Guidelines for the Management of Hypomagnesaemia in Adult Haematology and Oncology Patients

Transcription

1 Guidelines for the Management of Hypomagnesaemia in Adult Haematology and Version One Date of Publication: June 2011 Name of responsible committee/individual: Target audience: Date of Ratification: Original Author(s): Carole Connor, Nurse Consultant, South Warwickshire NHS Foundation Trust Arden Cancer Network Acute Oncology Group Haematology and Oncology Practitioners Ratified by: Date for Review: June 2014

2 Version History Version Date Brief Summary of Change One June 2011 First version of Network Wide document Version One 2 of 12

3 Contents Section Page 1.0 Introduction Purpose The Management of Hypomagnesaemia Consultation and Communication Process Equality Impact Assessment Review and Revision Arrangements including Version Control Dissemination and Implementation References Document Circulation 10 Appendices Appendix A Appendix B Equality Impact Assessment Tool 11 Plan for Dissemination of Procedural Documents 12 Version One 3 of 12

4 1.0 Introduction Magnesium plays a fundamental role in many functions of the cell, including energy transfer, storage, and use; protein, carbohydrate, and fat metabolism; maintenance of normal cell membrane function; and the regulation of parathyroid hormone (PTH) secretion. Systemically, magnesium lowers blood pressure and alters peripheral vascular resistance. Abnormalities of magnesium levels can result in disturbances in nearly every organ system and can cause potentially fatal complications (e.g., ventricular arrhythmia, coronary artery vasospasm, sudden death) (Fuller 2009). The prevalence of hypomagnesaemia in the general population ranges from % (Schimatscheck & Rempis 2001). This incidence may be higher amongst cancer patients. It is recognised that some chemotheraputic agents may cause hypomagnesaemia. However it also occurs in gastrointestinal disorders including diarrhoea, malnutrition and decreased dietary intake and also diuretics and other drug therapy (Saif 2008). 2.0 Purpose This Arden Cancer Network wide document has been developed because there is a need to provide a seamless service for cancer patients across the network. This guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. 3.0 The Management of Hypomagnesaemia 3.1 Causes of Hypomagnesaemia Common causes of hypomagnesaemia include gastrointestinal, renal, shifts from extracellular to intracellular fluid and transdermal losses. Table One lists the main causes of Hypomagnesaemia and table Two summarises the main drug causes in cancer patients. Hypomagnesaemia is particularly prevalent in patients receiving cisplatin chemotherapy (Hodgkinson, Neville-Webbe & Coleman 2005). Additionally elderly patients are more susceptible to hypomagnesaemia. Version One 4 of 12

5 Table One Main Causes of Hypomagnesaemia Gastrointestinal Renal Shifts from Extracellular to Intracellular Fluid Diarrhoea Alcoholism Acidosis (correction of) Dietary deficiency Diabetes Blood transfusion (massive) Familial magnesium Diuretics Epinephrine malabsorption Gastrointestinal Hypoparathyroidism Insulin/glucose/ fistula s refeeding syndrome Inflammatory bowel Hyperthyroidism Pancreatitis (acute) disease Malabsorption Hyperaldosteronism Surgical resection Syndrome of inappropriate antidiuretic hormone secretion Vomiting Excessive vitamin D Ketoacidosis Hypercalcaemia/ Hypophosphataemi a Tubular defects Transdermal Losses Excessive sweating Severe Burns Table Two The Main Agents Causing Hypomagnesaemia in Cancer Patients Chemotherapeutic Agents Cisplatin Carboplatin (less severe than cisplatin) Cyclosporin Epidermal Growth Factor Receptor (EGFR) Inhibitors (particularly Cetuximab) Interleukin-2 Pegylated Liposomal Doxorubicin Other Drugs Commonly used in Cancer Patients Aminoglycoside antibiotics Amphoteracin B Pentamidine Gentamycin Diuretics Version One 5 of 12

6 3.2 Main Clinical Manifestations Neuromuscular manifestations Muscular weakness Tremors Seizure Paresthesias Tetany Positive Chvostek sign and Trousseau sign Vertical and horizontal nystagmus (Fuller 2009) Cardiovascular manifestations Electrocardiographic abnormalities nspecific T-wave changes - U waves Prolonged QT and QU interval Repolarization alternans which may lead to ventricular arrhythmia s/sudden cardiac death Arrhythmias Premature ventricular contractions - Monomorphic ventricular tachycardia Torsade de pointes - uncommon form of ventricular tachycardia which may lead to ventricular fibrillation Ventricular fibrillation Enhanced digitalis toxicity (Fuller 2009) Metabolic manifestations Hypokalaemia Hypocalcaemia (Fuller 2009) Other Manifestations Depression Psychoses (UK Medicines Information 2010a). 3.3 Diagnosis Chronic hypomagnesaemia can occur as early as three weeks after initiation of chemotherapy and can persist for several months or years (Saif 2008). Hypomagnesaemia should be suspected in cancer patients receiving drugs identified in table two and also in those with chronic diarrhoea, hypocalcaemia, refractory hypokalaemia and ventricular arrhythmia (Saif 2008). The majority of patients with clinical manifestations of magnesium deficiency have hypomagnesemia. This must be confirmed by undertaking serum magnesium levels. However it should be noted that because 30% of magnesium is bound to albumin and is therefore inactive, hypoalbuminemic states may lead to spuriously low magnesium values. Additionally a person may have normal serum levels of magnesium but be Version One 6 of 12

7 intracellularly depleted and exhibit signs of magnesium deficiency. There is no quick, simple, and accurate test is available to measure intracellular magnesium (Fuller 2009). 3.4 Management Options Clinicians should consider undertaking serum magnesium levels in patients at potential risk of hypomagnesaemia (table one and two). Where indicated, this should be undertaken prior to starting chemotherapy and before each cycle of chemotherapy as early intervention is the best management option Drug Therapy In acute symptomatic hypomagnesaemia, rapid replacement therapy with intravenous magnesium salts may be necessary (UK Medicines Information 2010b). Intravenous magnesium replacement therapy should also be considered for patients with a serum magnesium concentration of 0.4 mmol/l or less (the reference range is mmol/litre). For patients with a serum magnesium concentration of mmol/l, magnesium replacement should be prescribed if the patient presents with symptoms of hypomagnesaemia or following a clinical risk/benefit decision (UK Medicines Information 2010a). Oral magnesium preparations may be given for the treatment of chronic or asymptomatic hypomagnesaemia in doses adjusted according to individual requirements. Patients with concomitant hypokalaemia or hypocalcaemia should also receive potassium and calcium replacement, because these disorders may take several days to correct when treated with magnesium alone (Fuller 2009). te: Caution must be exercised in patients with impaired renal function. These patients are at increased risk of acute hypermagnesemia and should only receive 25-50% dose Oral Magnesium There is no medicine licensed in the UK to be given orally for the treatment of hypomagnesaemia. The British National Formulary states magnesium glycerophosphate tablets or liquid are suitable preparations for oral magnesium supplementation (UK Medicines Information 2010b). The standard dose of oral magnesium for hypomagnesaemia is 24mmol daily in divided doses (UK Medicines Information 2010a). Please inform the Trust pharmacy department if oral magnesium is prescribed or intended to be prescribed in order for a supply to be ordered Intravenous Magnesium If oral magnesium replacement is not appropriate, intravenous magnesium therapy may be considered. Magnesium sulphate is the salt of choice. The licensed dose for severe Version One 7 of 12

8 or symptomatic hypomagnesaemia is 5 grams magnesium sulphate (20mmol magnesium) in 1 litre of sodium chloride 0.9% or glucose 5% infused over three hours. It has been suggested that a longer infusion period may be more suitable for nonemergency situations. Infusion rates above this will exceed the renal threshold and will be disproportionately excreted in patients with normal renal function. Bolus or rapid administration must not be used unless the patient is in the intensive care/high dependency unit as rapid administration can cause cardiac arrest. Regular clinical observations and cardiac monitoring must be undertaken as symptoms of magnesium excess include hypotension and respiratory distress. After initial intravenous administration, it may be appropriate to give oral magnesium supplements to replenish the magnesium stores (UK Medicines Information 2010a). Successful treatment usually takes 2-3 days of treatment (Dickerson 2001). te serum magnesium concentrations are usually elevated for 1-2 days following treatment beaches it takes hours for the magnesium to fully redistribute to the body tissues. It is recommended that serum magnesium levels are not re-checked until 48 hours following administration (Dickerson 2001). 3.5 Complications Full side-effect profiles are detailed within the Summary of Product Characteristics for each drug and in the BNF. However it should be noted that oral magnesium salts frequently cause diarrhoea. 4.0 Consultation and Communication Process The consultation process involves dissemination of draft documents for comment to: the Arden Cancer Network Drugs and Therapeutics Committee, consultants haematologists, oncologists and haematology/oncology specialist nurses, ward managers and pharmacists at George Eliot Hospital, South Warwickshire NHS Foundation Trust, University Hospitals Coventry and Warwickshire and Worcestershire Acute Hospitals NHS Trust. 5.0 Equality Impact Assessment See Appendix A. 6.0 Review and Revision Arrangements including Version Control The Chair of the Arden Cancer Network Acute Oncology Group will nominate an individual to undertake a review of the guidance 3 months prior to the revision date. Version One 8 of 12

9 7.0 Dissemination and Implementation Once documents are ratified, notification will be sent by to the Acute Oncology Lead and Acute Oncology Nurse for each Trust. It will be their responsibility to disseminate and implement the protocol locally. The final version of documents will be placed on the Arden Cancer Network intranet and each individual Trust s intranet via a designated lead for each Trust. Hard copies will not be circulated. It will be the responsibility of departmental managers to remove outdated copies and to ensure staff are aware of the new version. It is the responsibility of departmental managers to implement any identified training or support. (Appendix B). 8.0 References Dickerson RN (2001) Guidelines for the Intravenous Management of Hypophosphataemia, Hypomagnesaemia, Hypokalaemia and Hypocalcaemia Hospital Pharmacy 36 (11) Fuller T (2009) Hypomagnesaemia. Accessed online via on Hodgkinson E, Neville-Webbe HL, Coleman RE (2005) Magnesium Depletion in Patients Receiving Cisplatin-based Chemotherapy Clinical Oncology 18(9) Saif WM (2008) Management of Hypomagnesaemia in Cancer Patients Receiving Chemotherapy. Journal of Supportive Oncology. 6(5); Schimatschek HF, Rempis R (2001) Prevalence of hypomagnesaemia in an unselected German population of 16,000 individuals Magnesium Research 14; Sweetman S. Martindale: The Complete Drug Reference. Accessed online via: on UK Medicines Information (2010a) How is acute hypomagnesaemia treated in adults? Prepared by UK Medicines Information pharmacists for NHS healthcare professionals England. Leeds Medicines Information Centre. Accessed online via the National Electronic Library for Medicines on UK Medicines Information (2010b) What oral magnesium preparations are available in the UK and which preparation is preferred for the treatment and prevention of hypomagnesaemia? Prepared by UK Medicines Information pharmacists for NHS healthcare professionals England South West Medicines Information and Training. Accessed online via the National Electronic Library for Medicines on Version One 9 of 12

10 9.0 Document Circulation Name Title Trust Dates Circulated Dr Peter Correa** Chair of the Network Arden Cancer , Acute Oncology Network Group Patient , Representative Dr Jag Ghandla* Acute Oncology Lead George Eliot , Karen Pedley Matron & Lead Hospitals NHS , Cancer Nurse Trust Lynne Colbourne Acute Oncology Lead Worcestershire , Ann Sullivan Cancer services Manager Acute Hospitals NHS Trust , Carole Connor* Acute Oncology Lead South , Julia Edging ton Acute Oncology , Nurse Warwickshire NHS Foundation Trust * Dr Peter Correa Acute Oncology Lead University , Niahmh Hughes Acute Oncology Nurse Hospitals Coventry and Warwickshire NHS Trust *Responsible for circulating to relevant staff within their Trust including chemotherapy nurse specialists and haematologists/oncologists **Responsible for circulating to Network Chemotherapy Cross Cutting Group Version One 10 of 12

11 Appendix A - Equality Impact Assessment Tool 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? Yes/ 5. If so, can the impact be avoided? N/A 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? ne Comments Version One 11 of 12

12 Appendix B - Plan for Dissemination of Procedural Documents Title of document: Date finalised: Previous document already being used? Guidelines for the Management of Hypomagnesaemia in Adult Haematology and Dissemination lead: Carole Connor Nurse Consultant South Warwickshire NHS Foundation Trust If yes, in what format and where? Proposed action to retrieve out of date copies of the document: N/A First Network Wide document across Haematology and Oncology. Acute Oncology Nurse for each Trust to retrieve local documents To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Stephanie Connell Arden Cancer Network Karen Pedley Matron & Lead Cancer Nurse George Eliot Hospitals NHS Trust Julia Edgington Acute Oncology Nurse, South Warwickshire NHS Foundation Trust To inform all areas that revised network wide electronic version available on Trusts intranet and Arden Cancer network site with 7 days of receipt Electronic Niahm Hughes Acute Oncology Nurse University Hospitals Coventry and Warwickshire NHS Trust Lynne Colbourne Acute Oncology Lead Worcestershire Acute Hospitals NHS Trust Dissemination Record - to be used once document is approved Date put on register / library of procedural documents: Date due to be reviewed: June 2014 Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date Disseminated:. of Copies Sent: Contact Details / Comments: Directly Electronic One Carole Connor South Warwickshire NHS Foundation Trust Version One 12 of 12