Chapter 9 page number 1 Chapter 9 Nutrition and Blood First line drugs Drugs recommended in both primary and secondary care Second line drugs Alternatives (often in specific conditions) in both primary and secondary care Specialist initiated drugs Secondary care, authorised independent prescribers or GPs with special interest initiation. Suitable for continuation by primary care. Shared care agreements may be applicable.. Secondary care only drugs Drugs only suitable for secondary care use and initiated by appropriate team or specialist. Primary care prescribers should not be asked to prescribe. Drug Form & Strength Notes 9.1 Anaemias and some other blood disorders 9.1.1 Iron-deficiency anaemias see Acute Trust Guidance 9.1.1.1 Oral iron Ferrous fumarate (first line for PCT) Tablets: 210mg Contains 68mg iron. Recommended doses: Treatment: 1 tablet TDS Prevention : 1 tablet OD Ferrous fumarate Capsules: 305mg Contains 100mg iron. Recommended doses: Treatment: 1 capsule BD Prevention: 1 capsule OD Ferrous sulphate (first line for GWH) Tablets: 200mg Contains 65mg iron. Recommended doses: Treatment: 1 tablet TDS Prevention : 1 tablet OD Ferrous fumarate Syrup (Galfer ): 140mg / 5 ml Contains 45mg iron/5ml. Sodium feredetate SF Elixir : 190mg / 5ml Contains 27.5mg iron/5ml. Ferrous fumarate + folic acid 9.1.1.2 Parenteral iron Tablets: 305mg / 350microgram Used for prophylaxis during pregnancy in women who are at high risk of developing iron and folic acid deficiency Please see MHRA Drug Safety Update (August 2013) for recommendations to manage and minimise the risk of serious hypersensitivity reactions. Iron dextran (Cosmofer ) Iron sucrose (Venofer ) Ferric carboxymaltose (Ferinject ) For use only on the Renal Unit at GWH For use by Cherwell Unit/Aldbourne Ward ONLY for patients attending an IV iron clinic prior to hip or knee surgery. For use by Coate Water Unit ONLY for day patients with inflammatory bowel disease attending for IV iron infusion. Please note Ferinject is considerably more expensive than Cosmofer. In all other settings, Ferrinject may ONLY be used in patients with asthma, eczema or other atopic allergic conditions for whom cosmofer would be contraindicated.
Chapter 9 page number 2 9.1.2 Drugs used in megaloblastic anaemias Hydroxocobalamin Injection: 1mg / ml Folic Acid Tablets: 5mg, 400micrograms SF Oral solution: 2.5mg / 5ml 9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias Darbepoetin alfa Prefilled syringe: all strengths SureClick injection device: all strengths Desferrioxamine mesilate Injection: 500mg vial Deferiprone Tablets: 500mg 9.1.4 Drugs used in platelet disorders Anagrelide Capsules: 500micrograms Romiplostim Injection: To be used in accordance with NICE TA221. Same-day, PCT prior approval is required before romiplostim may be prescribed Eltrombopag 9.1.6 Drugs used in neutropenia Filgrastim (brand and indication must be specified when prescribing). Please see MHRA Drug Safety Update (September 2013) Tablets: To be used in accordance with NICE TA293 Ratiograstim Injection: 300micrograms, 480micrograms Neupogen Injection: 300micrograms, 600micrograms, 960 micrograms. 9.2 Fluids and electrolytes 9.2.1 Oral preparations for fluid and electrolyte imbalance 9.2.1.1 Oral potassium Potassium chloride Sando-K Effervescent Tablets: 12mmol K + Kay-Cee-L SF Syrup: 1mmol K + / ml For post chemotherapy neutropenia. For stem cell mobilisation by consultant only. Potassium chloride Slow-K MR Tablets: 600mg 8mmol K + Potassium removal Calcium polystyrene sulphonate Resonium A and Calcium Resonium Powder 9.2.1.2 Oral sodium and water Sodium chloride MR Tablets: 600mg Sodium chloride Oral solution: 30% For consultant prescribing only. Oral rehydration therapy (ORT) Oral Rehydration Salts Oral powder (Dioralyte, Electrolade ) 9.2.1.3 Oral bicarbonate Sodium bicarbonate Tablets: 600mg Paediatric oral solution: unlicensed. For paediatric consultant prescribing only.
Chapter 9 page number 3 9.2.2 Parenteral preparations for fluid and electrolyte imbalance 9.2.2.1 Electrolytes and water Refer to the following information: British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. NPSA Alert Reducing the risk of hyponatraemia when administering IV infusions to children. Sodium Chloride Glucose Potassium Chloride Sodium Bicarbonate Sodium Chloride 0.45% with Glucose 5% 9.2.2.2 Plasma and plasma substitutes Please see memo for information on availability of plasma expanders at GWH. Albumin solution Dextran 70 6 % in sodium chloride 0.9% Intravenous Infusion 500 ml Bag Gelofusine For endoscopy use only Plasmalyte 9.3 Intravenous nutrition Should only be prescribed by the Nutrition Team (Tel: 01793 605149) and ICU clinicians. 9.4 Oral nutrition Prescribers are reminded that the Advisory Committee on Borderline Substances recommends products on the basis that they may be regarded as drugs for the treatment of specified conditions. Doctors should satisfy themselves that the products can be safely prescribed, that patients are adequately monitored and that, where necessary, expert hospital supervision is available. Prescriptions for products recommended by the Committee should be endorsed "ACBS". 9.4.1 Foods for special diets Refer to BNF, appendix 7. 9.4.2 Enteral nutrition See 3Ts Guidelines on community MUST screening, Food First and use of oral nutrtional supplements. When introducing enteral nutrition to patients for the first time, prescribe a small number of assorted flavours or a starter pack as an acute prescription. It is always advisable to screen a patient to assess their requirements using the MUST tool. Please refer to following link http://www.bapen.org.uk/pdfs/must/must_full.pdf. If a patient does not find any formulary option palatable, please refer him/her to the GWH Dietetic Team (01793 605149). For further information, see NICE CG32 Nutrition Support in Adults.
Chapter 9 page number 4 9.5 Minerals 9.5.1 Calcium and magnesium 9.5.1.1 Calcium supplements See section 9.6.4 for combined calcium and vitamin D 3 preparations Adcal Chewable Tablets: 15mmol/tablet. Calcium Sandoz Sandocal-1000 Paediatric Syrup: 2.7mmol/5ml. Paediatric Tablets: 25mmol/tab. Calcium Gluconate Injection 10% Calcium Chloride Injection 9.5.1.2 Hypercalcaemia and hypercalciuria Cinacalcet Tablets: 30mg, 60mg, 90mg 9.5.1.3 Magnesium Refer to: UKMI Guidance on Treatment of Acute Hypomagnesaemia in adults Magnesium citrate Tablet: 150mg (6.2mmol per tablet) (Lambert s For use in secondary care ONLY for short-term Megasorb ) treatment of magnesium deficiency. This is NOT prescribable on FP10. Magnaspartate Sachet: 6.5g (10mmol per sachet). For use in primary (or secondary) care where longer term treatment of magnesium deficiency (or a liquid preparation) is necessary. This is prescribable on FP10. Magnesium sulphate Injection: 50% - 2ml, 10ml, 20ml 9.5.2 Phosphorus 9.5.2.1 Phospate supplements Phosphate-Sandoz Effervescent Tablets: 500mg Phosphates Polyfusor : 500ml Neo-nate50mg/1ml mixture (unlicensed special) 9.5.2.2 Phosphate-binding agents Calcium acetate Tablets: 1g Sevelamer Tablets: 800mg 9.5.3 Fluoride Sodium fluoride Toothpaste: 0.619% Weekly Mouthwash: 0.2% 9.5.4 Zinc Zinc sulphate Effervescent Tablets: 125mg Capsules: 220mg 9.6 Vitamins 9.6.1 Vitamin A Vitamin A + D Capsules: 4000 / 400 units
Chapter 9 page number 5 9.6.2 Vitamin B Thiamine Tablets: 50mg, 100mg Pyridoxine hydrochloride Tablets: 10mg, 20mg, 50mg Vitamin B Compound Strong Tablets Nicotinamide Capsules: 50mg, 500mg For Dermatology only. Unlicensed preparation. Yellow script only. Pabrinex I/V High potency injection 9.6.3 Vitamin C (Ascorbic acid) Ascorbic acid Tablets: 50mg, 100mg 9.6.4 Vitamin D See also: 3Ts Chapter 10 Musculoskeletal. DEXA and osteoporosis guidelines. The main aim of osteoporosis management is to prevent fractures. Prevention is most appropriately targeted at those at high risk of osteoporosis. While there is no evidence that population-based prevention strategies reduce fractures, stopping smoking, taking weight-bearing exercise, ensuring adequate dietary calcium intake and preventing falls may be beneficial. Patients at high risk of osteoporosis include: postmenopausal women premature menopause (< 45 years) previous fragility fracture small, thin women premenopausal amenorrhoea long-term steroid use (> 7.5mg oral prednisolone daily for 6 months) family history of osteoporosis smokers Either HRT or bisphosphonates + calcium and vitamin D3 may be used for the treatment and prevention of osteoporosis. The choice of therapy depends on acceptability, tolerability and the presence of other possible indications for HRT. Adcal D3 or Calceos chewable tablets Tablets: 500mg (Calceos ) or 600mg (Adcal D3 )of calcium per tablet. For daily requirements see osteoporosis guidelines. Prescribers should prescribe whichever product is more cost-effective in their care setting. Adcal D3 contains soya oil & gelatin. Calceos contains partially hydrogenated soybean oil & gelatin. Adcal D3 caplets Calfovit D3 Alfacalcidol Calcitriol Caplets: 300mg of calcium per tablet. Powder: 1.2g/ 20 micrograms. Capsules: 250nanograms, 500nanograms, 1microgram. Oral drops: 2micrograms/ml. Capsules: 250nanograms, 500nanograms. For patients who cannot chew the conventional preparations For pts unable to take chewable tablets or caplets. 1 drop contains approximately 100nanograms. See NPSA Statement (Sept 2011)
Chapter 9 page number 6 Colecalciferol 20,000unit capsules (Fultium D3 ) Licensed for use in children 12-18 years old and adults. Please note capsules contain gelatin. Colecalciferol 3200 unit capsules ( Fultium D3 ) Licensed for use in adults. Please note capsules contain gelatin. Colecalciferol 800 unit capsules ( Fultium D3 ) Colecalciferol oral solution 25,000 units/ml ( Invita D3 ) Licensed for use in children 12-18 years old and adults. Please note capsules contain gelatin. Licensed for use in children 0-18 years old and adults. May be mixed with a small amount of cold or lukewarm food immediately before administration. 9.6.5 Vitamin E (Tocopherols) Alpha tocopheryl Tablets: 100mg Available on a named patient acetate basis only. 9.6.6 Vitamin K Phytomenadione solution Menadiol sodium phosphate Phytomenadione injection Tablets: 10mg Paediatric IV/oral/IM: 2mg in 0.2ml Tablets: 10mg Injection: 100mg in 1ml Konakion MM Paediatric (for im/iv/oral use). Licensed for the prophylaxis and treatment of haemorrhagic disease of the newborn. Water soluble preferable in malabsorption states and cholestasis. In the absence of menadiol 10mg tablets, phytomenadione (vitamin K injection 10mg/ml) may be used orally. This is an unlicensed use. 9.6.7 Multivitamin preparations Multivitamin +/- mineral preparations are not required if the patient is taking a balanced diet. If a patient s diet is not nutritiously complete, consult the MUST tool for further advice at http://www.bapen.org.uk/pdfs/must/must_full.pdf.
Chapter 9 page number 7 Abidec Oral drops Contains less vitamin A than Dalivit. For neo-nates prescribe as per SCBU guidelines. Substitute with Dalivit if Abidec unavailable Dalivit dose should not exceed 0.3ml in neo-nates. Dalivit Oral drops Used for cystic fibrosis patients and adults. Abidec is not suitable for anyone > 12years. Forceval Capsules Junior Capsules Ketovite Multivitamin Tablets Tablets SF Liquid Secondary Care Use Only 9.8 Metabolic disorders 9.8.1 Drugs used in metabolic disorders Dependant on metabolic disorder presented. Penicillamine See 3Ts Chapter 10, section 10.1.3. Carnitine Oral Liquid: 100mg / ml (10 x 10ml single dose) Paediatric solution: 300mg / ml Mercaptamine Capsules: 50mg, 150mg Sodium phenylbutyrate Tablets: 500mg Biotin Tablets: 5mg Injection: 5mg/ml Arginine Tablets: 500mg Oral solution: 50mg/ml Powder: 100g Injection: 500mg/ml Sodium benzoate Tablets: 500mg Capsules: 50mg, 250mg, 400mg, 500mg Oral solution: 100mg/ml, 200mg/ml, 300mg/ml Injection: 200mg/ml For paediatric consultant prescribing only. 9.8.2 Acute porphyrias 9.8.2 Acute porphyrias Haem arginate Concentrate for IV infusion: 25mg / ml Miscellaneous Baby Milk Formulas See formulary guidelines. NHS Swindon, NHS Wiltshire and Great Western Hospitals NHS Foundation Trust in collaboration with Avon & Wilts Mental Healthcare Partnership Trust.