of
adverse drug reactions and special care needs
to be taken when prescribing for these groups.
They include children, older people, patients
with hepatic or renal failure, those receiving
multiple drugs and pregnant and breastfeeding
women (Lewis and Allen 2003).
Children are thought to be at particular risk of
adverse drug reactions because they are not
routinely included in clinical trials so little is
known about the safe use of medicines in this age
group. Polypharmacy in older people taking many
drugs puts them at increased risk of adverse drug
reactions and interactions. Additionally, some
drugs commonly linked with adverse drug
reactions are frequently prescribed for older
people including hypnotics, diuretics and NSAIDs
(Lewis and Allen 2003). Drugs prescribed in
pregnancy can harm the fetus and drugs taken by
breastfeeding mothers can often be found in small
amounts in the mothers milk. The amounts are
usually too small to affect the baby but
elimination of some drugs in neonates can be
impaired particularly in low birth weight infants
resulting in accumulation of the drug, which may
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have an adverse effect (Lewis and Allen 2003).

Appendices 4 and 5 of the BNF alert prescribers to
drugs that should be avoided or used with caution
in pregnancy and breastfeeding.
It is thought that some types of drugs, for
example, those that are newly licensed and
herbal products, are more likely to cause
adverse drug reactions than other medicines
(Lewis and Allen 2003).

Time out 6
What is the purpose of the
yellow cards located at the back
of the BNF? Read the BNF (2007)
page ten or visit www.yellowcard.
gov.uk to further your knowledge of
the detection, recording and reporting
of adverse drug reactions.

Yellow card reporting

The CSM requests that all suspected adverse drug
reactions including those involving herbal
remedies are reported by healthcare
professionals. Such adverse reactions are
reported directly to the CSM using the yellow
card system. Doctors, dentists, coroners,
pharmacists and nurses are urged to help by
reporting suspected adverse reactions. Patients,
parents and carers can also report suspected
reactions as part of a pilot scheme. The reports
can cover side effects of prescribed medicines,
those bought over the counter and
complementary substances. For this purpose
patient yellow cards are available from
pharmacies, GP surgeries and other NHS outlets.
Reports can also be submitted online. Guidelines
on reporting adverse drug reactions can be found
in the BNF (2007).

Drug licensing
Drugs are potent substances that can cause great
damage if they are not used and monitored
correctly by trained professionals. There are a
number of phases of drug development, which
include pre-clinical trials and clinical trials in four
phases (McGavock 2007). At the end of the first
three phases of clinical trials and following
thorough evaluation of the data by a licensing
authority, the drug may be approved to treat
patients. However, the effects of a drug continue to
be monitored closely after it has been registered in
what are termed phase four studies. These are
important in providing additional safety data
(Simonsen et al 2006).
It is in this phase that the types and incidence
of adverse drug reactions and adverse drug
interactions are usually defined. This is a process
NURSING STANDARD

that can take several years and may lead to the

withdrawal of a drug within a few years of its
licensing (McGavock 2007). New drugs are under
special surveillance in the early years of their
development and these drugs are denoted by a
black triangle in the BNF. There is no standard time
for which products retain a black triangle; safety
data are usually reviewed after two years.

Time out 7
According to the BNF the
licensed indication for the use of
metformin is diabetes mellitus.
What condition does the BNF
include as an unlicensed indication
for the use of metformin? Read the BNF
advice on marketing authorisation and note
the implications of prescribing medicines
outside the recommendations of their
marketing authorisation.

Unlicensed and off label medicines

Unlicensed medicines are those that do not have a
product licence, because there may not be enough
commercial interest in marketing the medicine in
the UK. This can happen if only a few people are
likely to require the medicine. Although medicines
cannot be promoted outside the limits of the licence,
the Medicines Act 1968 (BNF 2007) does not
prohibit the informed use of unlicensed medicines.
Such medicines are often available from specialist
manufacturers. Non-medical prescribers such as
nurses, pharmacists and allied health professionals
cannot prescribe unlicensed medicines (Griffith
2006). The term off licence or off label medicines
describes the use of licensed medicines outside the
strict conditions of the licence or marketing
authorisation. For example, metformin is licensed
for use in diabetes mellitus and although used in the
treatment of polycystic ovary syndrome it is not
licensed for use in this condition.
It is recognised that the informed use of licensed
medicines for unlicensed applications is sometimes
necessary and is often a requirement in paediatric
practice (BNF 2007). However, prescribing
medications outside the recommendations of their
marketing authorisation alters and probably
increases a practitioners professional
responsibility and liability. The prescriber should
be able to justify and feel competent in using such
medicines (Griffith 2006, BNF 2007).

Prescription writing
The prescription of a drug requires the use of sound
clinical and pharmacological knowledge.
Professionals who prescribe drugs are expected to
make a careful assessment of the need for
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Time out 8
Read the guidance on prescription writing in the
BNF (2007). You could access and download a
sample FP10 (prescription) from the internet at
www.ppa.org.uk/education/fp10.htm. Practise
writing a prescription for the following fictitious
patient using the guidance on prescription writing in the BNF.
Patient name: Harry Sloan
Address: Hazlewood Way, Sydney Parade, England YO92 SHT
Age: 44 years
Date of birth: 07/03/1963
Instructions: Harry has contact dermatitis affecting both hands.
He requires a prescription for the emollient Diprobase ointment.
He is required to apply the ointment liberally four times daily.
You are required to issue a written prescription for Harry.
Supply the maximum amount required for a four times daily
application for 14 days.
In calculating the supply please note that in an adult 50g of
ointment is the maximum amount required for a twice daily
application to both hands for one week (BNF 2007).
Now check your prescription with a colleague using the
following criteria:
Prescription for Diprobase ointment
Prescription is written legibly in ink
Prescription is dated
Prescription states the full name and address of the patient
Prescription states the age and date of birth of the patient
Appropriate drug and form is selected
Diprobase ointment
The dose and dose frequency are stated accurately
Apply liberally to both hands four times daily
The quantity to be supplied is stated accurately
Supply 200g
The prescription is signed in ink by the prescriber

treatment and to be observant when selecting

drugs, drug formulations, doses and dosing
intervals. It is also important that prescribers
adhere to local or national prescription writing
standards to ensure that prescriptions are clear,
unambiguous and leave no doubt as to the
intentions of the prescriber. Case studies from
primary and secondary care collated by the
Department of Health (Reddy 2006b) show
how mistakes can be made when prescriptions
are written carelessly. Prescribing errors can be
caused by poorly written prescriptions,
abbreviations and inappropriate use of decimal
points, which can lead to serious harm for patients
(Reddy 2006b). Detailed guidance on how to write
a prescription is available in the BNF (2007) and
should be read in conjunction with local guidance
before a prescription is written.

Conclusion
This article has provided an overview of how
to maximise use of the BNF within the context
of prescribing. The BNF contains important
information about the use of drugs and the
ability to use this reference manual is an essential
skill for prescribers and other healthcare
professionals. It is important to consult the BNF
when writing all prescriptions to ensure that
prescribing practice is safe. As well as the
information covered in this article, prescribers
should also become familiar with additional
information contained within the BNF to expand
their knowledge and skills in prescribing NS

Time out 9
Now that you have completed
the article, you might like to
write a practice profile. Guidelines
to help you are on page 60.

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Griffith R (2006) Legal

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Lewis C, Allen D (2003) Adverse

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