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9.0 Nutrition and blood

9.0 Nutrition and blood

 9.1.1 Iron-deficiency anaemias

Treat demonstrable iron-deficiency state only. Use prophylactically in some situations.
Patients should be directed to purchase nutritional supplements (including iron) over the counter post bariatric surgery. See
 Guideline 
 
9.1.1.1 Oral Iron
Treatment needs 100-200mg elemental iron per day. Prophylaxis 50-100mg elemental iron per day.  When treating
iron-deficiency anaemia, haemoglobin should rise by approximately 100-200mg/100ml (1-2g/litre) per day or 2g/100ml 
(20g/litre) over 3-4 weeks. Once it has reached reference range, treatment should be continued for a further 3 months 
in order to replenish iron stores, and then stopped.
 
GREEN      Ferrous sulphate tablets 200mg provide 65mg iron             
GREEN      Ferrous fumarate tablets 210mg provide 68mg iron
GREEN      Sodium feredetate elixir (Sytron®) provides 27.5mg iron/5mL           
GREEN      Ferrous fumarate syrup 140mg/5ml provides 45mg iron/5mlL                
 
** ELHT neonatal formulary recommends that babies started on Sytron® and/or Abidec® on the Neonatal Intensive 
     Care Unit  (ELHT) should remain on the treatment for 1 year post birth. GPs in Primary care are requested to 
     continue to prescribe these products for neonates until the age of 1 year old.
 
Modified release preparations give a reduced total daily dose of iron, and are less efficacious as they carry iron past 
the duodenum where absorption may be poor.  They should therefore only ever be used for low dose prophylaxis, not 
for treatment of iron-deficiency states.
 
GREEN      Ferrous sulphate modified release tablets 325mg (Ferrograd®) 
                   provides 105mg iron (give once daily)
 
Iron and folic acid
 
GREEN      Pregaday® tablets provide 100mg iron + 350microgram folic acid       
 
9.1.1.2 Parenteral Iron
The only valid reason for administering iron parenterally is non-tolerance of oral therapy, continuing blood loss or
malabsorption. If oral preparations are taken reliably and are absorbed, the haemoglobin response is not significantly 
faster with the parenteral route. 
CosmoFer® (iron dextran injection) has the advantage of being licensed for administration as a single total dose
infusion, and can also be given IM. Due to the association of administration of parenteral iron preparations with
severe anaphylactoid reactions prescribers are reminded to test dose patients and have anaphylactic emergency kits
close to hand when giving either Cosmofer® or Venofer®.
 
First Line 
AMBER     Iron dextran injection (CosmoFer®) 2ml provides 50mg/mL iron
 
Second Line
AMBER     Iron sucrose injection (Venofer®) 5ml provides 20mg/mL iron

RED           Ferric Carboxymaltose (Ferinject®) 50mg/mL *       

* Can be considered as a cost effective option where IV iron is required - shorter infusion time , reduced adverse effects 

9.1.2 Drugs used in megaloblastic anaemias

Megaloblastic anaemia is usually due to vitamin B12 or folate deficiency; the specific deficiency and underlying cause must be identified. Treatment is usually only begun once a firm diagnosis is made. In emergencies, where delayed treatment may be dangerous, both folate and vitamin B12 may be required initially, until assay results are known. Folate must not be used alone in undiagnosed megaloblastic anaemia due to the risk of B12 deficiency leading to peripheral neuropathy.

During pregnancy the prevention of a first occurrence of neural tube defects is with 400 microgram/day. A higher dose of folic acid at 5mg/day is used for folate deficiency and prevention of recurrence of neural tube defects.  Both should be continued for the first twelve weeks of pregnancy.

GREEN      Folic Acid
                   tablets 5mg
                   tablets 400 microgram
                   syrup 2.5mg/5mL
RED           Folic acid injection 15mg/ml (unlicensed)
GREEN      Hydroxocobalamin injection 1mg/mL
 
There is little place for use of low dose vitamin B12 orally. However, cyanocobalamin tablets can be used in doses of 
50-150micrograms daily for vegans or patients who have proven dietary deficiency (prescription must be endorsed 
SLS).


9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias

Epoetin for use in patients with renal disease will be supplied from the tertiary referral centre.  For all other indications
supply will usually be organised through a home delivery company. 
 
RED           Darbepoetin alfa (Aranesp®) Prefilled disposable SureClick™ devices
                     100micrograms, 150micrograms, 300micrograms, 500micrograms.
RED            Epoetin alfa (Eprex®) 
                     Vial 40 000unit/ml 1mL   
                  Prefilled syringes 1000units, 2000units, 4000units, 5000units, 6000units, 8000units, 10,000units.
 

Iron Overload 

Iron overload is the result of many disorders and can lead per se to the development of organ damage and increased mortality. In humans total body iron stores is maintained within the range of 200-1500 mg by adequate adjustment of intestinal iron absorption, since no excretory mechanisms exist.   

Frequent blood transfusions lead to excessive accumulation of iron with a toxic accumulation in 3 to 10 years. The toxicity of iron results from two related events:

1. excess iron deposits in various tissues of the body, particularly in liver, heart and endocrine organs with the consequence of liver diseases, diabetes mellitus and other complications, and

2. free iron that catalyzes the formation of highly reactive hydroxyl radicals which lead to membrane damage and denaturation of proteins.

Once iron exceeds a certain level, these effects lead to significant morbidity and mortality. Without specific chelation therapy to remove the iron, in 3 to 10 years almost all regularly transfused patients will have acquired a toxic accumulation of iron. The main cause of death is due to cardiac complications.

The management of established iron overload also involves venesection which is not always possible.  The subsequent aim is to make the iron as safe as possible by binding the toxic iron pools responsible for causing tissue damage. Iron chelation therapy reduces iron-related morbidity, reduces and retards liver diseases, diabetes and other endocrine failures, normalizes growth and sexual development, prevents, and in some cases reverses, cardiac insufficiency and improves quality of life. Consequently iron chelation therapy dramatically reduces mortality.

Deferasirox

Deferasirox should only be initiated and prescribed by a haematologist or paediatrician for the management of patients with chronic iron overload.  It can be used as a first line therapy for all beta thalassaemia patients aged 6yrs and older requiring frequent blood transfusions (>7 ml/kg/month packed red blood cells).  

It should be used as a second or third line therapy in the following groups: 

  • patients with beta thalassemia major 2-5 yrs, patients with beta thalassemia requiring infrequent blood transfusions, or
  • those patients with other rare anaemias where desferrioxamine (DFO) and/or deferiprone are contra-indicated, not tolerated or insufficiently effective.

Deferasirox should only be used in those patients with myelodyslplastic syndrome (MDS) requiring long term blood transfusions such as those with sideroblastic anaemia or 5q-- syndrome where concurrent immunosuppression prevents the use of DFO.  Treatment should be regularly monitored by the specialist according to the SPC.  Desferasirox should be funded by the patients PCT under ‘pass through’ funding.  Deferasirox requires intensive monitoring - consult the SPC.  A new drug review is available online - click here to access it.

RED           Deferasirox dispersible tablets 125mg, 250mg, 500mg (Exjade®)

Desferrioxamine
Desferrioxamine (deferoxamine) is given by sub-cutaneous infusion, usually over 12hrs for a certain number of days 
per week.  It is an alternative to desferasirox, where this cannot be used.  Supplies are made direct to the patients 
home through a homecare delivery service, funded by the patients CCG.  Contact pharmacy before prescribing.  
Specialist use only.
 
RED           Desferrioxamine mesilate 500mg, 2gram vial
 
Deferiprone
Deferiprone is only used in thalassaemia major where desferrioxamine is contra-indicated or is not tolerated.  Blood 
dyscrasias, particularly agranulocytosis have been reported with its use.  Specialist use only.
 
RED           Deferiprone tablets 500mg
RED           Deferiprone suspension 750mg/5ml (unlicensed special)


9.1.4 Drugs used in platelet disorders

Idiopathic thrombocytopenic purpura
Romiplostim is recommended by NICE TAG221 for the treatment of adults with chronic immune (idiopathic)
thromboycytopenic purpura:
             •   whose condition is refractory to standard active treatments and rescue therapies or 
             •   who have severe disease and a high risk of bleeding that needs frequent courses of rescue therapy and 
             •   if the manufacturer makes romiplostim available with the discount agreed as part of the patient access 
                 scheme
RED           Romiplostim (Nplate®) 250mcg vial     
 
Eltrombopag is recommended as an option by NICE (TAG293) for treating adults with chronic immune (idiopathic) 
thrombocytopenic purpura, within its marketing authorisation (that is, in adults who have had a splenectomy and
whose condition is refractory to other treatments, or as a second-line treatment in adults who have not had a
splenectomy because surgery is contraindicated), only if: 
             •   their condition is refractory to standard active treatments and rescue therapies, or
             •   they have severe disease and a high risk of bleeding that needs frequent courses of rescue therapies and    
             •   the manufacturer provides eltrombopag with the discount agreed in the patient access scheme
 
RED            Eltrombopag (Revolade®) tablets 25mg, 50mg
 
Essential thrombocythaemia
In thrombocythaemia, Anagrelide is recommended to be initiated for patients who have failed two previous treatments to control platelet counts and who have one or more of the following features:
             •     > 60 years of age, or
             •     a platelet count >1,000 x 109/l, or
             •     a history of thrombo-haemorrhagic events
Anagrelide treatment should be initiated by a clinician with experience in the management of essential thrombocythaemia.
 
RED           Anagrelide capsules 500micrograms 


9.1.6 Drugs used in neutropenia

Single dose pegfilgrastim is to replace the use of daily filgrastim (G-CSF) to reduce chemotherapy induced neutropenia
in cancer patients who would normally receive 5 or more days of daily filgrastim (G-CSF) following chemotherapy (except chronic myeloid leukaemia and myelodysplastic syndrome patients).
 
RED           Pegfilgrastim prefilled syringe 6mg
 
Pegfilgrastim is not licensed for the following indications:
 
             • Mobilisation of peripheral blood progenitor cells (PBPCs)
             • To reduce duration of neutropenia post transplant of PBPCs
             • To support weekly chemotherapy regimes
 
Filgrastim will continue to be used for these three indications.     
 
RED           Filgrastim
                  Injection 300micrograms 1mL vial

                  Prefilled syringes 300microgram, 480microgram 

 9.2.1 Oral preparations for fluid and electrolyte imbalance

9.2.1.1 Oral potassium
Compensation for potassium loss should be considered in those taking digoxin or anti-arrhythmics, in the elderly, with 
some specific drugs and when there is excessive loss in the faeces. Potassium is not recommended for those on small 
doses of diuretics.
 
GREEN      Potassium chloride
                   tablets effervescent (12mmol)
                   syrup 1mmol/mL
                   modified release tablets 600mg (8mmol)  (avoid unless effervescent tablets or liquid preparation inappropriate) 
                   
Potassium removal
Polystyrene sulphonate resins may be used to remove excess potassium in mild hyperkalaemia or in moderate
hyperkalaemia when there are not ECG changes. Intravenous therapy is required in emergencies.
 
GREEN      Polystyrene sulphonate resins (Calcium Resonium®, Resonium A®)
RED           Patiromer sorbitex calcium ( Veltassa®)
 
9.2.1.2 Oral sodium and water
GREEN      Sodium chloride tablets m/r 600mg (10mmol sodium)
 
Oral rehydration therapy (ORT)
Oral rehydration is the main treatment for mild-moderate diarrhoea.  Any unused reconstituted solution should be 
discarded after 1 hour unless stored in a fridge when it may be kept for up to 24 hours.
 
GREEN       Oral rehydration salts (Dioralyte® or Dioralyte Relief®)
AMBER      Sodium chloride oral solution 5mmoL/mL  Prescribe as SodiClor® (Arjun)
 
9.2.1.3 Oral bicarbonate
Chronic acidotic states
 
GREEN      Sodium bicarbonate
                   capsules 500mg  
                   tablets 600mg          


9.2.2 Parenteral preparations for fluid and electrolyte imbalance

9.2.2.1 Electrolytes and water
RED            Glucose infusion 5%
RED            Glucose 5% with potassium chloride 20mmol/l, 40mmol/l
RED            Glucose 10% with potassium chloride 20mmol/l
RED            Glucose 5%, sodium chloride 0.45%  with potassium chloride 20mmol/500ml
RED            Glucose 50%
RED            Ringer’s solution for injection 
RED            Sodium bicarbonate infusion 1.26%, 4.2%, 8.4%
RED            Sodium chloride infusion 0.18%, 0.9%, 2.7%
RED            Sodium chloride 0.18% and glucose 4%
RED            Sodium chloride 0.18% and glucose 4% with potassium chloride 20mmol/l, 40mmol/L
RED            Sodium chloride 0.9% with potassium chloride 10mmol (500ml)
RED            Sodium chloride 0.9% with potassium chloride 40mmol in 100ml (CCU use only)
RED            Potassium chloride concentrate 15%, ampoule (10ml) (Treat as a controlled drug)         
                   [Must be diluted with not less than 50 times its volume of sodium chloride  intravenous infusion 0.9% or                                        other suitable diluent and mixed well.  Use ready made infusions wherever possible.]
 
9.2.2.2 Plasma and plasma substitutes
RED            Gelatin (Volplex® or Geloplasma®) infusion
RED            Tetrastarch (Volulyte®) 6% infusion in sodium chloride 0.9%

CONTACT PHARMACY.

9.5.1 Calcium & Magnesium 

9.5.1.1 Calcium supplements

Supplements are usually only needed when dietary intake is deficient. In osteoporosis/osteopenia calcium and vitamin D supplementation are required.  See section 9.6.4 for such preparations.

First line
GREEN      Sandocal 1000® tablets (25mmol calcium)   
 
Second line 
GREEN      Calcium carbonate tablets chewable 1.25g (12.6mmol Ca)  (Calcichew®)   
GREEN      Calcium glubionate/calcium lactobionate syrup (2.7mmol Ca/5ml)    (Calcium-Sandoz®)  
 
Injections - for hypocalcaemia, cardiac resuscitation 
GREEN           Calcium chloride injection Min-I-Jet® (6.8mmol calcium/10ml)
RED                Calcium chloride injection ampoule (2.5mmol calcium/5ml)
RED                Calcium chloride injection 13.4% ampoule (9.1mmol calcium/10ml)
RED                Calcium gluconate injection 10% (2.2mmol calcium/10ml)
 
9.5.1.2 Hypercalcaemia and hypercalciuria
Dehydration should be corrected before other treatment is started.
             >     For IV bisphosphonates see section 6.6.2
             >     For calcitonin see section 6.6.1
             >     For corticosteroids see section 6.3
 
Cinacalcet for the treatment of secondary hyperparathyroidism in patients with end-stage renal disease on
maintenance dialysis therapy NICE TA117
 
            >      Cinacalcet is not recommended for the routine treatment of secondary hyperparathyroidism in patients with
                    end-stage renal disease on maintenance dialysis therapy.

            >      Cinacalcet is recommended for the treatment of refrectory secondary hyperparathyroidism in patients with 
                    end-stage renal disease (including those with calciphylaxis) only in those:
 
                        >      who have 'very uncontrolled' plasma levels of intact parathyroid hormone (defined as greater than 85
                                pmol/litre [800pg/ml]) that are refractory to standard therapy, and a normal or high adjusted serum
                                calcium level, and
                        >      in whom surgical parathyroidectomy is contraindicated, in that the risks of surgery are considered to
                                outweigh the benefits.
 
            >      Response to treatment should be monitored regularly and treatment should be continued only if a    
                    reduction in the plasma levels of intact parathyroid hormone of 30% or more is seen within 4 months of

                    treatment, including dose escalation as appropriate.

RED           Cinacalcet f/c tablets 30mg, 60mg, 90mg                                                            (NHS England Commissioned)

Secondary Hyperparathyroidism in adults withChronic Kidney Disease on haemodialysis -NICE TA448 

Etelcalcetide is recommended as an option for treating secondary hyperparathyroidism in 
adults with chronic kidney disease on haemodialysis, only if:
       >      treatment with a calcimimetic is indicated but cinacalcet is not suitable and
       >      the company provides etelcalcetide with the discount agreed in the patient access
               scheme.
RED         Etelcalcetide 2.5mg, 5mg, 10mg solution for injection
                                                                                                                                                                   (CCG Commissioned)


9.5.1.3 Magnesium
GREEN    Magnesium glycerophosphate chewable tablets 95mg (4mmol Mg2+)
                Prescribe by brand Magnaphate®

RED         Magnesium sulphate injection 10% 10mL (1gram) ampoule
RED         Magnesium sulphate injection 50%   
                2mL (1gram) ampoule
                10mL (5gram) ampoule
                10mL (5gram) prefilled syringe
Note: Magnesium sukphate 1gram is equivalent to Mg2+ approx. 4mmol. For intravenous injection concentration of
magnesium sulphate should not exceed 20%.                


Magnesium Aspartate (Magnaspartate®)

This product is a ‘food for special medical purposes’ and is indicated for the management of magnesium deficiency.  It is available as an oral powdercontaining magnesium-L-aspartate 6.5 g (10 mmol Mg2+)/sachet, at a net price 10-sachet pack = £7.95.  It can be prescribed on FP10 prescriptions in primary care, and is now available from Alliance Healthcare, or directly from KoRa Healthcare, Co Dublin, Ireland, UK Tel: 0845-3038631.  It will be used where there is intolerance or poor response to other oral magnesium products, to prevent use of intravenous magnesium where appropriate

AMBER     Magnesium Aspartate sachets (Magnaspartate®)

9.5.2 Phosphorus

9.5.2.1 Phosphate supplements
GREEN      Phosphate-Sandoz® effervescent tablets (16.1mmol phosphate)
RED           Phosphates intravenous infusion (100mmol/litre phosphate) 500mL

9.5.2.2 Phosphate binding agents
AMBER     Calcium acetate tablets 475 mg (Renacet®)
AMBER     Calcium acetate 435mg/235mg (OsvaRen®)
AMBER     Calcium acetate 1g tablets (Phosex®)
AMBER     Sevelamer carbonate tablets 800mg (Renvela®)
RED           Lanthanum carbonate  (when used in patients on dialysis)                                NHS England commissioned  
AMBER     Lanthanum carbonate (hyperphosphataemia with CKD and not on dialysis as per NICE CG157)  
                  500mg, 750mg, 1g tablets (Fosrenol®)     
 
Also Adcal® and Calcichew® see section 9.5.1.1


9.5.3 Fluoride

When the fluoride content of drinking water is less than 700micrograms per litre (0.7 parts per million), daily administration of fluoride tablets or drops provides suitable supplementation.

Provision of such supplements should be via the dentist.

For specific reference to high strength fluoride toothpaste which is dental prescribing only, please<click here>

In a small group of patients who are post radiotherapy for head and neck cancer, their consultant may request their GP to prescribe a high strength fluoride toothpaste on FP10. However the patient information leaflet advises that patients should obtain supplies from their dentist and should have regular 6-monthly visits to monitor oral health, please <click here>.

With respect to other dental/oral hygeine products it is felt that it is inappropriate to restrict the supply of such medications solely to dentistry, rather the overriding message/principle should be that patients presenting with symptoms pertaining to dental/oral health should be signposted to their dentist for treatment/advice.

9.5.4 Zinc

Zinc should only be given where there is good evidence of deficiency.

GREEN      Zinc Sulphate tablets effervescent 125mg (45mg zinc)

9.6.1 Vitamin A group

GREEN      Vitamin A and D capsules (vitamin A 4000units & vitamin D 400 units)

9.6.2 Vitamin B group

Deficiency of B vitamins is rare (except B12) and usually treated using a compound preparation. Pyridoxine is used to
protect against isoniazid neuropathy. Concerns over toxicity from high dose pyridoxine are not yet resolved.
 
GREEN      Pyridoxine tablets 10mg, 50mg
GREEN      Thiamine tablets 50mg, 100mg
 
The BNF advises that oral vitamin B complex preparations are less suitable for prescribing, and should not be 
considered drugs of first choice.

Intravenous/Intramuscular Vitamins B & C (High potency)
CSM advice – Since potentially serious allergic adverse reactions may occur during, or shortly after, parenteral
administration, the CSM advises;
 
        >    Use to be restricted to patients in whom parenteral administration is essential
        >    Intravenous injections should be administered slowly (over 10mins)
        >    Facilities for treating anaphylaxis should be available when administered 
 

AMBER     Vitamins B & C High potency IM injection 7ml (in 2 amps)
RED           Vitamins B & C High potency IV injection 10ml (in 2 amps)
 
For the prevention of re-feeding syndrome only
RED            Vitamin B Co Strong
 
Vitamin B12 - see hydroxocobalamin Section 9.1.2


9.6.3     Vitamin C

Divided doses are necessary due to the low renal threshold of ascorbic acid.

GREEN      Ascorbic acid tablets 100mg, 200mg, 500mg

9.6.4 Vitamin D

Patients should be directed to purchase nutritional supplements (including calcium and vitamin D) over the counter post bariatric surgery. See Guideline 

Please Note: Treatment doses of Vitamin D for paediatrics should be prescribed by the GP on hospital request and the ongoing maintenance to be purchased over the counter (self-care)

Ergocalciferol/ Colecalciferol

Simple vitamin D deficiency can be prevented using 10 micrograms (400 units) daily of ergocalciferol (calciferol, vitamin D2) or colecalciferol (vitamin D3). 

Vitamin D deficiency is not uncommon in Asians consuming unleavened bread and in the elderly living alone, and can be prevented by giving an oral supplement of 20micrograms (800units) of  colecalciferol (or ergocalciferol) daily. Patients are encouraged to buy their own supplements for vitamin D insufficiency, but where a clinician identifies a clinical need guidelines have been developed to assist in treatment decisions.

For East Lancashire Health Economy Guideline Diagnosis and Management of Vitamin D Deficiency for Non-Specialists click here

The patient information leaflet is available to print off for use click here
If it is necessary for the clinician to prescribe on an FP10, it is recommended that only  the following brand is used:
 
GREEN      HuxD3® (Colecalciferol) capsules 20,000iu 1st line choice
GREEN      Osteocaps (Colecalciferol ) capsules 20,000iu
GREEN      SunVitD3 (Colecalciferol) tablets 20,000iu
GREEN      ProD3 ® (Colecalciferol)  liquid 2,000iu/ml 
GREEN      Aciferol® D3 (Colecalciferol) liquid 2,000units/mL, 3,000units/mL
 
 
Please note:       LIQUID "SPECIALS" MUST NOT BE PRESCRIBED
Preparations containing calcium and colecalciferol are available for the management of combined calcium and vitamin
D deficiency (see below under prevention & treatment of osteoporosis).

Pharmacological strengths of ergocalciferol
AMBER      Ergocalciferol tablets 250microgram (10,000units) & 1.25mg (50,000units)
AMBER      Ergocalciferol injection 7.5mg (300,000 units)/ml - 1ml & 2ml ampoules


Prevention & treatment of osteoporosis

Those with, or at risk of, osteoporosis should maintain an adequate intake of calcium and vitamin D. If deficiency is suspected, this should be corrected by increasing dietary intake or taking supplements.  Calcium and vitamin D supplementation alone may reduce the risk of fracture but it is less effective than other agents. The best evidence supports its use in institutionalized or housebound elderly women.  Adcal D3® and Calcichew D3 Forte® should be given twice daily.  Calfovit D3® sachets should be given daily.  

For moderate to severe renal disease colicalciferol may not be metabolised to the active metabolite of vitamin D. In these circumstances a suitable alternative would be alfacalcidol.

First Line
GREEN     Calcium carbonate tablets chewable 1.5g (15mmol Ca) & colicalciferol
                 10micrograms (Vitamin D 400units) (Adcal D3®, Accrete D3®, Evacal D3®) (Give 1 tablet twice daily)  OR 
                  Calcium carbonate caplets 750mg (7.5mmol Ca) & colicalciferol 
                  5micrograms (Vitamin D 200units) (Adcal D3®(Give 4 caplets daily)   

Second Line
GREEN      Calcium phosphate 1.2g (30mmol Ca) & colecalciferol 20microgram sachets
                   (Vitamin D 800units)   (Calfovit D3®) (Give 1 sachet daily)  
                                      - for swallowing difficulties      
GREEN      Calcium carbonate tablets chewable 1.25g (12.6mmol Ca) & colicalciferol 10micrograms
                  (Vitamin D 400 units) (Calcichew D3 Forte®) (Give 1 tablet twice daily) 
                                   - if patient dislikes taste of chewable Adcal D3®       

Alfacalcidol and Calcitriol

Patients with severe renal impairment requiring vitamin D therapy should be prescribed alfacalcidol.                                   It is essential that healthcare professionals check that plasma calcium monitoring is undertaken.

Do NOT abbreviate nanograms or micrograms. Please see link.
Note that One-Alpha® capsules contain sesame.
 
AMBER      Alfacalcidol
                   capsules 250 nanograms, 1 microgram
                   oral drops 2 microgram/mL
AMBER      Calcitriol capsules 250nanograms 


9.6.5     Vitamin E

GREEN      Alpha Tocopheryl acetate suspension 500mg/5mL

9.6.6 Vitamin K

Essential for the production of blood clotting factors, antagonises effects of oral anticoagulants. Menadiol used when there are malabsorption syndromes, and in obstructive liver disease.

Malabsorption syndromes (water-soluble preparation required):
GREEN      Menadiol sodium phosphate tablets 10mg
 
Fat soluble formula (not malabsorption):
AMBER     Phytomenadione (vitamin K1) 2mg in 0.2ml amp (Konakion MM Paediatric®) *
RED           Phytomenadione 10mg in 1ml amp (Konakion MM®) **
RED            Phytomenadione 10mg tablets (most cost effective option)
 
*Note – Konakion MM Paediatric may be administered by mouth or by intramuscular injection or by intravenous 
 injection.
**Note – Konakion MM may be administered by slow intravenous injection or by intravenous infusion in glucose
5%; not for intramuscular injection.


Haemorrhagic disease of the newborn                                                                                                                                              
If parents do not want their baby to have the intramuscular injection of vitamin K, then Konakion MM® orally or Orakay®may be offered as an alternative (although Orakay® is unlicensed for this indication).

Dose 1mg on day 1 and also day 7 & day 28 for breast fed babies.

AMBER     Phytomenadione capsules 1mg (Orakay®) (unlicensed)

9.6.7  Multivitamin preparations

Prescribing of Multivitamins and phenylalanine-free amino acid substitutes for adults and 
children with phenylketonuria (PKU). There is no requirement to use specific multivitamins for 
people with PKU e.g Phlexy-Vit
  Please refer to Position Statement
AMBER     Multivitamins for adults and children with PKU (specialist initiation)
AMBER     Phenylalanine-free amino acid substitutes for adults with PKU (specialist 
                  initiation)
 
Dietary management of patients with Cystic Fibrosis Paravit-CF® capsules/liquid 
Paravit-CF® is a 'Food for Special Medical Purposes' for the dietary management of
patients with cystic fibrosis, which offers patients a decreased oral medication load whilst 
also being a cost-effective option
AMBER     Paravit-CF® capsules (specialist initiation)
                  Vitamin A (retinyl palmitate)  1500 micrograms (=5000 IU
                  Vitamin D3 (cholecalciferol)   37.5 micrograms  (=1500 IU) 
                  Vitamin E (tochopheryl acetate) 100 milligrams (=150 IU) 
                  Vitamin K1 (phytomenadione)  5000 micrograms
AMBER     Paravit-CF® liquid  (specialist initiation) - for use in young children or patients   
                  swallowing difficulties.
NOTE:  The prescriber should ensure that when patients with cystic fibrosis are initiated or switched to Paravit-CF® 
             that existing prescriptions for individual ingredients that are included in Paravit-CF ® are discontinued.

GREEN
  
    Dalivit® drops 25ml 
GREEN      ** Abidec drops® 25ml 
GREEN      Vitamin capsules/tablets 
 
** ELHT neonatal formulary recommends that babies started on Sytron® and/or Abidec® on the Neonatal Intensive 
     Care Unit  (ELHT) should remain on the treatment for 1 year post birth. GPs in Primary care are requested to 
     continue to prescribe these products  for neonates until the age of 1 year old.
    
Vitamin and mineral supplements and adjuncts to synthetic diets 
GREEN      Ketovite® tablets 
GREEN      Ketovite® liquid 
 
Forceval - *For vitamin and mineral supplementation and after gastric by-pass surgery
Patients should be directed to purchase nutritional supplements.
For further information please click here 

BLACK      *Forceval® capsules 
 
For the prevention of refeeding syndrome only 
RED           Forceval® capsules
 

Dietary management of water-soluble vitamin deficiency in adults with renal failure on dialysis

AMBER     Renavit® tablets 450mg

This a Borderline substance To be initiated by renal consultant/SpR.

9.8.1  Drugs used in metabolic disorders

Carnitine deficiency
RED           L-Carnitine paediatric solution 30% (3gram/10ml) – 20mL bottle
RED           L-Carnitine injection 1gram/5mL
 
Nephropathic cystinosis
RED          Mercaptamine (Cystagon®) capsules 50mg, 150mg
                 Please prescribe by brand to avoid confusion with similar sounding names.
RED          Mercaptamine (Cysteamine) eye drops
 This is a "special" for use in ophthalmic involvement of nephropathic cystinosis, available on named 
 patient basis only.
 
Metabolic disorders
RED         Sodium Bicarbonate 420mg/5mL (1mmol/mL) sugar free oral solution
                  Prescribe as SodiBic® (Arjun)
RED          Sodium Benzoate 500mg/5mL oral solution                               NHS England commissioned
RED          Joulies Solution (oral solution - unlicensed)
 
Other drugs
AMBER     L-Arginine 10% infusion 200mL
                  (may be given orally, see BNF-C for further information on administration)
RED          Sodium phenylbutyrate 500mg


9.8.2 Acute porphyrias

For use as haem replacement in moderate, severe or unremitting acute porphyria crises.

RED           Haem arginate (Normosang®) injection 25mg/mL