Aneurin Bevan Key Guidelines

Question 1

Gentamicin: When should you avoid using the dosing calculator?

Answer 1

For neutropenic Sepsis as 6mg/kg and calculator is based off 5mg/kg

Question 2

What is the recommended Dalteparin Dosing for VTE in Aneurin Bevan?

Answer 2

< 50kg = 2500 units
daily*

50-100kg = 5000 units
daily

100-150kg = 5000 units
twice daily*

> 150kg = 7500 units
twice daily*

*= unlicensed dose

Question 3

What are the exclusion criteria for once-daily gentamicin dosing?

Answer 3

Endocarditis, dialysis, major burns (>20% BSA), cystic fibrosis.

Question 4

If someone has had their Gentamicin level taken between 6-14 hours and it comes back as 0.5 what should be done

Answer 4

If a gentamicin level is taken between 6–14 hours post-dose, you use the nomogram (but only if patient is on 5 mg/kg, not neutropenic sepsis / critical care).
• A level of 0.5 mg/L is well below the target range on the nomogram (usually dosing lines are drawn much higher).
• That means the drug has cleared faster than expected → safe to continue dosing.
• You would plot it on the nomogram → it will almost certainly fall below the 24-hour line.

👉 Action:
• Continue with 24-hourly dosing.
• Ensure renal function is stable.
• Continue monitoring levels as per guidance.

⚠️ If the level is unexpectedly low, double-check:
• Dose prescribed and given correctly.
• Timing of blood sample (not taken too late).
• Renal function (rapid clearance if CrCl very high).

Question 5

If gentamicin levels are taken before 6 hours what should be done ?

Answer 5

⏱ If taken TOO EARLY (<6 hrs after infusion)
• Result is not interpretable on the nomogram.
• Options:
• Repeat level at the correct window (6–14 hrs), OR
• If that window has passed, take a pre-dose (trough) level before the next dose.
• Target trough = <1 mg/L.

Question 6

If gentamicin levels are taken between 14-18 hours what should be done ?

Answer 6

Take level before next dose is due

Question 7

What are the slow loading dose guidelines for vitamin D

Answer 7

DEFICIENCY
(<25 nmol/L in
ADULT)
“SLOW LOADING”
Either 50,000 units PER WEEK for 6 weeks
Or 2400-3200 units DAILY for 12 weeks.

Then give long term maintenance treatment as for “insufficiency” below.

Question 8

What is the fast loading dose for vit d in the aneurin bevan guidelines?

Answer 8

FAST LOADING
(specialist advice- hospital only)
Fast loading over 4-5 days (followed by maintenance therapy) –generally
for hospital in-patients where quick loading prior to IV bisphosphonate or
Denosumab administration is deemed appropriate. This regimen is
recommended only on the advice of a hospital bone health specialist. 2
Deficiency: 60,000units PO OD for 5 days
Insufficiency: 40,000units PO OD for 4 days

Question 9

What is key to remember if Tolvaptan is prescribed?

Answer 9

NICE TA358 recommends tolvaptan (Jinarc) tablets as an option for treating autosomal dominant polycystic kidney disease in adults to slow the progression of cyst development and renal insufficiency only if a) they have chronic kidney disease stage 2 or 3 at the start of treatment, b) there is evidence of rapidly progressing disease and c) the it is provided with the discount agreed in the patient access scheme.

As an option in the treatment of hyponatraemia secondary to SIADH initiation of tolvaptan (Samsca) is restricted to:
1. consultant chest physicians (specialising in lung cancer) and consultant endocrinologists only.
2. patients with SIADH who have marked hyponatraemia (defined as a serum sodium < 125mmol/l).
For chronic cases of SIADH (as would be referred to or encountered by endocrinology) tolvaptan should only be considered when other alternatives such as fluid restriction and/or oral demeclocycline have been unsuccessful.
The initial supply of tolvaptan be restricted to a maximum of 30 tablets (of either 15 or 30mg) and that uptake of Otsuka’s joint funding proposal must apply for courses requiring more than this quantity.
It is important that, wherever practicable, those administering the tablets should be made aware of the high cost per tablet, in order to help minimise wastage on the wards.

Bloods need to be taken

Question 10

What is key to remember regarding Midodrine?

Answer 10

Specialist initiated and repeat prescribing
make sure referral done on discharge
Always try to provide 2 months when checking