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                

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 *                                                                                                                                      as a second line treatment when there is hypersensitivity to iron dextran.  

* 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 PCT.  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®)

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®)

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%

AMBER Sodium chloride oral solution 5mmoL/mL

               Prescribe as SodiClor® (Arjun)

RED       Sodium chloride 0.9% with potassium chloride 20mmol/l, 40mmol/l

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.

Prescribing Oral Nutrition Supplements

 (sip feeds) for Care Home Residents

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.

                    treatment, including dose escalation as appropriate.

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

9.5.1.3 Magnesium

Magnasparte® - is the first licensed oral magnesium preparation and is the preferred choice for treatment and prevention of magnesium deficiency. 

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 powder, containing 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

9.5.2.2 Phosphate binding agents

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

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 

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

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.

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.

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.

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

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. 

 Arjun 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

AMBER    Sodium Bicarbonate 420mg/5mL (1mmol/mL) sugar free oral solution

                  Prescribe as SodiBic® (Arjun)

RED          Sodium Benzoate 500mg/5mL oral solution                                                                                                                                        NHS England funded

Other drugs

AMBER     L-Arginine 10% infusion 200mL

                  (may be given orally, see BNF-C for further information on administration)

RED          Sodium phenylbutyrate tablets 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