9: Nutrition and blood

Transcription

1 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 1 of 18 9: Nutrition and blood 9.1 Anaemias and some other blood disorders Iron-deficiency anaemias Oral iron Iron contant of different salts Iron salt Amount Content of ferrous iron Ferrous fumarate Ferrous gluconate Ferrous succinate Ferrous sulphate Ferrous sulphate (dried) 200mg 300mg 100mg 300mg 200mg 65mg 35mg 35mg 60mg 65mg First line Second line Ferrous Sulphate Tablets (200mg) Ferrous Fumarate Syrup (140mg/5ml) (Fersamal) Sodium Feredetate SF Elixir (190mg) (Sytron) Ferrous fumarate 322mg Tablets (100mg iron) Ferrous fumarate 210mg Tablets (68mg iron) Ferrous Gluconate Tablets (300mg) Comments Usual dose for iron deficiency is dried ferrous sulphate 200mg three times a day. 200mg once or twice a day may be effective for prophylaxis or for mild deficiency. Theser are available for patients who come in on them. Ferrous frumarate is cheaper than ferrous suphate in the community.

2 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 2 of Parenteral iron Formulary C C C Ferric Carboxymaltose injection (50mg/ml) (Ferinject) Iron-Hydroxide Sucrose Complex Injection (100mg/5ml) (Venofer) Iron-III Hydroxide Dextran Complex (50mg/ml) (Cosmofer) For Consultant Haematologists and Consultant Obstetricians and Gynaecologists use only First line choice on grounds of safety and faster administration time. A single dose of Ferrinject should not exceed 1000mg of iron (or 15mg/kg) Do not administer 1000mg of iron more than once a week Administer via IV bolus or IV infusion Refer to SPC for rates Consultant Haematologist use only Reserved for patients who need to attend clinic every 4-6 weeks to maintain blood count. Facilities for cardiopiulmonary resuscitation must be at hand Test dose must be given before first infusion. Dose calculated according to body weight and iron deficit Cumulative dose administered in single doses of 100mg (may be increased to 200mg) of iron given not more than 3 times a week. Slow IV injection or IV infusion (preferred route) Consultant Haematologist use only Facilities for cardiopiulmonary resuscitation must be at hand Test dose must be given before first infusion. Dose calculated according to body weight and iron deficit Cumulative dose administered in single doses of 100mg (may be increased to 200mg) of iron given not more than 3 times a week or As a total dose infusion up to a total replacement dose of 20mg iron / kg body weight. Slow IV injection or IV infusion (preferred route) or IM injection

3 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 3 of Drugs used in megaloblastic anaemias First line Hydroxocobalamin Injection (1mg/1ml) Folic Acid SF Solution (2.5mg/5ml) Folic Acid Tablets (400micrograms, 5mg) Comments Hydroxocobalamin has completely replaced cyanocobalamin as the form of vitamin B 12 of choice. Treatment is generally initiated with frequent administration of IM injection to replenish body stores. Thereafter, maintenance treatment which is usually for life, 1mg every 3 months. See BNF for details `Drugs used in hypoplastic, haemolytic, and renal anaemias Formulary R R R Darbepoetin Alfa Syringe (Aranesp) 10micrograms/0.4ml 15micrograms/0.375ml 20micrograms/0.5ml 30micrograms/0.3ml 40micrograms/0.4ml 50micrograms/0.5ml 60micrograms/0.3ml 80micrograms/0.4ml 100micrograms/0.5ml Epoetin Alfa Syringe (Eprex) 6,000units/0.6ml 8,000units/0.8ml 10,000units/1ml Epoetin Beta Syringe (Neorecormon) For renal patients only at Skipton Renal Unit By subcutaneous or intravenous injection. Subcutaneous injection of Eprex is contra-indicated in patient with chronic renal failure Consultant Haematologist should be informed if any patients are started on this treatment. By subcutaneous or intravenous injection.

4 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 4 of 18 1,000units 2,000units 3,000units 4,000units 10,000units Consultant Haematologist should be informed if any patients are started on this treatment. Iron overload First line Desferrioxamine Injection (500mg) Comments Second line Deferiprone Tablets 500mg Oral iron chelator, is licensed for treatment of iron overload in patients with thalassaemia major in whom desferrioxamine is contraindicated or is not tolerated Drugs used in platelet disorders Formulary C Anagrelide Capsules 500micrograms Consultant Haematologist only G6PD deficiency NIL Drugs used in neutropenia Formulary C C Filgrastim Injection (Zarzio brand) Pre filled syringes 30million units (300micrograms/0.5ml) 48million units (480micrograms/0.5ml) Filgrastim Injection (Neupogen Brand) Consultant Haematologist and Oncologist use only in accordance with YCN guidelines Link to YCN guidelines Not licensed for paediatric patients. For paediatric patients

5 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 5 of 18 C Pre filled syringes 30million units (300micrograms/0.5ml) Pegfilgrastim Prefilled Syringe (6mg in 0.6ml) Consultant Haematologist and Oncologist use only in accordance with YCN guidelines Link to YCN guidelines Consultant Haematologist and Oncologist use only in accordance with YCN guidelines. Link to YCN guidelines Fluids and electrolytes Oral preparations for fluid and electrolyte imbalance Oral potassium replacement Potassium Chloride 7.5% SF Syrup (1mmol/ml) Potassium Chloride Tablets (600mg) Sando-K Effervescent Tablets Potassium removal Calcium Resonium Powder Oral sodium and water Dioralyte Sachets Sodium Chloride Tablets (600mg) Oral bicarbonate Sodium Bicarbonate 500mg Capsules

6 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 6 of Parenteral preparations for fluid and electrolyte imbalance Electrolytes and water Glucose 5% Infusion (100ml, 250ml, 500ml, 1L) Glucose 500ml Infusion (10%, 20%, 40%, 50%) Glucose 50% Injection (50ml) Potassium Chloride 0.3% Sodium Chloride 0.18% Glucose 5% (500ml) Potassium Chloride 0.3% in Sodium Chloride 0.9% (500ml, 1L) Potassium Chloride 0.3% in Glucose 5% Infusion (500ml) Potassium Chloride 0.15% Sodium Chloride 0.45% Glucose 5% (500ml) Potassium Chloride 0.15% in Sodium Chloride 0.9% (1L) Potassium Chloride 0.15% in Glucose 5% Infusion (500ml) Potassium Chloride 0.15% Sodium Chloride 0.18% Glucose 4% (1L) Sodium Chloride 0.9% Infusion (50ml, 100ml, 250ml, 500ml, 1L) Sodium Chloride 0.9% Injection (10ml) Sodium Chloride 0.9% Glucose 5% infusion (500ml) Sodium Chloride 0.18% Glucose 10% Infusion (500ml) Sodium Chloride 0.18% Infusion (500ml) Sodium Chloride 1.8% Infusion (500ml) Sodium Chloride 0.18% Glucose 4% Infusion (500ml, 1L) Sodium Chloride 0.45% Glucose 5% Infusion (500ml) Sodium Chloride 5% Infusion (500ml) Sodium Bicarbonate 1.26% Infusion (500ml) Sodium Bicarbonate 2.7% Infusion (500ml) Sodium Bicarbonate 4.2% Infusion (500ml) Sodium Bicarbonate 8.4% Miniject (50ml) Sodium Bicarbonate 8.4% Infusion (200ml) Sodium Lactate Compound Infusion (500ml, 1L) Water for Injections (5ml, 10ml, 100ml) Formulary S Potassium Chloride 15% Injection (20mmol in 10ml ampoule) S Potassium Chloride 7.5% (50mmol in 50ml syringe) R Potassium Chloride 0.6% in Sodium Chloride 0.9% (500ml) R Potassium Chloride 0.6% in Glucose 5% Infusion (500ml) Controlled Drug Restricted to children s unit Controlled Drug Restricted to theatre and ICU These products contain 80mmol K+ per litre for correction of severe hypokalaemia. Concentration exceeds that recommended for peripheral infusion.

7 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 7 of 18 S Potassium Chloride 0.15% in Ward 21 Maternity use only Glucose 10% Infusion (500ml) S Potassium 8mmol, Calcium 3mmol in Glucose 10%and Sodium Chloride 0.18% 500ml For use only under the recommendation of the paediatricians, mainly for patients on ANU but occasionally childrens unit R Prismasol 4 (5L) For use on ICU only for renal patients Plasma and plasma substitutes Voluven 6% Infusion (500ml) Volplex Infusion (500ml) 9.3 Intravenous nutrition Formulation of parenteral nutrition use under the recommendation of the pharmacists Addiphos Solution (20ml) Additrace Solution (10ml) Babiven Intrafusin 22 Intralipid 20% (100ml, 500ml) Intralipid 30% (500ml) Neo-Natal TPN (with fat, without fat) Nutriflex Lipid Plus 1875ml Nutriflex Lipid Special 1875ml Nutriflex Lipid Peri 1250ml Nutriflex Lipid Peri 1875ml Nutriflex Lipid Special Electrolyte Free 1250ml Nutriflex Lipid Special Electrolyte Free 1875ml Nutriflex Lipid Special Electrolyte Free 2500ml Peditrace Solution (10ml) Solivito N Injection Structokabiven 8gEF, 12gEF, 16gEF Vaminolact (100ml) Vamin 9 Glucose (100ml, 500ml) Vamin 14 (500ml) Vamin 14 electrolyte-free (500ml) Vamin 18 electrolyte-free (500ml) Vitlipid N Adult (10ml) Vitlipid N Infant (10ml)

8 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 8 of Oral nutrition For use under the recommendation of the dietitians Aptamil 1 st Milk Build up fortified soup Build up Calogen Emulsion (Strawberry) (250ml, 500ml) Calogen Emulsion (Banana) (250ml, 500ml) Calogen Emulsion (unflavored) (500ml) Carobel Powder (135g) Complan Shake (57g) Cow + Gate 1 (450g) Dextrose Monohydrate Powder (500g) Duocal super soluble powder (400g) Elemental 028 Extra powder 100g sachets Elemental 028 Extra Liquid (18 x 250ml) Efamil AR powder Farleys First Milk Powder (900g) Fortijuice Assorted (200ml) Forticreme Complete Assorted (125g) Fortimel Liquid (200ml) Fortisip Compact Assorted (125ml) Fortisip Extra Assorted (200ml) Fortisip Fruit Dessert Assorted (125g) Fortisip yoghurt style Assorted (200ml) Fortini (200ml) Fortini multifibre Glutamine sachets 5g Glutafin (Gluten and Wheat Free Fibre loaf 400g) Infasoy powder Infatrini (100ml) Kindergen Liquigen Loprofin bread Loprofin biscuits Milupa Aptamil Pepti (900g) Modulin IBD Monogen Powder (400g) Neocate Advance Neocate LCP Nepro

9 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 9 of 18 Nutilis oral powder Nutramigen powder 1 and 2 Nutrini (500ml) Nutrini Energy (500ml) Nutrini Energy Multifibre (500ml) Nutrini Low Energy Multifibre (500ml) Nutriprem Powder 2 Nutrison (1L, 1.5L) Nutrison Multifibre (1L, 1.5L) Nutrison Low Sodium (500ml, 1L) Nutrison Soya (500ml, 1L) Nutrison Water Pack (1L) Nutrison Energy (1L) Nutrison Peptisorb (1L) Nutrison Energy Multifibre (500ml, 1L, 1.5L) Nutrison Multifibre (500ml, 1L, 1.5L) Nutrison Concentrated (500ml) Phlexy 10 Phlexy Vits PKU Anamix infant Polycal Liquid (200ml) Polycal (400g) Pregestimil Powder (450g) Prosure Feed (240ml) Pulmocare Liquid (500ml, 1L) Scandishake Mix (6 x 85g) SMA High Energy (250ml) SMA Gold Powder (450g) Sodium Benzoate Liquid (500mg/5ml) Thixo-D Powder (375g) Wysoy (430g) XP Maxamaid powder (unflavoured) (500g) Formulary R Nutricia preop drinks (200ml) For use in patients undergoing elective colorectal surgery as part of the Enhanced Recovery Programme R Calogen Extra Shots (Neutral) (6X 40ml) For use only on recommendation of a dietitian R Calogen Extra Shots (Strawberry) (6X 40ml) For use only on recommendation of a dietitian

10 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 10 of Minerals Calcium and magnesium Calcium supplements Oral preparations Calcium Carbonate Chewable Tablets (1.5g) (Ca+ 15mmol) Calcium Lactate Tablets (300mg)(Ca+ 1mmol) Calcium Sandoz Syrup (2.7mmol Ca+/5ml) Sandocal 400 Effervescent Tablets (Ca+ 10mmol) Sandocal 1000 Effervescent tablets (Ca+ 25mmol) Parenteral preparations Calcium Chloride 10% Miniject (10ml) Calcium Chloride 13.4% Injection (10ml) Calcium Gluconate 10% Injection (10ml) Hypercalcaemia and Hypercalcuria Formulary C Cinacalcet 30mg For Hypercalcaemia of primary hyperparathyroidism or parathyroid carcinoma Magnesium Magnesium L-Aspartate Dihydrate Sachets (10mmol) (Magnaspartate) Magnesium Sulphate 50% Injection (50ml) Magnesium Sulphate 20% Injection (50ml) Magnesium sulphate infusion 20mmol in 100ml sodium chloride 0.9% Formulary S Magnesium Sulphate 50% Injection 5g/10ml For aseptics use only

11 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 11 of Phosphorus Phosphate supplements Phosphate-Sandoz Effervescent Tablets Formulary S Potassium Acid Phosphate 13.6% Solution (100ml) Reserved for SCBU only Phosphate-binding agents NIL Fluoride NIL Zinc Zinc Sulphate Capsules (220mg) Zinc sulphate 125mg effervescent tablets (Solvazinc) Formulary R Zinc Sulphate Injection 100micromols/ml Reserved for use in TPN only

12 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 12 of Vitamins Vitamin A Vitamins A & D Capsules Vitamin B Pyridoxine Oral Solution (100mg/5ml) Pyridoxine Injection (100mg/2ml) Pyridoxine Tablets (10mg, 50mg) Thiamine Tablets (50mg, 100mg) Vitamins B & C I/M High Potency Injection Vitamins B & C I/V High Potency Injection Vitamin B Compound Strong Tablets Formulary R Vigranon B Syrup Liquid oral Vitamin B preparation for N-G refeeding. (Compound vitamin B is required for NG fed patients they need to be crushed and do not fully dissolve so risk of blocking NG tubes) NICE (CG100) recommends: Offer thiamine to people at high risk of developing, or with suspected, Wernicke s encephalopathy. Thiamine should be given in doses toward the upper end of the British national formulary range. It should be given orally or parenterally as follows: Offer prophylactic oral thiamine to harmful or dependent drinkers: if they are malnourished or at risk of malnourishment or if they have decompensated liver disease or if they are in acute withdrawal or before and during a planned medically assisted alcohol withdrawal. Offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers: if they are malnourished or at risk of malnourishment or if they have decompensated liver disease and in addition attend an emergency department or are admitted to hospital with an acute illness or injury. Offer parenteral thiamine to people with suspected Wernicke s encephalopathy. Maintain a high level

13 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 13 of 18 of suspicion for the possibility of Wernicke s encephalopathy, particularly if the person is intoxicated. Parenteral thiamine should be given for a minimum of 5 days, unless Wernicke s encephalopathy is excluded. Oral thiamine should follow parenteral therapy Vitamin C Ascorbic Acid Tablets (50mg, 100mg, 200mg, 500mg)

14 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 14 of Vitamin D The term vitamin D is used for a range of compounds which possess the property of preventing or curing rickets. They include: available Type of Vitamin D Usual use and dose Dose Cacium and ergocalciferol Tablets Calciferol Tablets (250micrograms)(10,000units), (1.25mg)(50,000 units) Ergocalciferol Injection (300,000units/ml, 600,000units/2ml) Ergocalciferol (calciferol,vitamin D2) (10micrograms) (400units) with Calcium lactate 300mg, Calcium phosphate 150mg (Calcium 97mg Ca mmol) Ergocalciferol (calciferol,vitamin D2) Simple vitamin D deficiency can be prevented by taking an oral supplement of only 10micrograms (400units) ergocalciferol daily. Since there is no plain tablet of this strength available calcium and ergocalciferol can be given if patients come in on them. Vitamin D deficiency caused by intestinal malabsorption or chronic liver diease usually requires vitamin D in doses of calciferol up to 1mg (40,000 units) daily. Hypocalcaemia of hypoparathyroidism often requires doses of up to 2.5mg (100,000units) daily to achieve normocalcaemia Ergocalciferol injection is currently unavailable long-term. We are currently able to obtain unlicensed colecalciferol injection 300,000 units as an alternative for those patients who would otherwise have received ergocalciferol injection. Doses are equivalent. Unlicensed medicines paperwork needs to be completed for colecalciferol injection. Written patient consent is not required but use of an unlicensed medicine should be documented in the patient s notes.

15 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 15 of 18 Alfacalcidol Capsules (250nanograms, 1microgram) Alfacalcidol Drops (2micrograms/ml) Calcitriol Capsules (250 nanograms, 500nanograms) Calcitriol Injection (2micrograms/1ml) Alfacalcidol (1αhydroxycholecalciferol) Calcitriol (1,25- dihydroxycholecalciferol) Vitamin D requires hydroxylation by the kidney to its active form therefore the hydroxylated derivatives alfacalcidol and calcitriol should be prescribed if patients with severe renal impairment require vitamin D therapy Adult and child over 20kg, initially 1microgram daily (Elderly 500nanograms) adjusted to avoid hypercalcaemia; maintenance usually 250nanograms to 1microgram daily See BNF Vitamin D with Calcium Comments First line Adcal-D3 Chewable Tablets Calcium carbonate 1.5g (Calcium 600mg Ca mmol) Colecalciferol (Vitamin D3) 10micrograms (400units) Others Calcichew-D3 Chewable Tablets Calcium carbonate 1.25g (Calcium 500mg Ca2+12.5mmol) Colecalciferol 5micrograms (200units) orange falvoured tablets Calcichew D3 Forte Tablets Calcium carbonate 1.25g (Calcium 500mg Ca2+12.5mmol) Colecalciferol 10micrograms (400units) lemon flavoured chewable tablets Calceos Tablets Calcium carbonate 1.25g (Calcium 500mg Ca2+12.5mmol) Colecalciferol 10micrograms Calcium and Ergocalciferol Tablets (400units) patient may come in on Calceos Ergocalciferol (calciferol, Vitamin D2) (10micrograms) (400units) with Calcium lactate 300mg, Calcium phosphate 150mg (Calcium 97mg Ca2+ 2.4mmol) This is expensive and should only be used for patients who come in on it.

16 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 16 of 18 Formulary R R Calcium and vitamin D sachets (Cacit) Colecalciferol oral drops (100units/drop) (Pro-D3) These are expensive and are restricted for use in patients who have difficulties in swallowing tablets For use in paediatric patients with vitamin D insufficiency under the recommendation of a consultant paediatrician R Paricalitol Injection 5mcg/mL Renal Unit use only Vitamin E Alpha Tocopheryl Acetate Suspension (500mg/5ml) Vitamin K All available on the formulary Menadiol Sodium Phosphate Tablets (10mg) Phytomenadione Capsules (1mg) Phytomenadione Injection (1mg/0.5ml) Comments Because vitamin K is fat soluble, patients with fat malabsorption, especially in biliary obstruction or hepatic disease, may become deficient. For oral administration to prevent vitamin K deficiency in malabsorption syndromes, this water soluble preparation must be used. Dose usually 10mg daily Vitamin K can be given orally for prevention of vitamin K deficiency in haemorrhagic disease of the newborn, where the injection is not appropriate. Two doses of 2mg should be given in the first week. For breast fed babies, a third dose of phytomenadione 2mg is given at one month of age: the third dose is omitted in formula fed babies because formula feeds contain vitamin K 1mg may be given as a single intramuscular injection at birth. This prevents vitamin K deficiency bleeding in virtually all babies. Fears about safety of parenteral vitamin K appear to be unfounded

17 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 17 of 18 Phytomenadione Injection (10mg/1ml) Phytomenadione Chewable Tablets (10mg) Multivitamin Preparations Abidec Drops Dalivit Drops (50ml) Ketovite Liquid Ketovite Tablets Vitamin Tablets Oral coumarins act by interfering with vitamin K metabolism in hepatic cells their effects can be antagonised by giving Vitamin K See BNF section Formulary R Forceval Capsules For the prevention of re-feeding syndrome. Use to be restricted to patients at high risk of re-feeding syndrome for a treatment period of 10 days in-line with NICE guidance. R Forceval Soluble Tablets For patients at risk of re-feeding syndrome who are unable to swallow Forceval capsules. Use to be restricted to patients at high risk of refeeding syndrome for a treatment period of 10 days in-line with NICE guidance. 9.7 Bitters and Tonics NIL

18 Original date of issue: 30/01/2006 Last Reviewed: 17/09/2011 Version:4 Page 18 of Metabolic disorders Drugs used in metabolic disorders Formulary S Arginine Infusion (20%) 20g in 100ml For metabolic disorders only S L-Carnitine Oral Liquid (1g in 10ml) L-Carnitine 30% paediatric usually in paediatric patients S S S S Dichloroacetate Sodium Liquid 50mg/1ml (200ml) Mercaptamine Capsules 50mg Sodium benzoate Liquid 500mg/5ml (50ml) Sodium benzoate Injection 1000mg/5ml Sodium Phenylbutyrate 1250mg/5ml (100ml) Acute porphyrias NIL