NHS Grampian Staff Guidance For The Management Of Hypomagnesaemia In Adults

Transcription

1 NHS Grampian Staff Guidance For The Management Of Hypomagnesaemia In Adults Co-ordinators: Sarah Gethings Medicine Information Pharmacist Consultation Group: See Page 4 Approver: Medicine Guidelines and Policies Group Signature: Signature: Identifier: NHSG/Hypomag/MGPG802 Review Date: June 2018 Date Approved: June Uncontrolled when printed Version 3 Executive Sign-Off This document has been endorsed by the Director of Pharmacy and Medicines Management Signature:

2 Title: Unique Identifier: NHS Grampian Staff Guidance For The Management Of Hypomagnesaemia In Adults NHSG/Hypomag/MGPG802 Replaces: NHSG/Hypomag/MGPG557, Version 2 Across NHS Boards Organisation Wide Yes Directorate Clinical Service Sub Department Area This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Lead Author/Co-ordinator: Subject (as per document registration categories): Key word(s): Process Document: Policy, Protocol, Procedure or Guideline Document application: Purpose/description: Medicine Information Pharmacist Prescribing and Prescription Policy management acute hypomagnesaemia adults symptoms signs hypomagnesaemia side magnesiumo intravenous supplementation oral IV Infusion Guidance NHS Grampian Instruction on how to correct hypomagnesaemia in adults in NHS Grampian Responsibilities for implementation: Organisational: Corporate: Departmental: Area: Hospital/Interface services: Operational Management Unit: Policy statement: Review: Chief Executive and Management Teams Senior Managers Heads of Service/Clinical Leads Line Managers Assistant General Managers and Group Clinical Directors Unit Operational Managers It is the responsibility of all staff to ensure that they are working to the most up to date and relevant policies, protocols procedures. This policy will be reviewed in two years or sooner if current treatment recommendations change UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG802 - i -

3 This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) or (01224) Responsibilities for review of this document: Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo: Physical location of the original of this document: Job/group title of those who have control over this document: Responsibilities for disseminating document as per distribution list: Medicine Information Pharmacist Pharmacy and Medicines Directorate Pharmacy and Medicines Directorate Medicine Information Pharmacist Medicine Information Pharmacist Revision History: Revision Previous Date Revision Date Summary of Changes (Descriptive summary of the changes made) Sentence describing where policy should be used. Addition of product licensed for magnesium replacement therapy (Magnesium aspartate dehydrate) as 1 st line therapy. Changes Marked* (Identify page numbers and section heading ) P1 - Under title Co-magaldrox 195/220 changed to 2 nd line therapy. Dose adjusted to 40ml based on current practice and to facilitate practical dosing. Magnesium glycerophosphate changed to 3 rd line. Removal: These products are unlicensed for this indication. as licensed product now available. Rephrasing of paragraph that follows to reflect the above information. UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG802 - ii -

4 Revision Date Previous Revision Date Summary of Changes (Descriptive summary of the changes made) Removal: Dose is empirical as there is now a licensed product and licensed dose. Note added regarding alternative intravenous magnesium preparations. Removal: infuse Insertion: administer as an intravenous infusion for clarity. Removal: saline Insertion: sodium chloride 0.9% for clarity. Changes Marked* (Identify page numbers and section heading ) P4 - Intravenous Magnesium P4 - Intravenous Magnesium P4 - Intravenous Magnesium * Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading. UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG802 - iii -

5 NHS Grampian Staff Guidance For The Management Of Hypomagnesaemia In Adults This guidance is for use within primary or secondary care in NHS Grampian. Intravenous magnesium replacement should only be used in an acute setting, as outlined below. This guidance is for the use of magnesium 50% and does not include information on the administration of intravenous magnesium 10%, used in specialist areas only (e.g. ITU, HDU, theatres). The NHS Grampian reference range for magnesium in plasma is mmol/l. Causes of Magnesium Depletion: Please note, this list is not exhaustive Inadequate dietary intake 1, 2 Severe chronic diarrhoea or vomiting 1, 2 Malabsorption syndromes 2, including short bowel syndrome and other cause of intestinal failure Refeeding syndrome Prolonged administration of magnesium-free intravenous fluids Renal disease 1, 2, e.g. acute tubular necrosis Endocrine disorders, e.g. primary hyperaldosteronism 1, 2, diabetic acidosis 2, parathyroid disorders 1 Hypercalcaemia 8 Hypokalaemia 8 Chronic alcoholism 1 Acute pancreatitis 1 Lactation 2 Drugs, e.g. Aminoglycosides 3, 10, 11, amphotericin B 3, 10, 11, ciclosporin 3, 10, pentamidine 3, cisplatin 2,3, 10, carboplatin 4, loop and thiazide diuretics 2, 3, 9, 10, proton 11, 12 pump inhibitors NB: For advice relating to drug interactions with magnesium, please contact your pharmacist or Medicines Information on (internal ext ). Dosage and Administration The specific regimen for magnesium supplementation is dependent upon the magnesium level and the clinical presentation of the patient. See over for guidance. UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG

6 Symptoms and Signs of Hypomagnesaemia Anorexia, vomiting 2 Tremor and choreiform movements 1 Weakness 2, lethargy 2 Tetany 2 Anxiety 8, depression 1, 8, confusion 1, 8, agitation 1 Seizures 1, 8 1, 2, 8 Cardiac arrhythmias and ECG changes Hypertension 8 Hypomagnesaemia is often accompanied by hypokalaemia and hypocalcaemia 2, 10, which may be responsible for many clinical features. Magnesium Level (mmol/l) < >0.70 Symptomatic Asymptomatic Symptomatic Asymptomatic No management required IV Magnesium (see below) (Admission to hospital required) Oral Magnesium (see below) No management required. May consider oral supplementation, with monitoring Oral Magnesium Normal Dose: mmol/day in divided doses 6. 1 st Line Magnesium aspartate dihydrate (Magnaspartate ) 10 mmol (243mg)/sachet: - Dose: 1-2 sachets/day (licensed product). 2 nd Line Co-magaldrox 195/220 (Maalox or Mucogel ) 3.34 mmol/5ml: - Initial dose: 40mL/day in divided doses (off-label use). 3 rd Line Magnesium glycerophosphate tablets - 4mmol (97.2mg)/tablet: Initial dose: 4-6 tablets/day in divided doses (unlicensed medicine). Magnesium glycerophosphate liquid 1mmol/mL: Initial dose: 15-24mL/day in divided doses (unlicensed medicine). Magnasparate is the preferred choice for treatment and prevention of magnesium deficiency as it is the only licensed oral magnesium preparation for these indications. Co-magaldrox can be used as a 2 nd line option as the off-label use of a licensed product is preferred over the use of an unlicensed product. 13 UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG

7 Dose should be adjusted to tolerability and response. Diarrhoea may limit the maximum tolerated dose. The aluminium component of co-magaldrox is constipating, and may counteract the diarrhoea to some extent. Magnesium levels should be monitored, and therapy should be reviewed on a weekly basis. Discontinue treatment if levels are stable and within the normal therapeutic range. Intravenous Magnesium (Only To Be Used In Acute Setting). Magnesium sulphate injection 50% (50% = 500 mg/ml = 2 mmol/ml). 1mmol magnesium is contained in approximately 250mg magnesium sulphate (0.5mL of 50% injection). ECG monitoring is recommended, especially in the elderly. Use with extreme caution in heart block. Extravasation may cause tissue damage 7. Reduce the dose in renal impairment. It has been suggested to give 25-50% of the normal dose 9. IV Infusion Dose: 1 st 24 hours: Dilute 18mL of 50% solution (9g; 36 mmol) in at least 250mL 0.9% sodium chloride or 5% glucose, and administer as an intravenous infusion over 10 hours. This dose may be repeated once during the first 24 hours, guided by serum magnesium levels. Dose: 24 hours onward: Dilute up to 12mL of 50% solution (6g; 24 mmol) in at least 100mL sodium chloride 0.9% or 5% glucose, and administer as an intravenous infusion over 4-24 hours. Continuous infusion is more effective 8. Repeat daily with daily monitoring until magnesium is normal. A total of 5 days therapy may be required. Maximum concentration: 200mg/mL (20%; 0.8 mmol/1ml) 5, 6, 7. Maximum rate: 150mg/minute (0.6 mmol/minute) 5, 6, 7. Infusion is incompatible with alkaline agents. Do not infuse with any other agents unless discussed with a pharmacist. Please note: alternative intravenous preparations (e.g. magnesium 10%) are available and may be used in some specialist areas only (e.g. ITU, HDU, theatres) and are not covered in this guidance. For information on Y-siting with other drugs, contact Medicines Information on (internal extension 52316). UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG

8 Side Effects of Magnesium Administration Generally associated with hypermagnesaemia Flushing 5 Respiratory depression 5 Nausea 5 Vomiting 5 Thirst 5 Hypotension 5 Drowsiness 5 Muscle weakness 5 Cardiac arrhythmias 5 Confusion 5 Diarrhoea following oral administration 5,6 Consultation Group: Dr. Gillian Bain Ms Lynne Crighton Mrs Janet Hassell Dr. Alastair McKinlay Ms Charity Shonge Consultant Gastroenterologist GI Pharmacist ITU Pharmacist Consultant Gastroenterologist Endocrine Pharmacist References: 1. Davidson s Principles and Practice of Medicine, Hunter et al, 22 nd Edition,. 2. The Merck Manual, 19 th Edition, Meyler s Side Effects of Drugs, Dikes and Aronson, 15 th Edition, Summary of Product Characteristics Carboplatin (Accord). Last updated on emc Accessed October Summary of Product Characteristics Magnesium sulphate 50% (South Devon Healthcare) available at /Magnesium%20Sulfate%20DS11-5.pdf 6. British National Formulary, accessed online (October 2015). 7. Injectable MedicinesAdministration Guide, 3 rd Edition, UCL Hospitals, Kim-Sing A and Birmingham CL. Clinical Use of Magnesium, Canadian Journal of Hospital Pharmacy 43(4): , August Topf JM and Murray PT. Hypomagnesaemia and hypermagnesaemia, Reviews in Endocrine and Metabolic Disorders 4(2): , May Kraft MD et al. Treatment of Electrolyte Disorders in Adult Patients in the Intensive Care Unit, American Journal of Health-System Pharmacy 62(16): Drug-induced hypomagnesaemia, Hassam R, Arulanantham N, Adverse Drug Reaction Bulletin (262) (pp ), Food and Drug Administration Safety Communication: Low Magnesium Levels can be Associated with Long-Term Use of Proton Pump Inhibitor Drugs. Available at Accessed October The supply of unlicensed medicinal products ( specials ) MHRA Guidance Note 14 (available at /The_supply_of_unlicensed_medicinal_products specials_.pdf UNCONTROLLED WHEN PRINTED Review Date: June 2018 Identifier: NHSG/Hypomag/MGPG