The Countess of Chester Health Park Liverpool Road Chester CH2 1UL Telephone: 01244 365000 26th June 2014 Countess of Chester NHS foundation trust Paediatric & Pharmacy Department position on the use of Domperidone in children. Dear all, Following on from the recent MHRA release surrounding the concerns of domperidone use with the risk of cardiac side effects, the Paediatric Department at COCH has reviewed current practice in conjunction with the advice provided by the NPPG (Neonatal & Paediatric Pharmacists Group). The MHRA/EMEA review took place around adult patients already predisposed to arrhythmias over 60 years of age taking large doses of domperidone or taking QT prolonging medicines or CYP 3A4 inhibitors concomitantly. Cardiac arrhythmias in children are more often genetic or secondary to congenital heart defects. Domperidone is commonly used to treat gastric reflux in neonates and infants in whom other treatment options have proven unsuccessful in symptom control. Few options for alternative therapy remain for this indication. Our action: Consider stopping treatment with domperidone in children with congenital heart disease. If it is not possible to stop this then ensure that cardiac monitoring is undertaken regularly. Children already established on domperidone should continue reviewing the dose to ensure it does not exceed 250micrograms/kg three times per day, (750micrograms/kg in 24 hours) Before starting therapy consider a trial of at least 2 weeks of nonpharmacological methods such as, feeding the infant upright and keeping them upright following a feed, raising the head of the cot or bed and considering thickeners. If pharmacological therapy is considered necessary then a step wise approach should be taken with a good trial of each step (ideally 2 weeks) before proceeding to the next step. Infant Gaviscon should be tried first line, ranitidine should be added in second line and then finally domperidone should be added in if symptom control is not achieved. Review of continued need to treat should take place as is usual practice and consideration should be made to stop medication when the child is weaned. Chairman Sir Duncan Nichol CBE Chief Executive Tony Chambers Uploaded by: Liz Kowlessar, December 2014 Review by: December 2016 Domperidone should not be used concomitantly in children taking any drugs that lengthen QT interval or that inhibit CYP 3A4. For information a table of drugs known to inhibit CYP 3A4 can be found below. We will continue to review the evidence available and will liaise with you if any changes are necessary. Yours sincerely Ravi Jayaram Consultant Paediatrician Clinical Lead for Childrens Services Gemma Webster Lead Pharmacist for Women & Children Drugs that are known to inhibit CYP 3A4: indinavir telaprevir fluconazole chloramphenicol gestodene starfruit saquinavir grapefruit juice boceprevir imatinib ritonavir suboxone verapamil ciprofloxacin mifepristone clarithromycin telithromycin diltiazem voriconazole itraconazole aprepitant cimetidine norfloxacin ketoconazole erythromycin amiodarone fluvoxamine Chairman Sir Duncan Nichol CBE Chief Executive Tony Chambers Uploaded by: Liz Kowlessar, December 2014 Review by: December 2016
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