The history of the BNF
Most pharmacy students will have come across or used the BNF, but many may not know its origins. Lisa Britton looks at the history of the BNF and explains why it is one of the most important reference texts future pharmacists will use, whichever sector they work in
Most pharmacy students will have come across or used the British National Formulary, but many may not know its origins. Lisa Britton looks at the history of the BNF and explains why it is one of the most important reference texts future pharmacists will use, whichever sector they work in
The BNF (British National Formulary) is a direct descendant of the National War Formulary, in which the titles of the preparations were in Latin and the doses in minims and grains. In 1939, the minister for health appointed a committee to prepare a wartime formulary to contain a “selection of medicaments sufficient in range to meet ordinary requirements of therapeutics”.
When the war ended, it was the Royal Pharmaceutical Society and the British Medical Association that wanted to continue publication of a formulary for general use. Therefore, the BNF was born.
Evolution of the BNF
The first edition was published in 1949 and new editions appeared thereafter about every three years until 1976. It became increasingly clear during the early 1970s that the formulary was being used less and less by doctors. The pharmaceutical industry was publishing the “Monthly index of medical specialities” every month. Compared with this, the BNF, which was produced every three years, was soon out of date.
The Medicines Commission was becoming concerned that the prescribing habits of doctors were being unduly influenced by the pharmaceutical industry and it was suggested to the Department of Health and Social Security that a new and more comprehensive national formulary was needed that would:
- No longer be selective but give information about all medicines available in the country for prescribing by doctors
- Give information about the price of medicines
- Be easy to use
- Be a handbook and fit into a coat pocket
- Be kept up to date
The first edition of the new BNF, bound in ultramarine cloth, rolled off the press for publication and distribution throughout the NHS in February 1981. A new edition was published every six months.
In each new edition, there were 3,000–4,000 changes. Some of these may be important changes, for example, a new product is introduced, a preparation is taken off the market because a serious adverse reaction is reported, a new warning is needed or a dose schedule is changed.
Today, each edition of the BNF’s layout and outward appearance are similar to the previous edition except for the colour of the cover. The book still fits comfortably into a coat pocket, despite the increase in the number of pages, a challenge that has been met by the use of thin, bible-weight paper. Yet, BNF 57 (March 2009) contains 978 pages — nearly two-and-a-half times the number in BNF 1.
Although the layout and size of the book have changed little over the years, its stature and reputation certainly have. One illustration of this is that the BNF therapeutic classification now underlies the structure of much of the medicines data in the UK.
Therefore, prescribing analysis reports list prescribed items by BNF therapeutic class, the MeReC Bulletin classifies its tables of contents according to BNF chapters, and the National Electronic Library for Medicines divides its information into BNF categories.
Such is the reputation of the BNF abroad that it has been translated into Italian, Spanish, Turkish and Polish. Saudi Arabia and South Africa, among other countries, have produced BNF look-alikes to suit their own country’s needs.
An independent publication
The BNF does not market medicines. It includes in its monographs only information it believes is required by its users. Differences between manufacturers’ summaries of product characteristics (SPCs) and the BNF monographs exist because SPCs reflect the data for which the licence or marketing authorisation was given and they can, therefore, take time to change.
Evidence and best practice may soon supersede the data used for granting the licence. For example, effective doses for angiotensin-converting enzyme inhibitors in heart failure may exceed the licensed doses.
The BNF aims to provide a dose that will result in good management of the patient’s condition.In such circumstances, it gives details of the effective dose rather than the licensed one. It is the provision of authoritative and impartial guidance that has made the BNF the key prescribing resource in Britain today.
Produced by professionals for professionals, with no commercial agenda, it is, as it always has been, independent of both the pharmaceutical industry and the Government.
The layout of the BNF
The main text consists of classified notes divided into 15 chapters, each of which is related to a particular system of the body or to an aspect of medical care. Each chapter is then divided into sections, which begin with appropriate notes for doctors, dental surgeons, pharmacists, nurses and other healthcare professionals to facilitate the selection of suitable treatment.
The notes are followed by a series of monographs that provide details of relevant drugs and preparations including cautions, contra-indications, side effects and doses. Only those characteristics that are considered to be clinically relevant at the point of care are included.
Appendices cover drug interactions, the use of drugs in liver disease, renal impairment, pregnancy and breast-feeding, as well as intravenous additives, borderline substances, wound management products and elastic hosiery, and cautionary and advisory labels for dispensed medicines.
Information is also provided on prescribing for patients with porphyria and glucose-6-dehydrogenase deficiency. In addition, there is an index of manufacturers, cardiovascular risk prediction charts, and yellow cards for reporting adverse drug reactions to the Commission on Human Medicines.
BNF for Children
The first comprehensive information resource for doctors, pharmacists, nurses and other healthcare professionals on medicines in children, BNF for Children (BNFC), was published in September 2005. It provides practical information on the use of medicines in children of all ages, from neonates (including preterm neonates) to 18-year olds.
BNFC provides a range of guidance from choosing the best available drug to specific doses and formulations, information that has been significantly lacking until BNFC was first published.
Built on bedrock of the BNF with its tried-and-trusted processes, BNFC is constructed by the same editorial team responsible for the BNF. Being able to focus specifically on children is important because children respond to ill health and drug treatment in different ways to adults.
Drawing information from manufacturers’ literature where appropriate, BNFC also includes a great deal of advice that goes beyond marketing authorisations (product licences). For example, lansoprazole for childhood gastro-oesophageal reflux disease and levamisole for nephrotic syndromes.
This information is necessary because licensed indications frequently do not cover the clinical needs of children. In some cases, products for children need to be specially manufactured or imported. Careful consideration is given to establishing the clinical need for unlicensed interventions with respect to the evidence and experience of its safety and efficacy.
What about the future for the BNF in the electronic age? In recent years, the BNF has pursued an extensive programme of digital developments. The portfolio of products provides reliable online access (bnf.org and bnfc.org), availability for a wide range of handheld devices, including the BlackBerry, as well as a customisable version designed for hospital intranets.
Significant work has been done to align the BNF with national standards that allow integration with a wide variety of clinical systems. As a result, the BNF can be accessed easily from GP prescribing systems, hospital pharmacy systems, ambulance systems, the Map of Medicine and Microsoft’s Research Pane. Also, work is underway to integrate BNF knowledge into hospital prescribing systems.
The BNF has collaborated with Onexamination to produce an online revision aid providing a collection of clinically rich questions that help medical students improve their knowledge of safe and effective prescribing while using the BNF. Consideration is underway for developing a similar revision aid for pharmacy students as well.
Often described as the “therapeutic bible”, the BNF is considered by many as essential for clinical practice. It is unique in bringing together authoritative and independent guidance on best practice with clinically validated drug information, enabling healthcare professionals to select safe and effective medicines for individual patients.
The BNF is, arguably, the most important reference text pharmacists will use in their career.
This article draws on information presented in the following publications:
1. Wade OL. British National Formulary: its birth, death, and rebirth. BMJ 1993;306:1051–4.
2. Mason P. The British National Formulary: development and evolution over the last 25 editions. Available at bnf.org (accessed 5 November 2008).
Lisa Britton was staff editor at the BNF
Citation: Tomorrow's Pharmacist URI: 10975975
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